To integrate virtue and ethics education into a health assessment curriculum for nursing students: A controlled study

To integrate virtue and ethics education into a health assessment curriculum for nursing students: A controlled study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article To integrate virtue and ethics education into a health assessment curriculum for nursing students: A controlled study Jin Xiaofeng, Zhao Ying, Chen Feier, Wu Chuanling, Duan Kaixuan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3384740/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective To integrate virtue and ethics education into a health assessment course for nursing students, and to investigate the effects of such education on the students' perceptions and behaviors related to medical ethics. Methods Freshmen nursing students in a Chinese college were randomly divided into two groups, each including 105 students. In the health assessment course, the control group was given regular teaching contents according to the teaching standards, while the innovation group was given the teaching content required by the teaching standards, with the virtue and ethics education integrated into the corresponding knowledge points in the teaching design.The two groups' following performances were compared: the scores of the Nurses' Professional Values Scale - Revised (NPVS-R), the scores of virtue and ethics in the practice assessment, and the average volunteer service time. Results The innovation group scored higher than the control group in terms of the total score, Factor 1, Factor 3, Factor 4, and Factor 5 modules of the NPVS-R (P 0.05); and the scores of virtue and ethics in the practical assessment and the average volunteer service hours of the innovation group were significantly higher than those of the control group (P < 0.05). Conclusion Integrating virtue and ethics education into the teaching of the health assessment course is a useful supplement to medical ethics education, and it can influence students positively in cognition, skills and behavior for virtue and ethics. Educational Philosophy and Theory Nursing Medical Ethics medical education virtue ethics education nursing students health assessment Figures Figure 1 Figure 2 1. Background With social progress and development, medical treatments have gradually changed from biomedical models to bio-psycho-social medical ones. In such a context, medical students need to be able to understand and respond to the unprecedented ethical challenges posed by the digitalization of healthcare systems and the society [ 1 ] . As increasingly more countries incorporate medical ethics into their medical teaching systems, ethics education is nowadays regarded as the key to medical training [ 2 ] . According to a report published by the Association of American Medical Colleges, 143 of 145 medical schools addressed medical ethics in their curricula [ 3 ] . In addition, a survey conducted in Barbados indicated that 100% of the participants agreed that medical ethics courses should be offered in medical schools [ 4 ] . Despite these views, however, there is often a lack of clarity about the specific objectives of medical ethics courses [ 5 ] . Two main pedagogical goals regarding the teaching of medical ethics are generally agreed: (1) To develop ethical healthcare professionals; and (2) To provide healthcare professionals with a set of skills for analyzing and resolving ethical dilemmas encountered in clinical settings [ 6 ] . The heterogeneity of these ethics teaching objectives has led to significantly varied ethics curriculum contents across institutions. As revealed by a large-scale multicenter survey, medical schools in the United States and Canada still lack consensus on the contents and teaching methods of medical ethics courses [ 7 ] . Another survey found 10 curricular objectives and 39 content areas from the ethics syllabi of 58 schools; however, only 2 of these curricular objectives and 6 content areas appeared in the syllabi of more than half of the schools [ 8 ] . It is also identified that the relatively concentrated content areas in the current medical ethics education are focused more on moral reasoning and decision making [ 9 , 10 ] , but less on the development of virtues and professionalism, such as empathy. The subject of medicine tends to define a good health care professional as a person possessing many qualities. Then, what specific qualities shall be included? The Canadian Medical Association's Code of Ethics and Professionalism states in its opening chapter that the virtues embodied by ethical physicians shall include compassion, honesty, humility, integrity and discretion [ 11 ] . Although medical ethics is generally recognized as an important element and has been designed as a separate course in many institutions, a self-contained curriculum, while having some value, can also deliver the effect of marginalizing ethics to some extent [ 12 ] . Indeed, there is a growing concern that medical students are not engaged in ethics education as seriously as in other courses [ 13 ] . In a survey, for example, some medical students noted that medical ethics was irrelevant or just "common sense" [ 14 ] . Many reasons may explain this case. According to Liu Y et al., when very theoretical and abstract content is combined with passive learning activities, no meaningful and sustainable form of learning may be expected for students [ 5 ] . Given the above discussion, this study would attempt to integrate some elements of virtue and medical ethics, outside of a separate medical ethics course, into a professional curriculum for nursing students through an instructional design, while observing the impact of this integrated teaching model on nursing students' professional values as well as the ability of such students to apply the values in their practice. 2. Methods 2.1 Samples and contexts The study population included a total of 210 freshman nursing students from a college in China, who were divided into two groups with stratified regional group randomization based on their genders and entrance scores in the entrance examination. Specifically, 105 students were included in the control group and 105 in the innovation group, with their general parameters shown in Table 3. Students in both groups had completed such basic medical courses as anatomy, tissue embryology and physiology in the first semester, each of which was taught by the same groups of teachers. For the health assessment course in the second semester, the control group accepted the regular teaching according to the teaching standards, while the innovation group was given virtue and ethics education incorporated into the corresponding knowledge points in the teaching design, in addition to the teaching content required by the teaching standards. Other courses offered in the second semester were the same for both groups. 5 students were transferred to the nursing program from other majors at the end of the first semester, and these studies were not included in this study. 2.2 Pedagogical design of virtue and ethics education ① The teaching goals To strengthen the nursing students' perceptions of professional values; to enhance the students' skills in using their knowledge of virtues and ethics to solve practical clinical problems; and in turn to positively influence the students' behavior. ②Teaching content and methods In reference to the classification of virtues and ethics in the literature [ 11 , 15 ] , this study combined it with the Chinese Medical Student Oath, finally classifying the content of virtues and ethics into the following six areas: professional responsibility, communication, professionalism, personal development, decisions about treatment, and justice, with a total of 21 entries included (Table 1). In classrooms, the content of virtue and ethics education was introduced through the professional knowledge points, and about 5–10 minutes were allocated to the discussion of these issues, mainly by means of group discussions. In this process, students worked in small groups to express their views on related cases, while the teachers guided the students in forming proper concepts of virtue and ethics. ③ To build a library of case materials At least once a month, the members of the course team brainstormed and dynamically enriched and improved the cases related to virtue and ethics education through faculty activities, so as to build up a continuous library of case materials and keep the teaching content continuously updated. 2.3 Ethical considerations This study was conducted with the approval of the College's Social Research Ethics Committee, and the privacy of the participatory students was adequately protected. 2.4 Evaluation indicators (1) NPVS-R: At the end of the course, the NPVS-R (Table 2) was released to all students, which was designed and revised by the American Nurses Association, covering factors in five modules: care, action, trust, professional characteristics, and justice, with 26 entries. And the Cronbach's alpha coefficient of its scale was 0.92 [ 16 ] , using a five-point Likert scale with the following scores: 1 -- unimportant, 2 -- somewhat important, 3 -- important, 4 -- very important, and 5 -- most important; the total score ranged from 26 to 130, with higher scores indicating a stronger orientation to professional values among the nurses [ 17 ] . (2) Virtue and ethics scoring in the practical assessment of the course: In the practical assessment at the end of the health assessment course, an objective structured clinical examination (OSCE) model was adopted, which was divided into 3 stations: assessment of health history taking; cardiopulmonary auscultation; and interpretation of common laboratory test results. The first two stations were assessed by instructors as standard patients for students. Five scoring points on virtues and ethics were added to the scoring criteria for these two stations (Table 5), with each scoring point given a score of 0–5 according to the actual situation of each student, totaling 25 scores. The same teachers were assigned as a standard patient at each station to ensure uniformity of scoring. (3) Volunteer service time: Half a year after the course was concluded (the 1st semester of the sophomore year), the durations of the two groups of students going to communities or nursing homes to participate in volunteer services were calculated. 