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Online Journal of Health Ethics

Volume 8 | Issue 1 Article 4

Ethical Decision Making in Online Graduate Nursing Education and Implications for Professional Practice Anita Davis Boykins DNSc, FNP-BC, PMHNP-BC The University of Southern Mississippi, anita.boykins@usm.edu

Melanie Gilmore PhD, FNP-BC The University of Southern Mississippi, Melanie.Gilmore@usm.edu

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Recommended Citation Boykins, A. D., & Gilmore, M. (2012). Ethical Decision Making in Online Graduate Nursing Education and Implications for Professional Practice. Online Journal of Health Ethics, 8(1). http://dx.doi.org/10.18785/ojhe.0801.04

ETHICAL DECISION MAKING IN ONLINE GRADUATE NURSING EDUCATION 1

Online Journal of Health Ethics Vol 8, No 1, April 2012

Ethical Decision Making in Online Graduate Nursing Education and Implications for Professional Practice

Anita Davis Boykins, DNSc, FNP-BC, PMHNP-BC Assistant Professor

Melanie Gilmore, PhD, FNP-BC

Assistant Professor & Coordinator for Master’s Programs

School of Nursing The University of Southern Mississippi

Any correspondence concerning this article should be addressed to Dr. Anita Boykins or Dr. Melanie Gilmore, School of Nursing, The University of Southern Mississippi, 118 College Drive #5095, Hattiesburg, MS 39406. Email: Anita.Boykins@usm.edu or Melanie.Gilmore@usm.edu

Abstract

Academic dishonesty is an issue in academic institutions, which is escalating due to digital cheating. Cheating in online courses is a challenge in health science disciplines where high ethical standards are expected in professional practice. Unethical behaviors may begin in the academic career and persist into the professional career. The purposes of this article are to examine academic dishonesty within the online learning environment, transference of unethical behavior into professional practice, and strategies to reduce academic dishonesty in online graduate nursing education. In order to maintain high academic and professional standards, the individual must feel a moral obligation to engage in ethical behaviors in academia using online instructional technologies and in professional practice. Educators that teach in online courses are obligated to develop pedagogical and instructional designs that discourage dishonesty and encourage ethical decision making in the academic and professional setting. This article provides a glimpse of online cheating in academia and its implications for graduate nursing education and professional practice. KEYWORDS: online learning; ethical decision making; professional practice; nursing; academic dishonesty

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Ethical Decision Making in Online Graduate Nursing Education and Implications

for Professional Practice

In most institutions of higher education, distance education through courses on the

internet has become a common method of class delivery (Means, Toyama, Murphy, Bakia, &

Jones, 2009). Modern students are acclimated to digital technology for communication and

educational methods. Online courses, electronic learning, distance learning, or distance education

are terms that have been used to describe courses that are delivered electronically. Distance

education technology provides students in colleges and universities with greater flexibility, less

travel and the opportunity to obtain an education regardless of geographic limitations (Means, et

al., 2009). Perhaps one of the greatest challenges and concerns with distance education is

academic integrity. Academic dishonesty or cheating has always been an issue in academic

institutions, but it is perceived that digital cheating is escalating (Kasprzak & Nixon, 2004).

Cheating in online courses is an increasing concern in professions such as nursing and other

health science disciplines where high ethical standards are expected in their professional career

(Clark & Carnosso, 2008). Consequently, it is the opinion of the authors that unethical behavior

may begin in a students’ academic career and persist into the professional career.

The authors teach in a fully online graduate program that provides education for nurse

practitioner (NP) students. The NP students will function in the role of primary care providers in

health care settings after graduation. Because of the nature of the professional education, we are

interested in students’ normative behaviors related to cheating in an online learning environment.

The literature is replete with research about academic integrity and academic dishonesty. Studies

have consistently shown that a significant number of college students cheat (Jordon, 2001;

Stephens, Young, & Calabrese, 2007). Limited empirical research about online cheating in

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professional graduate education has been conducted. For this reason, we conducted a review of

the literature to determine the need for a survey of graduate nursing students’ perceptions about

academic integrity in the online environment. It is our considered opinion that students may

translate academic integrity into professional practice.