2.5 Data analysis Data were analyzed with SPSS 25.0. Continuous variables are expressed as mean ± standard deviation. For the comparison of quantitative indicators between the two groups of students, the independent sample t-test was used; and for the comparison of rates, the chi-square test was adopted. The difference would be considered statistically significant if P < 0.05. 3. Results 3.1 General characteristics of participants There were no statistical differences between the two groups in terms of mean age, enrollment performance and gender composition (Table 3). 3.2 NPVS-R scores A total of 210 copies of the NPVS-R were distributed, all of which were found valid after collected. The innovation group outperformed the control group in total score, with a statistically significant difference between the two groups; in the sub-factor analysis, the innovation group outperformed the control group in factor 1, factor 3, factor 4, and factor 5 modules, with a statistically significant difference between the two groups; and the module scores of the two groups in factor 2 were not statistically different (Table 4). The mean scores and the standard deviations of all items for the two groups are compared in Fig. 1. 3.3 Virtue and ethics scores in the practical assessment The innovation group is found scoring significantly higher than the control group in all five virtue and ethics scoring assessment points in the practical assessment of the course; and the differences between the two groups are statistically significant (Table 5). 3.4 Volunteer service time Within six months after the course, the control group registered 11.50 ± 6.16 hours for the average volunteer service time, while the innovation group did 13.97 ± 7.29 hours, so the difference between the two groups is statistically significant (Fig. 2). 4. Discussion Although it has become a consensus to introduce medical ethics and other medical humanities courses in medical schools, the conventional virtue and ethics education tends to instill theoretical ideas to students in traditional lecture formats, which in fact are not well accepted by students [ 6 ] , thus delivering no good teaching effectiveness. In order to improve the effectiveness of ethics education, many novel teaching strategies have been proposed in curricula. For example, the use of group sessions is found superior to lecture-based teaching formats [ 18 ] . In addition, teaching with real-life cases is more likely to make medical students aware of themselves as members of the medical culture, thus encouraging them to monitor their own personal ethical development [ 19 ] . A survey in Turkey showed that team learning is more effective in long-term knowledge retention than conventional classroom teaching [ 20 ] . In addition, scenario-based simulations have been implemented in ethics teaching, uniquely helping students apply ethical concepts in a near-realistic environment, rather than simply memorizing definitions of ethical principles from textbooks [ 21 ] . With the development of new media technologies, screenplays and playwriting have also been deployed in the teaching of medical ethics as a powerful form of reflective learning [ 22 ] . However, with predominantly theoretical content, ethics courses are generally less attractive to medical students than clinical specialty courses, leading to a lower-than-expected result in the teaching of virtue and medical ethics. To address this dilemma, this study tries to integrate part of the contents of virtue and ethics into the clinical specialty courses, in addition to the independent medical ethics course, so that students can implicitly receive the knowledge on virtue and ethics while learning professional knowledge. In terms of specific teaching strategies, this study mainly uses the case-based group discussion method. The existing researches have shown that when combined with case scenarios through storytelling, narrative medicine can help enhance students' ethical reasoning [ 23 ] . Given that outdated materials are currently a prominent drawback in the teaching of medical ethics in China [ 24 ] , this study has explored the concept of building a dynamic case material repository, which can ensure that the teaching cases and materials are kept up-to-date. This study chose health assessment as a vehicle course for the integration of virtue and ethics teaching, because the health assessment course would teach the skills necessary for the first step of nursing practice: assessment and diagnosis [ 25 ] . The content of this course would cover the entire process of nursing assessment. Using the health assessment curriculum as a vehicle, virtue and ethical themes are integrated into clinical thinking skills training for nursing students, enabling students to better understand scenarios in which virtue and ethical perspectives are applied, thereby substantially shaping student behavior. The ultimate goal of medical ethics teaching is to help students and future health care professionals enhance their ethical competencies [ 26 ] . However, it is a challenge to evaluate the effectiveness of medical ethics education. Traditional course evaluation models often take written examinations, such as multiple-choice questions and essay assignments; yet, such approaches cannot truly reflect whether students' ethical competencies have been improved. It is shown that diverse assessment models will help medical ethics education shift from passive learning to ICAP (Interactive, Constructive, Active, and Passive) learning [ 27 ] . This study's approach to integrating virtues and ethics into clinical curricula was originally intended to influence students' values and, in turn, boost their behaviors in some way. Therefore, this study has designed three forms to evaluate the effectiveness of this teaching strategy. First, it uses the mature NPVS-R model, as values are an important component of the ethical system in determining moral behaviors [ 28 ] . In this study, the innovation group outperformed the control group in the other four factors, except for the rating of Factor 2, which shows no obvious differences between the two groups, probably because the five items related to Factor 2 were the least involved in the virtue and ethics teaching designed by this study. Second, teaching medical ethics ultimately involves actions and behaviors [ 29 ] ; therefore, this study included the evaluation of medical humanistic attitudes in the practical operation assessment when evaluating the effectiveness of virtue and ethics education as a way to examine whether students can truly apply their knowledge on virtue and ethics in real clinical practice. Finally, this study used volunteer service hours as an evaluation index. A study in Singapore showed that one of the intrinsic motivations for nursing students to participate in volunteer services is their desire to make contribution and give help to others [ 30 ] ; therefore, volunteer service hours could reflect, to some extent, the improvement of nursing students' ethical competence. Virtually, the results of this study demonstrate that the average volunteer service hours of the students in the innovation group were significantly longer than those in the control group. The three aforementioned approaches are able to illustrate the effectiveness of integrative virtue and ethics teaching in terms of cognition, skills and behavior, respectively. Of course, a perfect evaluation methodology should include both formative and summative evaluations [ 31 ] . However, the formative evaluation was missing in the instructional design of this study, so a more effective design shall be taken in the future explorations. Additionally, as a new attempt to teach virtues and ethics, this study showcases some other shortcomings. For instance, the general categories of virtues and ethics are broader than those listed in this study, because the former may include moral reasoning, altruism, kindness, honesty and integrity [ 32 ] . In this study's integrative instructional design of virtues and ethics, only a portion of the topics of virtues and ethics were selected, mainly based on the characteristics of health assessment as a vehicle course. As an attempt for a new pedagogical strategy, the integration of virtues and ethics into the clinical specialty curricula is only a complement to the teaching of medical ethics, so it cannot shake the pedagogical goals of the main courses on health assessment. As indicated by some other studies, ethics education should be integrated with all aspects of medical education in a student-centered approach, so that students can eventually solve practical problems [ 33 , 34 ] . To achieve this goal, a stand-alone course for medical ethics is clearly not sufficient. This study's exploration in integrating virtue and ethics education into clinical specialty curricula proves effective, because it can make each specialty clinical course a vehicle for conducting virtue and ethics teaching; in this way, the position of ethics teaching can be significantly expanded. 