Nurse educators and nurses in professional practice define cheating in the academic and

clinical practice environment as incivil behavior. Incivility in nursing from the academic setting

to the practice setting has been identified as an area of concern for the nursing profession

(Luparell, 2011). An examination of the role that perception plays in creating a civil

environment, student’s attitudes regarding online cheating, and the extent to which incivility

(cheating) in nursing education may be linked to incivility in the practice setting has been

recommended (Clark & Carnosso, 2008; Mastin, Peszka, & Lilly, 2009). The purpose of this

article is to examine academic dishonesty within the online learning environment and the ethical

consequences of academic dishonesty translating to dishonesty in the professional practice of

registered nurses in a graduate nurse practitioner program.

Online Learning for Graduate NP Students

Primary health care has been defined as care that is person-centered, comprehensive,

integrated, and continuous with a regular and trusted provider as the entry point into the health

care system (World Health Organization [WHO], 2008). Nurse practitioners provide primary

health care. Their professional role as primary care providers includes direct care of individuals

and families in primary care settings. Nurse practitioner educators have traditionally taught in

face-to-face, traditional, or conventional delivery methods. Innovative instructional technologies

that use online technology are now being used to teach nurse practitioner students in graduate

nursing schools. Delivery methods for the online learning environments include web-based and

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web-enhanced or hybrid courses with synchronous or asynchronous learning. Different course

management systems and web-based instructional platforms are used to deliver the courses

online. Student-centered, self-directed, collaborative, and cooperative learning and the use of

interactive technology is now the focus of the student’s learning environment as opposed to the

traditional face to face, on campus instruction. The instructional design and delivery of the new

instructional modalities promotes increased student-faculty interaction. Teaching strategies

include online discussions, written assignments, and assessment and evaluation. Electronic

methods of assessment and evaluation may include tests or quizzes that range from multiple

choice exams to essay and case study exams. As is expected, academic grades play an important

factor in students’ success. Within the online learning environment, students have more

opportunities to indulge in behaviors of academic dishonesty in order to achieve high academic

grades than in the traditional classroom monitored environment. It can be conjectured that the

same behaviors may be transmitted into clinical practice. Graduate nurse practitioner students’

behaviors related to decision making and cheating using distance instructional technology has

not been reported extensively. Hence, the purpose of this article is to examine current literature

related to academic dishonesty, instructional technology, moral obligation and cheating, and

ethical behavior in graduate nursing and its potential ethical consequences in the realm of

professional practice.

Academic Dishonesty and Instructional Technology

Although technology influences modern communication and education, electronic device

technologies including cell phones, personal digital assistants (PDA), computers, and the internet

facilitate the problem of cheating in the academic setting. Students connect with each other via

email, text, chat rooms, and online social networking sites. In the 21st century, it is common for

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students to develop their own social communities via the internet. Students have greater access

and ability to defraud or deceive others using instructional technology (Kasprzak & Nixon, 2004;

Lanier, 2006; Rowe, 2004).

Academic dishonesty is defined as not doing one’s own work and submitting for credit.

These dishonest and unethical behaviors may range from cheating on a test which is not

proctored digitally, intentional and non-intentional plagiarism, copying another students’ work,

and having someone else complete the work and submit digitally. The internet provides a vast

amount of information with ease of access and the ability for student’s to cut and paste others’

work and submit as their own. The digital environment has increased the ease of text plagiarism

using the internet, which in turn increases the temptation to cheat among students (Rowe, 2004).

According to The Center for Academic Integrity (2005) (as cited in Ma, Wan, and Lu, 2008)

digital cheating and plagiarism are increasing among undergraduate college students, with 70%

of the students surveyed admitted to some cheating. Another study of undergraduate students

taking online courses found that 14.1% of psychology students cheated (Mastin et al., 2009).

Lanier (2006) found that cheating in online courses surpasses that in face to face classes and 36%

of the students reported that they had assisted someone with an online examination. This

information that is based on self-report of students suggests a whole new culture of academic

intergrity that has ensued because of the ease of access to digital media and information and

students’ behaviors related to cheating.