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Professional duties (1) Respect for patients and families Beth Israel Deaconess Medical Center in Boston has set up a web portal for its ICU, so that patients' families can upload some photos and details of the patients' lives before they became ill, purposed to help doctors understand their patients better Assessment of social health history (2) Objective comments on colleagues or peers When treating a patient with Type-II diabetes who had been adopted insulin, a registered Chinese-medicine practitioner in Sydney instructed the patient to stop taking Western medicine but take only the Chinese medicine he prescribed. Eventually, the patient died of deteriorated conditions. Clinical significance of blood glucose (3) Collaboration with colleagues A team of orthopaedic surgeons in Shanghai was able to deliver more than a dozen arthroscopic surgeries each working day, because it improved its efficiency through collaboration between operating-room nurses, anesthesiologists, and medical and ward nurses Nursing diagnosis (collaborative questions) (4) Respect for different cultures and religious beliefs A study published in Nature by a team from Harvard University in 2021 demonstrated successful treatment of sepsis (septicemia) by electro-acupuncture stimulation of the San Li points on animals' feet. Clinical significance of blood counts 2. Communication (1) Full communication Dr. Walter Baile of M.D. Anderson Hospital in Texas, USA, proposed the SPIKES model for effective doctor-patient communication Taking health history into consideration (2) Privacy protection Three Boston hospitals were fined a total of $999,000 for inviting a film crew to shoot a medical documentary without patients' consent Analysis of health information (3) Listening A Guangdong hospital set up a life and health narrative sharing center and used narrative regulation to help a silicosis patient improve his quality of life Lung X-rays 3. Professionalism (1) Meticulousness Lax lens disinfection in a hospital in Anhui Province caused post-operative infection with ten cataract surgery patients, nine of whom had their eyes removed finally. Eye evaluation (2) Meticulous work attitudes towards patients A doctor in Shanghai meticulously analyzed a patient's condition and eventually confirmed aortic valve bilobar malformation through CT examination, avoiding misdiagnosis. CT examination (3) Kindness A study in Massachusetts found that patients who were treated kindly and encouraged by anesthesiologists would recovered faster and be discharged from hospital 2.7 days earlier than other patients on average. General condition assessment (4) Not giving up easily Colorectal and anal surgeons at a hospital in Guangzhou successfully resuscitated a patient in cardiac arrest by insisting on CPR for 2 hours. Electrocardiogram (ventricular fibrillation heart rate) (5) Truthfulness and pragmatism John Snow's fieldwork to determine how cholera spreads disproved a common belief that it was caused by the "miasma" that permeated the city of London. Examination of stool 4. Personal development (1) Self-control The importance of emotional control was illustrated through a parable about a donkey that fell into a dry well. Psychological Assessment (2) Humility A case of ankylosing spondylitis misdiagnosis occurred due to a rheumatologist casually questioning an orthopedic surgeon's diagnosis Spinal assessment (3) Prudence and independence A nurse forgot to loosen a tourniquet after an infusion, causing ischemic necrosis of the patient's arm. Vascular assessment 5. Decisions about treatment (1) Reconciliation of the doctor-patient cognitive gap Differences in perceptions of tracheotomy between doctors and patients Inspiratory dyspnea (2) Right to informed consent A U.S. state first adopted the Natural Death Act, the first law in the world to legalize living wills. Cachexia assessment (3) Empathy In a mitral valve surgery, a Harvard girl's father chose his hospital first for empathy Cardiac evaluation 6. Justice (1) Avoiding overmedication "Choosing Wisely" campaign encouraged doctors and patients to abandon overmedication habits Head and face assessment (2) Honesty A cardiologist made academic fraud on cardiac stem cells Cardiac assessment (3) Integrity A doctor defrauded insurance companies on premiums by helping uremic patients who were living in hardship Renal function tests Table 2. Nurses' Professional Values Scale - Revised (NPVS-R) Factor Item 1. Caring 16. Uphold the moral dignity and legal rights of patients 17. Refuse to participate in care that is contrary to the ethical requirements of one's professional values 18. Be a patient advocate and take on the role of being a patient advocate 20. Provide equal/unbiased care to patients with different lifestyles 21. Maintain the patients' right to privacy 22. Follow the nursing practice in which nurses make conscious judgments about the correctness of medical advice 23. Practice nursing according to the principles of fidelity and respect for persons 24. Protect the rights of patients who participate in nursing research 25. Maintain the trust of patients and families in health care professionals 2. Activism 4. Participate in public decision-making to improve the allocation of public health resources 10. Actively participate in health-related activities to promote the nursing profession or specialty 11. Recognize the role of nursing professional organizations in the development of health care policies 19. Participate in nursing research and apply the findings to appropriate nursing practice 26. Participate in the scholarly activities of nursing professional organizations 3. Trust 1. Conduct frequent self-evaluations 2. Actively request consultation or collaboration when patients' needs cannot be met 9. Seek alternative educational pathways or continually learn to update knowledge or skills 14. Assume responsibilities and accountabilities in nursing practice 15. Maintain competence in the practical and clinical work of the profession involved 4. Professionalism 5. Participate in evaluation activities among colleagues 6. Develop codes of practice for each nursing job 7. Establish and meet teaching objectives for nursing teaching 8. Actively take effective measures to improve the environment for nursing practice 5. Justice 3. Maintain the health and safety of the public 12. Provide equitable health care services for the public 13. Perform nursing duties to meet the health needs of culturally diverse populations Table 3. Parameters of general characteristics of students in both groups Control group Innovation group Statistical value P-value Number of cases (person) 105 105 Age (years) 19.48±0.65 19.52±0.62 -0.542 * 0.598 Enrollment score (points) 469.10±30.54 469.81±31.18 -0.168 * 0.867 Sex Male (person) 10 9 0.058 # 0.81 Female (person) 95 96 Table 4. Mean scores on the NPVS-R in both groups Factors Control group n=105 Innovation group n=105 t-value P-value Factor 1 Caring 36.20±6.12 39.16±5.42 -3.710 0.000 Factor 2 Activism 20.48±3.27 21.22±3.42 -1.610 0.109 Factor 3 Trust 19.64±3.57 21.30±3.25 -3.520 0.001 Factor 4 Professionalism 15.35±2.99 16.66±2.89 -3.220 0.001 Factor 5 Justice 11.88±2.08 12.86±1.95 -3.520 0.001 Total score 103.54±17.78 111.19±16.72 -3.210 0.002 Table 5. Virtue and ethics scores in the practical assessment in both groups Scoring points Control group n=105 Innovation group n=105 t-value P-value 1. Provide comfort when patients tell about their misfortune 3.10±0.41 3.66±0.59 -7.89 0.00 2. Listen attentively to patients when they describe their medical history, instead of interrupting them frequently 2.91±0.40 3.50±0.50 -9.47 0.00 3. Introduce yourself to patients before starting the examination, so as to obtain patients' cooperation 3.52±0.50 3.91±0.48 -5.75 0.00 4. Close the bed curtains before examination, so as to protect patients' privacy 1.99±0.38 3.68±0.55 -25.98 0.00 5. Warm the stethoscope before examining. 1.95±0.21 3.27±0.51 -24.55 0.00 Total Score 13.49±0.85 18.02±1.32 -29.71 0.00 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3384740","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264316857,"identity":"2278efed-bba5-44ad-82e4-7a1409426fa1","order_by":0,"name":"Jin Xiaofeng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvUlEQVRIiWNgGAWjYBACNvnHhx9+qLCp7ydaCx9DWpqxxJk0xpkNxGqRY8gxkOBtO8y44QDRDmM4YGAgwZbGbHw8eQPDj4ptRGhhbEh4UMBjw2Z25lkBY8+Z20RoYQZaIyGRxmN2I8eAmbGNGC1AayR4DA5LGM8gWgsPM4MET8JhoIeI1iLBxmYscSAtQQLol4NE+UV+Bv/nhx//2STwtydvfPCjgggtSCDB4ABJ6sFaSNUxCkbBKBgFIwQAANQlOWSF6FOgAAAAAElFTkSuQmCC","orcid":"","institution":"Health Branch, Zhejiang Industry Polytechnic College","correspondingAuthor":true,"prefix":"","firstName":"Jin","middleName":"","lastName":"Xiaofeng","suffix":""},{"id":264316858,"identity":"eeb8dd37-47b8-435a-828f-9f3f373c0b75","order_by":1,"name":"Zhao Ying","email":"","orcid":"","institution":"Shaoxing Second Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhao","middleName":"","lastName":"Ying","suffix":""},{"id":264316859,"identity":"fbf78004-b344-41c5-8590-1b33c42a1935","order_by":2,"name":"Chen Feier","email":"","orcid":"","institution":"Health Branch, Zhejiang Industry Polytechnic College","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Feier","suffix":""},{"id":264316860,"identity":"ed80a066-cad2-4df3-abe0-e60e6c77102e","order_by":3,"name":"Wu Chuanling","email":"","orcid":"","institution":"Health Branch, Zhejiang Industry Polytechnic College","correspondingAuthor":false,"prefix":"","firstName":"Wu","middleName":"","lastName":"Chuanling","suffix":""},{"id":264316861,"identity":"14316cf8-b737-464a-abaa-419a3fe407ee","order_by":4,"name":"Duan Kaixuan","email":"","orcid":"","institution":"Health Branch, Zhejiang Industry Polytechnic College","correspondingAuthor":false,"prefix":"","firstName":"Duan","middleName":"","lastName":"Kaixuan","suffix":""}],"badges":[],"createdAt":"2023-09-25 12:09:03","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3384740/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3384740/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49017474,"identity":"ca4d72a5-407b-4b3b-90f7-6beea21b9e41","added_by":"auto","created_at":"2024-01-01 05:52:45","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":192052,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean scores and standard deviations of each item on NPVS-R in both groups\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3384740/v1/4e386632b4448c024b1b625b.jpg"},{"id":49017475,"identity":"7ef8fdc9-4501-4cfc-9745-123ebc6a7a8b","added_by":"auto","created_at":"2024-01-01 05:52:45","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69651,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of the volunteer service hours of the two groups\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3384740/v1/363726882dd83543f8ffbe93.jpg"},{"id":49017647,"identity":"6291b373-4987-4f2e-b0ab-3fe8efef7dca","added_by":"auto","created_at":"2024-01-01 06:00:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":527757,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3384740/v1/7c12a50d-efb6-4b20-a873-0ffe0f735a54.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eTo integrate virtue and ethics education into a health assessment curriculum for nursing students: A controlled study\u003c/p\u003e","fulltext":[{"header":"1. Background","content":"\u003cp\u003eWith social progress and development, medical treatments have gradually changed from biomedical models to bio-psycho-social medical ones. In such a context, medical students need to be able to understand and respond to the unprecedented ethical challenges posed by the digitalization of healthcare systems and the society \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. As increasingly more countries incorporate medical ethics into their medical teaching systems, ethics education is nowadays regarded as the key to medical training \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. According to a report published by the Association of American Medical Colleges, 143 of 145 medical schools addressed medical ethics in their curricula \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In addition, a survey conducted in Barbados indicated that 100% of the participants agreed that medical ethics courses should be offered in medical schools \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite these views, however, there is often a lack of clarity about the specific objectives of medical ethics courses \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Two main pedagogical goals regarding the teaching of medical ethics are generally agreed: (1) To develop ethical healthcare professionals; and (2) To provide healthcare professionals with a set of skills for analyzing and resolving ethical dilemmas encountered in clinical settings \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe heterogeneity of these ethics teaching objectives has led to significantly varied ethics curriculum contents across institutions. As revealed by a large-scale multicenter survey, medical schools in the United States and Canada still lack consensus on the contents and teaching methods of medical ethics courses \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Another survey found 10 curricular objectives and 39 content areas from the ethics syllabi of 58 schools; however, only 2 of these curricular objectives and 6 content areas appeared in the syllabi of more than half of the schools \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIt is also identified that the relatively concentrated content areas in the current medical ethics education are focused more on moral reasoning and decision making \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, but less on the development of virtues and professionalism, such as empathy. The subject of medicine tends to define a good health care professional as a person possessing many qualities. Then, what specific qualities shall be included? The Canadian Medical Association's Code of Ethics and Professionalism states in its opening chapter that the virtues embodied by ethical physicians shall include compassion, honesty, humility, integrity and discretion \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough medical ethics is generally recognized as an important element and has been designed as a separate course in many institutions, a self-contained curriculum, while having some value, can also deliver the effect of marginalizing ethics to some extent \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Indeed, there is a growing concern that medical students are not engaged in ethics education as seriously as in other courses \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. In a survey, for example, some medical students noted that medical ethics was irrelevant or just \"common sense\" \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Many reasons may explain this case. According to Liu Y et al., when very theoretical and abstract content is combined with passive learning activities, no meaningful and sustainable form of learning may be expected for students \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGiven the above discussion, this study would attempt to integrate some elements of virtue and medical ethics, outside of a separate medical ethics course, into a professional curriculum for nursing students through an instructional design, while observing the impact of this integrated teaching model on nursing students' professional values as well as the ability of such students to apply the values in their practice.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1 Samples and contexts\u003c/h2\u003e\n\u003cp\u003eThe study population included a total of 210 freshman nursing students from a college in China, who were divided into two groups with stratified regional group randomization based on their genders and entrance scores in the entrance examination. Specifically, 105 students were included in the control group and 105 in the innovation group, with their general parameters shown in Table\u0026nbsp;3. Students in both groups had completed such basic medical courses as anatomy, tissue embryology and physiology in the first semester, each of which was taught by the same groups of teachers. For the health assessment course in the second semester, the control group accepted the regular teaching according to the teaching standards, while the innovation group was given virtue and ethics education incorporated into the corresponding knowledge points in the teaching design, in addition to the teaching content required by the teaching standards. Other courses offered in the second semester were the same for both groups. 5 students were transferred to the nursing program from other majors at the end of the first semester, and these studies were not included in this study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2 Pedagogical design of virtue and ethics education\u003c/h2\u003e\n\u003cp\u003e① The teaching goals\u003c/p\u003e\n\u003cp\u003eTo strengthen the nursing students' perceptions of professional values; to enhance the students' skills in using their knowledge of virtues and ethics to solve practical clinical problems; and in turn to positively influence the students' behavior.\u003c/p\u003e\n\u003cp\u003e②Teaching content and methods\u003c/p\u003e\n\u003cp\u003eIn reference to the classification of virtues and ethics in the literature \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, this study combined it with the Chinese Medical Student Oath, finally classifying the content of virtues and ethics into the following six areas: professional responsibility, communication, professionalism, personal development, decisions about treatment, and justice, with a total of 21 entries included (Table\u0026nbsp;1). In classrooms, the content of virtue and ethics education was introduced through the professional knowledge points, and about 5\u0026ndash;10 minutes were allocated to the discussion of these issues, mainly by means of group discussions. In this process, students worked in small groups to express their views on related cases, while the teachers guided the students in forming proper concepts of virtue and ethics.\u003c/p\u003e\n\u003cp\u003e③ To build a library of case materials\u003c/p\u003e\n\u003cp\u003eAt least once a month, the members of the course team brainstormed and dynamically enriched and improved the cases related to virtue and ethics education through faculty activities, so as to build up a continuous library of case materials and keep the teaching content continuously updated.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e2.3 Ethical considerations\u003c/h2\u003e\n\u003cp\u003eThis study was conducted with the approval of the College's Social Research Ethics Committee, and the privacy of the participatory students was adequately protected.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003e2.4 Evaluation indicators\u003c/h2\u003e\n\u003cp\u003e(1) NPVS-R: At the end of the course, the NPVS-R (Table\u0026nbsp;2) was released to all students, which was designed and revised by the American Nurses Association, covering factors in five modules: care, action, trust, professional characteristics, and justice, with 26 entries. And the Cronbach's alpha coefficient of its scale was 0.92 \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, using a five-point Likert scale with the following scores: 1 -- unimportant, 2 -- somewhat important, 3 -- important, 4 -- very important, and 5 -- most important; the total score ranged from 26 to 130, with higher scores indicating a stronger orientation to professional values among the nurses \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e(2) Virtue and ethics scoring in the practical assessment of the course: In the practical assessment at the end of the health assessment course, an objective structured clinical examination (OSCE) model was adopted, which was divided into 3 stations: assessment of health history taking; cardiopulmonary auscultation; and interpretation of common laboratory test results. The first two stations were assessed by instructors as standard patients for students. Five scoring points on virtues and ethics were added to the scoring criteria for these two stations (Table\u0026nbsp;5), with each scoring point given a score of 0\u0026ndash;5 according to the actual situation of each student, totaling 25 scores. The same teachers were assigned as a standard patient at each station to ensure uniformity of scoring.\u003c/p\u003e\n\u003cp\u003e(3) Volunteer service time: Half a year after the course was concluded (the 1st semester of the sophomore year), the durations of the two groups of students going to communities or nursing homes to participate in volunteer services were calculated.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003e2.5 Data analysis\u003c/h2\u003e\n\u003cp\u003eData were analyzed with SPSS 25.0. Continuous variables are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. For the comparison of quantitative indicators between the two groups of students, the independent sample t-test was used; and for the comparison of rates, the chi-square test was adopted. The difference would be considered statistically significant if P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1 General characteristics of participants\u003c/h2\u003e\n \u003cp\u003eThere were no statistical differences between the two groups in terms of mean age, enrollment performance and gender composition (Table 3).