Moral Obligation and Cheating

Ethics is about what people should do. Ethical decision making is reflected in the German

philosopher, Immanuel Kant’s deontological theory of obligation. This theory compels one to

avoid certain circumstances such as cheating without exception. Actions such as cheating are

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always immoral regardless of good intentions, extenuating circumstances or good circumstances

coming from the actions. Actions in the deontological theory are considered morally correct or

incorrect according to ethical principles and rules of conduct. Applying the ethical principles of

autonomy, beneficence, nonmaleficence, and judgment as well as following the rules of veracity,

confidentiality and fidelity are core competencies for nursing practice. With respect to cheating

by graduate nursing students, it seems evident that students entering a profession would have a

moral obligation to refrain from dishonesty. However, when grades and passing or failing a

class are at stake, this sense of moral obligation can be deactivated or neutralized through various

methods (Devettere, 2000).

According to Beck and Ajzen (1991), feeling a moral obligation to refrain from cheating

may determine the degree of cheating because a sense of obligation can be deactivated or

neutralized through various techniques such as minimizing consequences, displacing

responsibility and diffusing responsibility (“everyone else was doing it”). Also, in the Theory of

Planned Behavior, prior and future behavior will not change with time if the underlying

determinants remain the same. Determinants of future behaviors include attitude, subjective

norms, and perceptions of behavioral control. Actions are guided by the individual’s attitude

toward the behavior, perceived social norms, and perceptions on whether it is easy or difficult to

perform the behavior. Behavioral, normative, and control beliefs lead to intentions and intentions

predict behavior. In other words, the behavior is a result of the intention (Ajzen, 1991).

In a study that examined students’ beliefs, moral judgments, and peer perceptions related

to cheating, 45.6% of undergraduate students surveyed self-reported cheating behaviors with a

low sense of moral responsibility to refrain from cheating and a tendency to neutralize the

responsibility not to cheat (Stephens et al., 2007). In essence, students become desensitized to the

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moral obligation to maintain academic integrity. The research suggests that attitudes and student

beliefs concerning academic dishonesty are closely related ( (Bernardi, 2004). One study found

that gender, religiousness, and type of degree, business major, and age significantly impacted

students’ intention to engage in unethical behaviors (Devonish, Alleyne, Cadogan-McClean, &

Greenridge, 2009). In another study, a connection between decision making in academic

dishonesty and professional practice dishonesty was found among undergraduate engineering

students (Harding, Carpenter, Finelli, & Passow, 2004). Jordon (2001) identified a significant

correlation between college students’ perceived social norms and their self-reported cheating.

The idea that these unethical behaviors in academic integrity could extend into professional

practice is of consequence and grave concern. More importantly, the knowledge of ethics and the

application of ethical behaviors in education and professional practice is a concern for future

nurse practitioner primary care providers.

Ethical Behavior in Professional Nursing Practice

In the nursing profession, several professional organizations have identified core

competencies regarding ethical conduct. The American Nurses Association (ANA, 2010) has a

professional code of ethics. Provisions in the code of ethics for nurses address acceptance of

accountability and responsibility for nursing judgment and action and most importantly, duties to

self. Duties to self are moral self-respect, professional growth and maintenance of competence

and wholeness of character. Graduate nursing and nurse practitioner education professional

organizations outline essentials for masters education in nursing and ethical competencies for

nurse practitioners, respectively (American Association of Colleges of Nursing [AACN], 2011;

National Organization for Nurse Practitioner Faculty [NONPF], 2011). Ethical conduct related to

nursing practice and informatics and healthcare technologies are addressed in the ethical

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competencies for nurse practitioners and masters’ essentials for nursing education. The

competency and essential are: application of ethical analysis and clinical reasoning to assess,

intervene, and evaluate advanced nursing care delivery; and promote policies that incorporate

ethical principles and standards for use of health and information technology (AACN, 2011).

Other key ethical concepts identified are self-mastery, social justice, professionalism, human

dignity, altruism, autonomy and integrity. Integrity has been defined as acting within a code of

ethics and acceptable standards of practice. Integrity is reflected in professional practice when

the nurse is honest and provides care based on the code of ethics of the profession (ANA, 2008).

The nurse practitioner ethical competencies include ethical principles in decision making; ethical

consequences of decisions; and ethically sound solutions to complex issues related to

individuals, populations, and systems of care (NONPF, 2011).