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2 NPVS-R scores\u003c/h2\u003e\n \u003cp\u003eA total of 210 copies of the NPVS-R were distributed, all of which were found valid after collected. The innovation group outperformed the control group in total score, with a statistically significant difference between the two groups; in the sub-factor analysis, the innovation group outperformed the control group in factor 1, factor 3, factor 4, and factor 5 modules, with a statistically significant difference between the two groups; and the module scores of the two groups in factor 2 were not statistically different (Table 4). The mean scores and the standard deviations of all items for the two groups are compared in Fig. 1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3 Virtue and ethics scores in the practical assessment\u003c/h2\u003e\n \u003cp\u003eThe innovation group is found scoring significantly higher than the control group in all five virtue and ethics scoring assessment points in the practical assessment of the course; and the differences between the two groups are statistically significant (Table 5).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4 Volunteer service time\u003c/h2\u003e\n \u003cp\u003eWithin six months after the course, the control group registered 11.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.16 hours for the average volunteer service time, while the innovation group did 13.97\u0026thinsp;\u0026plusmn;\u0026thinsp;7.29 hours, so the difference between the two groups is statistically significant (Fig.\u0026nbsp;2).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eAlthough it has become a consensus to introduce medical ethics and other medical humanities courses in medical schools, the conventional virtue and ethics education tends to instill theoretical ideas to students in traditional lecture formats, which in fact are not well accepted by students \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, thus delivering no good teaching effectiveness.\u003c/p\u003e \u003cp\u003eIn order to improve the effectiveness of ethics education, many novel teaching strategies have been proposed in curricula. For example, the use of group sessions is found superior to lecture-based teaching formats \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. In addition, teaching with real-life cases is more likely to make medical students aware of themselves as members of the medical culture, thus encouraging them to monitor their own personal ethical development \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. A survey in Turkey showed that team learning is more effective in long-term knowledge retention than conventional classroom teaching \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. In addition, scenario-based simulations have been implemented in ethics teaching, uniquely helping students apply ethical concepts in a near-realistic environment, rather than simply memorizing definitions of ethical principles from textbooks \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. With the development of new media technologies, screenplays and playwriting have also been deployed in the teaching of medical ethics as a powerful form of reflective learning \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHowever, with predominantly theoretical content, ethics courses are generally less attractive to medical students than clinical specialty courses, leading to a lower-than-expected result in the teaching of virtue and medical ethics. To address this dilemma, this study tries to integrate part of the contents of virtue and ethics into the clinical specialty courses, in addition to the independent medical ethics course, so that students can implicitly receive the knowledge on virtue and ethics while learning professional knowledge. In terms of specific teaching strategies, this study mainly uses the case-based group discussion method. The existing researches have shown that when combined with case scenarios through storytelling, narrative medicine can help enhance students' ethical reasoning \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Given that outdated materials are currently a prominent drawback in the teaching of medical ethics in China \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e, this study has explored the concept of building a dynamic case material repository, which can ensure that the teaching cases and materials are kept up-to-date.\u003c/p\u003e \u003cp\u003eThis study chose health assessment as a vehicle course for the integration of virtue and ethics teaching, because the health assessment course would teach the skills necessary for the first step of nursing practice: assessment and diagnosis \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. The content of this course would cover the entire process of nursing assessment. Using the health assessment curriculum as a vehicle, virtue and ethical themes are integrated into clinical thinking skills training for nursing students, enabling students to better understand scenarios in which virtue and ethical perspectives are applied, thereby substantially shaping student behavior.\u003c/p\u003e \u003cp\u003eThe ultimate goal of medical ethics teaching is to help students and future health care professionals enhance their ethical competencies \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. However, it is a challenge to evaluate the effectiveness of medical ethics education. Traditional course evaluation models often take written examinations, such as multiple-choice questions and essay assignments; yet, such approaches cannot truly reflect whether students' ethical competencies have been improved. It is shown that diverse assessment models will help medical ethics education shift from passive learning to ICAP (Interactive, Constructive, Active, and Passive) learning \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e This study's approach to integrating virtues and ethics into clinical curricula was originally intended to influence students' values and, in turn, boost their behaviors in some way. Therefore, this study has designed three forms to evaluate the effectiveness of this teaching strategy. First, it uses the mature NPVS-R model, as values are an important component of the ethical system in determining moral behaviors \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. In this study, the innovation group outperformed the control group in the other four factors, except for the rating of Factor 2, which shows no obvious differences between the two groups, probably because the five items related to Factor 2 were the least involved in the virtue and ethics teaching designed by this study. Second, teaching medical ethics ultimately involves actions and behaviors \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e; therefore, this study included the evaluation of medical humanistic attitudes in the practical operation assessment when evaluating the effectiveness of virtue and ethics education as a way to examine whether students can truly apply their knowledge on virtue and ethics in real clinical practice. Finally, this study used volunteer service hours as an evaluation index. A study in Singapore showed that one of the intrinsic motivations for nursing students to participate in volunteer services is their desire to make contribution and give help to others \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e; therefore, volunteer service hours could reflect, to some extent, the improvement of nursing students' ethical competence. Virtually, the results of this study demonstrate that the average volunteer service hours of the students in the innovation group were significantly longer than those in the control group. The three aforementioned approaches are able to illustrate the effectiveness of integrative virtue and ethics teaching in terms of cognition, skills and behavior, respectively. Of course, a perfect evaluation methodology should include both formative and summative evaluations \u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e. However, the formative evaluation was missing in the instructional design of this study, so a more effective design shall be taken in the future explorations.\u003c/p\u003e \u003cp\u003eAdditionally, as a new attempt to teach virtues and ethics, this study showcases some other shortcomings. For instance, the general categories of virtues and ethics are broader than those listed in this study, because the former may include moral reasoning, altruism, kindness, honesty and integrity \u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. In this study's integrative instructional design of virtues and ethics, only a portion of the topics of virtues and ethics were selected, mainly based on the characteristics of health assessment as a vehicle course. As an attempt for a new pedagogical strategy, the integration of virtues and ethics into the clinical specialty curricula is only a complement to the teaching of medical ethics, so it cannot shake the pedagogical goals of the main courses on health assessment.\u003c/p\u003e \u003cp\u003eAs indicated by some other studies, ethics education should be integrated with all aspects of medical education in a student-centered approach, so that students can eventually solve practical problems \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. To achieve this goal, a stand-alone course for medical ethics is clearly not sufficient. This study's exploration in integrating virtue and ethics education into clinical specialty curricula proves effective, because it can make each specialty clinical course a vehicle for conducting virtue and ethics teaching; in this way, the position of ethics teaching can be significantly expanded. A systematic integration of teaching design shall be explored according to the characteristics of different courses, so that the goals and contents of virtue and ethics teaching get more complete and the teaching effect is further improved. This will be the next direction of this study.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eNo competing interests to declare.\u003c/p\u003e "},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGille F, Nardo A. A Case for Transformative Learning in Medical Ethics Education[J]. J Med Educ Curric Dev, 2020, 7:2382120520931059. 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Medical ethics education: where are we? Where should we be going? A review[J]. Acad Med, 2005, 80(12):1143-1152. DOI: 10.1097/00001888-200512000-00020.\u003c/li\u003e\n\u003cli\u003eLehmann LS, Kasoff WS, Koch P, et al. A survey of medical ethics education at U.S. and Canadian medical schools[J]. Acad Med, 2004, 79(7):682-689. DOI: 10.1097/00001888-200407000-00015.\u003c/li\u003e\n\u003cli\u003eDuBois JM, Burkemper J. Ethics education in U.S. medical schools: a study of syllabi[J]. Acad Med, 2002, 77(5):432-437. DOI: 10.1097/00001888-200205000-00019.\u003c/li\u003e\n\u003cli\u003eKhatiban M, Falahan SN, Amini R, et al. Lecture-based versus problem-based learning in ethics education among nursing students[J]. Nurs Ethics, 2019, 26(6):1753-1764. DOI: 10.1177/0969733018767246.\u003c/li\u003e\n\u003cli\u003eLee S, Robinson EM, Grace PJ, et al. Developing a moral compass: Themes from the Clinical Ethics Residency for Nurses\u0026apos; final essays[J]. Nurs Ethics, 2020, 27(1):28-39. 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DOI: 10.1136/jme.2005.014597.\u003c/li\u003e\n\u003cli\u003eFeudtner C, Christakis DA. Making the rounds. The ethical development of medical students in the context of clinical rotations[J]. Hastings Cent Rep, 1994, 24(1):6-12. \u003c/li\u003e\n\u003cli\u003eOzgonul L, Alimoglu MK. Comparison of lecture and team-based learning in medical ethics education[J]. Nurs Ethics, 2019, 26(3):903-913. DOI: 10.1177/0969733017731916.\u003c/li\u003e\n\u003cli\u003eOkuda Y, Bryson EO, DeMaria S Jr, et al. The utility of simulation in medical education: what is the evidence?[J]. Mt Sinai J Med, 2009, 76(4):330-343. DOI: 10.1002/msj.20127.\u003c/li\u003e\n\u003cli\u003eRattani A, Kaakour AH. Screenplays and Screenwriting as an Innovative Teaching Tool in Medical Ethics Education[J]. J Med Humanit, 2021, 42(4):679-687. DOI: 10.1007/s10912-019-09584-8.\u003c/li\u003e\n\u003cli\u003eEvans BC, Bendel R. Cognitive and ethical maturity in baccalaureate nursing students: did a class using Narrative Pedagogy make a difference?[J]. Nurs Educ Perspect, 2004, 25(4):188-195. \u003c/li\u003e\n\u003cli\u003eQian Y, Han Q, Yuan W, et al. Insights into medical humanities education in China and the West[J]. J Int Med Res, 2018, 46(9):3507-3517. DOI: 10.1177/0300060518790415.\u003c/li\u003e\n\u003cli\u003eChen SL, Liu CC. Development and evaluation of a physical examination and health assessment course[J]. Nurse Educ Today, 2021, 107:105116. DOI: 10.1016/j.nedt.2021.105116.\u003c/li\u003e\n\u003cli\u003eMartins V, Santos C, Bataglia P, et al. The Teaching of Ethics and the Moral Competence of Medical and Nursing Students[J]. Health Care Anal, 2021, 29(2):113-126. DOI: 10.1007/s10728-020-00401-1.\u003c/li\u003e\n\u003cli\u003eChi M. Translating a Theory of Active Learning: An Attempt to Close the Research-Practice Gap in Education[J]. Top Cogn Sci, 2021, 13(3):441-463. DOI: 10.1111/tops.12539.\u003c/li\u003e\n\u003cli\u003eİlaslan E, Ge\u0026ccedil;kil E, Kol E, et al. Examination of the professional values of the nurses and the associated factors[J]. Perspect Psychiatr Care, 2021, 57(1):56-65. DOI: 10.1111/ppc.12524.\u003c/li\u003e\n\u003cli\u003eLyon W. Virtue and medical ethics education[J]. Philos Ethics Humanit Med, 2021, 16(1):2. DOI: 10.1186/s13010-021-00100-2.\u003c/li\u003e\n\u003cli\u003eSeah B, Ho B, Liaw SY, et al. To Volunteer or Not? Perspectives towards Pre-Registered Nursing Students Volunteering Frontline during COVID-19 Pandemic to Ease Healthcare Workforce: A Qualitative Study[J]. Int J Environ Res Public Health, 2021, 18(12). DOI: 10.3390/ijerph18126668.\u003c/li\u003e\n\u003cli\u003eMcIntosh T, Higgs C, Mumford M, et al. Continuous Evaluation in Ethics Education: A Case Study[J]. Sci Eng Ethics, 2018, 24(2):727-754. DOI: 10.1007/s11948-017-9927-x.\u003c/li\u003e\n\u003cli\u003eDoukas DJ, Ozar DT, Darragh M, et al. Virtue and care ethics \u0026amp; humanism in medical education: a scoping review[J]. BMC Med Educ, 2022, 22(1):131. DOI: 10.1186/s12909-021-03051-6.\u003c/li\u003e\n\u003cli\u003eGoldie J, Schwartz L, Morrison J. A process evaluation of medical ethics education in the first year of a new medical curriculum[J]. Med Educ, 2000, 34(6):468-473. DOI: 10.1046/j.1365-2923.2000.00496.x.\u003c/li\u003e\n\u003cli\u003eGoldie J, Schwartz L, McConnachie A, et al. Impact of a new course on students\u0026apos; potential behaviour on encountering ethical dilemmas[J]. Med Educ, 2001, 35(3):295-302. DOI: 10.1046/j.1365-2923.2001.00872.x.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Key case bearers for ethics and virtue education, together with associated knowledge points\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003eVirtues and Ethical Themes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eCase carriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eCourse-associated Knowledge Points\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e1. Professional duties\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(1) Respect for patients and families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eBeth Israel Deaconess Medical Center in Boston has set up a web portal for its ICU, so that patients\u0026apos; families can upload some photos and details of the patients\u0026apos; lives before they became ill, purposed to help doctors understand their patients better\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eAssessment of social health history\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(2) Objective comments on colleagues or peers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eWhen treating a patient with Type-II diabetes who had been adopted insulin, a registered Chinese-medicine practitioner in Sydney instructed the patient to stop taking Western medicine but take only the Chinese medicine he prescribed. Eventually, the patient died of deteriorated conditions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eClinical significance of blood glucose\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(3) Collaboration with colleagues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA team of orthopaedic surgeons in Shanghai was able to deliver more than a dozen arthroscopic surgeries each working day, because it improved its efficiency through collaboration between operating-room nurses, anesthesiologists, and medical and ward nurses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eNursing diagnosis (collaborative questions)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(4) Respect for different cultures and religious beliefs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA study published in \u003cem\u003eNature\u003c/em\u003e by a team from Harvard University in 2021 demonstrated successful treatment of sepsis (septicemia) by electro-acupuncture stimulation of the San Li points on animals\u0026apos; feet.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eClinical significance of blood counts\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"81.51408450704226%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2. Communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.485915492957748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(1) Full communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eDr. Walter Baile of M.D. Anderson Hospital in Texas, USA, proposed the SPIKES model for effective doctor-patient communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eTaking health history into consideration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(2) Privacy protection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eThree Boston hospitals were fined a total of $999,000 for inviting a film crew to shoot a medical documentary without patients\u0026apos; consent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eAnalysis of health information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(3) Listening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA Guangdong hospital set up a life and health narrative sharing center and used narrative regulation to help a silicosis patient improve his quality of life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eLung X-rays\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"81.51408450704226%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e3. Professionalism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.485915492957748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(1) Meticulousness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eLax lens disinfection in a hospital in Anhui Province caused post-operative infection with ten cataract surgery patients, nine of whom had their eyes removed finally.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eEye evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(2) Meticulous work attitudes towards patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA doctor in Shanghai meticulously analyzed a patient\u0026apos;s condition and eventually confirmed aortic valve bilobar malformation through CT examination, avoiding misdiagnosis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eCT examination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(3) Kindness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA study in Massachusetts found that patients who were treated kindly and encouraged by anesthesiologists would recovered faster and be discharged from hospital 2.7 days earlier than other patients on average.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral condition assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(4) Not giving up easily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eColorectal and anal surgeons at a hospital in Guangzhou successfully resuscitated a patient in cardiac arrest by insisting on CPR for 2 hours.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eElectrocardiogram (ventricular fibrillation heart rate)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(5) Truthfulness and pragmatism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eJohn Snow\u0026apos;s fieldwork to determine how cholera spreads disproved a common belief that it was caused by the \u0026quot;miasma\u0026quot; that permeated the city of London.