Strategies to Reduce Academic Dishonesty in an Online Learning Environment

There are many forms of cheating that can be used by students when using instructional

technology and online computer-based testing. Solutions to address academic dishonesty in

online higher education classes have been proposed by nursing and other professional

disciplines. Implementing policies on student academic conduct, reviewing the university

honesty code, informing students of what is considered acceptable and unacceptable ethical

behavior in online learning environment, informing students of consequences of actions and

penalties for cheating, and providing a link to honor code documents in courses are some

strategies that have been recommended (Brown, Weible, & Olmosk, 2010; Chiesel, 2007;

Koecheritz, Malkiewicz & Henderson, 2002; Lanier, 2006). In one study (Mastin, et al., 2009),

students had a higher rate of cheating if they were not provided an honesty pledge. In another

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study with an advanced practice nursing course, students had to read and sign the honor code

before each online exam (Caudle, Bigness, Daniels, Gillmor-Kahn, & Knestrick, 2011).

Assessment and evaluation solutions that have been proposed by faculty that teach in

online courses include: designing exams to reduce cheating such as providing proctored exams

with logins and passwords; changing the process by which exams are administered (short time

frame to take the exam, show one question at a time, no backtracking, randomize the questions,

large number of exams during the semester, low points for each exam); using a variety of course

evaluation methods; using cameras during testing, proctoring and biometrics (fingerprinting,

face, handwriting, voice recognition and iris scans); and providing supervised testing in regional

academic institutions for testing and open book exams with time limitations (Chiesel, 2007;

Kasprzak & Nixon, 2004; Lanier, 2006; Sileo & Sileo, 2008). The university where the authors

teach has a policy that addresses academic dishonesty and integrity as well as ethical and

responsible behavior. Ensuring high academic standards and maintaining a culture of academic

integrity is reflected in the university’s Academic Code of Conduct which is written in the

Student Handbook of the university and academic unit and is referred to in course syllabi. The

university has also recently initiated mechanisms to report unethical conduct and other violations

of university policies.

Research on ways to reduce academic dishonesty in online courses offers some solutions.

Minton and Willett’s (2003) study revealed that exams administered without a proctor was

preferred over proctored exams by the majority of distance education students due to flexibility

and less interaction with the instructor. Malgwi and Rakovski (2009) identified determinants

and measures to prevent academic fraud. Most effective strategies identified by students at the

university were stronger penalties, anonymous tip line, and a uniform penalty policy

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administered by all faculty in all departments. They concluded that in order to maintain an

ethical academic environment, students and faculty have a shared responsibility (Malgwi &

Rakovski, 2009). Least effective strategies reported by the students were honor codes and an

ethics course. However, business students in a different study reported higher intentions to

behave ethically if they had a higher number of courses in their curriculum containing ethics

(Devonish et al., 2009).

An ethics course requirement has also been identified as a solution to the problem of

academic dishonesty by educators (Brown et al., 2010; Devonish et al., 2009). Moreover, it has

been suggested that institutions of higher learning need to do more to help students understand

and appreciate core moral values in order to encourage academic integrity (Stephens, et al.,

2007). An ethics course is a curriculum course requirement for the NP students at the university

where we teach. The course looks at analysis and decision making to clarify or resolve an ethical

situation in professional practice.

Ethical Decision Making in Nursing Education and Professional Practice

In a recent study that examined nursing education nationally, a key finding was that in the

process of teaching and learning in clinical situations, nurse educators and nursing students

reported that they focused on everyday ethical comportment, on becoming good practitioners,

and on continuously improving their practice with the patient in mind (The Carnegie Foundation

for the Advancement of Teaching, 2010). The study also recommended that nursing programs

change their focus from critical thinking to an emphasis on clinical reasoning and multiple ways

of thinking. Key policy changes recommended as it relates to the student experience is to

redesign the ethics curricula so that the focus is on the everyday ethical comportment. Narratives

such as debriefing and reflecting on practice are strategies recommended.

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Clinical reasoning is thinking through the various aspects of patient care to arrive at a

reasonable decision regarding the management of a clinical problem in a specific patient

(Hawkins, Elder, & Paul, 2010). Clinical decision making has to be reasonable and ethical

principles can be used in clinical decision making to help guide ethical reasoning. Ethical

principles that are translated from academia to clinical practice are autonomy, beneficence,

nonmaleficence, and judgment as well as following the rules of veracity, confidentiality and

fidelity (Lachman, 2009a; 2009b). Graduate nurse practitioner students are independent

providers who have to make their own decisions about the management of a patient’s health.