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eExamination of stool\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"81.51408450704226%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e4. Personal development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.485915492957748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(1) Self-control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eThe importance of emotional control was illustrated through a parable about a donkey that fell into a dry well.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003ePsychological Assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(2) Humility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA case of ankylosing spondylitis misdiagnosis occurred due to a rheumatologist casually questioning an orthopedic surgeon\u0026apos;s diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eSpinal assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(3) Prudence and independence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA nurse forgot to loosen a tourniquet after an infusion, causing ischemic necrosis of the patient\u0026apos;s arm.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eVascular assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"81.51408450704226%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e5. Decisions about treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.485915492957748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(1) Reconciliation of the doctor-patient cognitive gap\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eDifferences in perceptions of tracheotomy between doctors and patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eInspiratory dyspnea\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(2) Right to informed consent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA U.S. state first adopted the Natural Death Act, the first law in the world to legalize living wills.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eCachexia assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(3) Empathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eIn a mitral valve surgery, a Harvard girl\u0026apos;s father chose his hospital first for empathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eCardiac evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"81.51408450704226%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e6. Justice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.485915492957748%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(1) Avoiding overmedication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026quot;Choosing Wisely\u0026quot; campaign encouraged doctors and patients to abandon overmedication habits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eHead and face assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(2) Honesty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA cardiologist made academic fraud on cardiac stem cells\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eCardiac assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.604569420035148%\" valign=\"top\"\u003e\n \u003cp\u003e(3) Integrity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"56.94200351493849%\" valign=\"top\"\u003e\n \u003cp\u003eA doctor defrauded insurance companies on premiums by helping uremic patients who were living in hardship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.45342706502636%\" valign=\"top\"\u003e\n \u003cp\u003eRenal function tests\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Nurses\u0026apos; Professional Values Scale - Revised (NPVS-R)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"574\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.99651567944251%\" valign=\"top\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.00348432055749%\" valign=\"top\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.99651567944251%\" valign=\"top\"\u003e\n \u003cp\u003e1.\u0026nbsp;Caring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.00348432055749%\" valign=\"top\"\u003e\n \u003cp\u003e16. Uphold the moral dignity and legal rights of patients\u003c/p\u003e\n \u003cp\u003e17. Refuse to participate in care that is contrary to the ethical requirements of one\u0026apos;s professional values\u003c/p\u003e\n \u003cp\u003e18. Be a patient advocate and take on the role of being a patient advocate\u003c/p\u003e\n \u003cp\u003e20. Provide equal/unbiased care to patients with different lifestyles\u003c/p\u003e\n \u003cp\u003e21. Maintain the patients\u0026apos; right to privacy\u003c/p\u003e\n \u003cp\u003e22. Follow the nursing practice in which nurses make conscious judgments about the correctness of medical advice\u003c/p\u003e\n \u003cp\u003e23. Practice nursing according to the principles of fidelity and respect for persons\u003c/p\u003e\n \u003cp\u003e24. Protect the rights of patients who participate in nursing research\u003c/p\u003e\n \u003cp\u003e25. Maintain the trust of patients and families in health care professionals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.99651567944251%\" valign=\"top\"\u003e\n \u003cp\u003e2.\u0026nbsp;Activism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.00348432055749%\" valign=\"top\"\u003e\n \u003cp\u003e4. Participate in public decision-making to improve the allocation of public health resources\u003c/p\u003e\n \u003cp\u003e10. Actively participate in health-related activities to promote the nursing profession or specialty\u003c/p\u003e\n \u003cp\u003e11. Recognize the role of nursing professional organizations in the development of health care policies\u003c/p\u003e\n \u003cp\u003e19. Participate in nursing research and apply the findings to appropriate nursing practice\u003c/p\u003e\n \u003cp\u003e26. Participate in the scholarly activities of nursing professional organizations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.99651567944251%\" valign=\"top\"\u003e\n \u003cp\u003e3.\u0026nbsp;Trust\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.00348432055749%\" valign=\"top\"\u003e\n \u003cp\u003e1. Conduct frequent self-evaluations\u003c/p\u003e\n \u003cp\u003e2. Actively request consultation or collaboration when patients\u0026apos; needs cannot be met\u003c/p\u003e\n \u003cp\u003e9. Seek alternative educational pathways or continually learn to update knowledge or skills\u003c/p\u003e\n \u003cp\u003e14. Assume responsibilities and accountabilities in nursing practice\u003c/p\u003e\n \u003cp\u003e15. Maintain competence in the practical and clinical work of the profession involved\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.99651567944251%\" valign=\"top\"\u003e\n \u003cp\u003e4.\u0026nbsp;Professionalism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.00348432055749%\" valign=\"top\"\u003e\n \u003cp\u003e5. Participate in evaluation activities among colleagues\u003c/p\u003e\n \u003cp\u003e6. Develop codes of practice for each nursing job\u003c/p\u003e\n \u003cp\u003e7. Establish and meet teaching objectives for nursing teaching\u003c/p\u003e\n \u003cp\u003e8. Actively take effective measures to improve the environment for nursing practice\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.99651567944251%\" valign=\"top\"\u003e\n \u003cp\u003e5.\u0026nbsp;Justice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"77.00348432055749%\" valign=\"top\"\u003e\n \u003cp\u003e3. Maintain the health and safety of the public\u003c/p\u003e\n \u003cp\u003e12. Provide equitable health care services for the public\u003c/p\u003e\n \u003cp\u003e13. Perform nursing duties to meet the health needs of culturally diverse populations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Parameters of general characteristics of students in both groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"555\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.71480144404332%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003eInnovation group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.870036101083034%\"\u003e\n \u003cp\u003eStatistical value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.815884476534295%\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.71480144404332%\"\u003e\n \u003cp\u003eNumber of cases (person)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.870036101083034%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815884476534295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.71480144404332%\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e19.48\u0026plusmn;0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e19.52\u0026plusmn;0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.870036101083034%\"\u003e\n \u003cp\u003e-0.542\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.815884476534295%\"\u003e\n \u003cp\u003e0.598\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.71480144404332%\"\u003e\n \u003cp\u003eEnrollment score (points)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e469.10\u0026plusmn;30.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e469.81\u0026plusmn;31.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.870036101083034%\"\u003e\n \u003cp\u003e-0.168\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.815884476534295%\"\u003e\n \u003cp\u003e0.867\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.71480144404332%\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"17.870036101083034%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.815884476534295%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"26.71480144404332%\"\u003e\n \u003cp\u003eMale (person)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.299638989169676%\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.870036101083034%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.058\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.815884476534295%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.541666666666664%\"\u003e\n \u003cp\u003eFemale (person)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.729166666666668%\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.729166666666668%\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Mean scores on the NPVS-R in both groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"568\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.1195079086116%\"\u003e\n \u003cp\u003e Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.362038664323375%\"\u003e\n \u003cp\u003eControl group\u003cbr\u003e\u0026nbsp;n=105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.61687170474517%\"\u003e\n \u003cp\u003eInnovation group\u003cbr\u003e\u0026nbsp;n=105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.599297012302285%\"\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.302284710017574%\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.1195079086116%\" valign=\"top\"\u003e\n \u003cp\u003eFactor 1 Caring\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.362038664323375%\"\u003e\n \u003cp\u003e36.20\u0026plusmn;6.