They also have to provide quality and safe care that is based on a standard of care and best

practices that are evidence-based. More importantly, each patient has to be treated fairly and with

dignity and respect. A key aspect in the nurse-patient relationship is establishing trust. Although

telling the truth and keeping promises are essential ethical rules of conduct, respecting privileged

information regarding patients is extremely important in today’s complex health care

environment.

It has also been recommended that health informatics be a part of the core nursing

curriculum and information technology integrated throughout the nursing program (Kenny,

2002). Furthermore, nursing practice should incorporate ethical principles related to the use of

healthcare and information technologies (AACN, 2011). Competency in the ethical use of

instructional and healthcare technology is important for the graduate nurse in the academic and

practice setting. Basic computer competencies, information literacy, and information

management are clinical information competencies for nurses (Technology Informatics Guiding

Educational Reform [TIGER], 2009). One of the domains of information literacy is that the nurse

should evaluate information and its sources critically and incorporate selected information into

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his or her knowledge base and value system. In the competency, information management, one

standard related to electronic health records is due care which states that the nurse will assure

confidentiality of protected health information and assure access control and the security of

health information systems under his or her control.

Professionalism and integrity are ethical concepts that are taught in the graduate nurse

practitioner educational training and applied in professional practice. Integrity, competence and

professional and personal values reflect a wholeness of the nurse’s character (ANA, 2010:

Lachman, 2009b). Unethical behavior may be demonstrated and have legal implications in

professional practice through the actions of falsifying records, breach of confidentiality, and

failure to warn, protect, and honor individual rights. The nursing profession’s code of conduct

states that nurses should be accountable for their personal actions (ANA, 2010, Lachman,

2009a). In the nurse practitioner’s professional practice, competency is vital and the NP should

be able to recognize when to seek consultation or refer a client when the management of care is

outside his/her competency area or scope of practice. The NP also has moral duties to self as well

as to the patients that she provides primary care.

The literature suggests that educators should adhere to the academic code of conduct or

honesty pledge and enforce penalties for violating the code of conduct equally for all students in

order to reduce cheating in online courses. Conversely, it is sometimes difficult for educators that

teach in online courses to change instructional methods to decrease cheating. It is the authors’

opinion that focusing on ethical dilemmas which students encounter in their professional practice

is a teaching strategy that may be used for nurse educators to reduce academic dishonesty among

registered nurses in a nurse practitioner graduate program. Hopefully, gaining knowledge on the

ethical consequences of decisions regarding cheating and the ethical principles in decision

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making will translate to clinical practice. In clinical practice, integrity is demonstrated when the

nurse provides care based on a code of ethics; however, ethical behavior requires clinical and

ethical reasoning. Reflecting on ethical and unethical behaviors in clinical practice is especially

important for nurse practitioners who are responsible for the majority of the health care that they

provide to patients in primary care settings. Graduate NP students are expected to apply clinical

reasoning in practice and promote policies that include ethical principles. Decision making

regarding ethical dilemmas should be based not only ethical principles but also ethical reasoning.

In summary, an academic code of conduct guides the graduate nursing student’s actions as it

relates to cheating and a professional code of conduct guides the nurse’s practice as it relates to

unethical behavior. In order to maintain high academic and professional standards, decisions

about unethical behavior in academia using distance education technologies and decision making

in professional practice rests with the individual. The nurse has to be accountable and

responsible for his or her own actions.

Conclusion

The authors’ thesis is with the explosion of digital technology and the internet, along with

high expectations for success in graduate programs, students must maintain the moral obligations

and ethical behaviors of trustworthiness and honesty in the academic setting or jeopardize the

moral obligation of trustworthiness and honesty in professional practice. Pedagogical standards

in healthcare academia must continue to offer courses in ethics that includes information literacy,

business ethics, and relational ethics. It is incumbent among academic faculty teaching in online

programs to develop pedagogical and instructional designs that discourage dishonesty and

encourage ethical decision making in both the academic setting and the professional practice

setting.

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Please note that the opinions expressed by the authors represent those of the authors and do not reflect the opinions of the Online Journal of Health Ethics’ editorial staff, editors or reviewers. Funder’s Disclaimer Funding for this project was made possible (in part) by D11HP14611 from the Health Resources and Services Administration (HRSA). The views expressed in written printed materials or publications do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention by trade names, commercial practices or organization imply endorsement by the U.S. government.

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