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.61687170474517%\"\u003e\n \u003cp\u003e39.16\u0026plusmn;5.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.599297012302285%\"\u003e\n \u003cp\u003e-3.710\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.302284710017574%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.1195079086116%\" valign=\"top\"\u003e\n \u003cp\u003eFactor 2 Activism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.362038664323375%\"\u003e\n \u003cp\u003e20.48\u0026plusmn;3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.61687170474517%\"\u003e\n \u003cp\u003e21.22\u0026plusmn;3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.599297012302285%\"\u003e\n \u003cp\u003e-1.610\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.302284710017574%\"\u003e\n \u003cp\u003e0.109\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.1195079086116%\" valign=\"top\"\u003e\n \u003cp\u003eFactor 3 Trust\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.362038664323375%\"\u003e\n \u003cp\u003e19.64\u0026plusmn;3.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.61687170474517%\"\u003e\n \u003cp\u003e21.30\u0026plusmn;3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.599297012302285%\"\u003e\n \u003cp\u003e-3.520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.302284710017574%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.1195079086116%\" valign=\"top\"\u003e\n \u003cp\u003eFactor 4 Professionalism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.362038664323375%\"\u003e\n \u003cp\u003e15.35\u0026plusmn;2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.61687170474517%\"\u003e\n \u003cp\u003e16.66\u0026plusmn;2.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.599297012302285%\"\u003e\n \u003cp\u003e-3.220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.302284710017574%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.1195079086116%\"\u003e\n \u003cp\u003eFactor 5 Justice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.362038664323375%\"\u003e\n \u003cp\u003e11.88\u0026plusmn;2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.61687170474517%\"\u003e\n \u003cp\u003e12.86\u0026plusmn;1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.599297012302285%\"\u003e\n \u003cp\u003e-3.520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.302284710017574%\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.1195079086116%\"\u003e\n \u003cp\u003eTotal score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.362038664323375%\"\u003e\n \u003cp\u003e103.54\u0026plusmn;17.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.61687170474517%\"\u003e\n \u003cp\u003e111.19\u0026plusmn;16.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.599297012302285%\"\u003e\n \u003cp\u003e-3.210\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.302284710017574%\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Virtue and ethics scores in the practical assessment in both groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"564\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.93617021276596%\"\u003e\n \u003cp\u003eScoring points\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\"\u003e\n \u003cp\u003eControl group\u003cbr\u003e\u0026nbsp;n=105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.31205673758865%\"\u003e\n \u003cp\u003eInnovation group\u003cbr\u003e\u0026nbsp;n=105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.106382978723405%\"\u003e\n \u003cp\u003et-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.93617021276596%\" valign=\"top\"\u003e\n \u003cp\u003e1. Provide comfort when patients tell about their misfortune\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\"\u003e\n \u003cp\u003e3.10\u0026plusmn;0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.31205673758865%\"\u003e\n \u003cp\u003e3.66\u0026plusmn;0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.106382978723405%\"\u003e\n \u003cp\u003e-7.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.93617021276596%\" valign=\"top\"\u003e\n \u003cp\u003e2. Listen attentively to patients when they describe their medical history, instead of interrupting them frequently\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\"\u003e\n \u003cp\u003e2.91\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.31205673758865%\"\u003e\n \u003cp\u003e3.50\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.106382978723405%\"\u003e\n \u003cp\u003e-9.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.93617021276596%\" valign=\"top\"\u003e\n \u003cp\u003e3. Introduce yourself to patients before starting the examination, so as to obtain patients\u0026apos; cooperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\"\u003e\n \u003cp\u003e3.52\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.31205673758865%\"\u003e\n \u003cp\u003e3.91\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.106382978723405%\"\u003e\n \u003cp\u003e-5.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.93617021276596%\" valign=\"top\"\u003e\n \u003cp\u003e4. Close the bed curtains before examination, so as to protect patients\u0026apos; privacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\"\u003e\n \u003cp\u003e1.99\u0026plusmn;0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.31205673758865%\"\u003e\n \u003cp\u003e3.68\u0026plusmn;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.106382978723405%\"\u003e\n \u003cp\u003e-25.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.93617021276596%\" valign=\"top\"\u003e\n \u003cp\u003e5. Warm the stethoscope before examining.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\"\u003e\n \u003cp\u003e1.95\u0026plusmn;0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.31205673758865%\"\u003e\n \u003cp\u003e3.27\u0026plusmn;0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.106382978723405%\"\u003e\n \u003cp\u003e-24.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"48.93617021276596%\"\u003e\n \u003cp\u003eTotal Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.070921985815604%\"\u003e\n \u003cp\u003e13.49\u0026plusmn;0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.31205673758865%\"\u003e\n \u003cp\u003e18.02\u0026plusmn;1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.106382978723405%\"\u003e\n \u003cp\u003e-29.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.574468085106384%\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Zhejiang Industry Polytechnic College","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"medical education, virtue, ethics education, nursing students, health assessment","lastPublishedDoi":"10.21203/rs.3.rs-3384740/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3384740/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo integrate virtue and ethics education into a health assessment course for nursing students, and to investigate the effects of such education on the students' perceptions and behaviors related to medical ethics.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFreshmen nursing students in a Chinese college were randomly divided into two groups, each including 105 students. In the health assessment course, the control group was given regular teaching contents according to the teaching standards, while the innovation group was given the teaching content required by the teaching standards, with the virtue and ethics education integrated into the corresponding knowledge points in the teaching design.The two groups' following performances were compared: the scores of the Nurses' Professional Values Scale - Revised (NPVS-R), the scores of virtue and ethics in the practice assessment, and the average volunteer service time.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe innovation group scored higher than the control group in terms of the total score, Factor 1, Factor 3, Factor 4, and Factor 5 modules of the NPVS-R (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); no significant difference was found between the two groups in terms of the module score of Factor 2 (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05); and the scores of virtue and ethics in the practical assessment and the average volunteer service hours of the innovation group were significantly higher than those of the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIntegrating virtue and ethics education into the teaching of the health assessment course is a useful supplement to medical ethics education, and it can influence students positively in cognition, skills and behavior for virtue and ethics.\u003c/p\u003e","manuscriptTitle":"To integrate virtue and ethics education into a health assessment curriculum for nursing students: A controlled study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-01 05:52:40","doi":"10.21203/rs.3.rs-3384740/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2c9f3e54-f301-422b-beb4-60e3182d4b54","owner":[],"postedDate":"January 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":27864748,"name":"Educational Philosophy and Theory"},{"id":27864749,"name":"Nursing"},{"id":27864750,"name":"Medical Ethics"}],"tags":[],"updatedAt":"2024-01-01T05:52:40+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-01 05:52:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3384740","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3384740","identity":"rs-3384740","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}