This was a cross-sectional correlational study. The research population consisted of students of nursing colleges in 2 southern provinces of Iran (Kerman, Sistan & Baluchistan). Two nursing colleges were randomly selected from each province (4 colleges). Then, the first- to fourth-year nursing students were enrolled in the study (395 students). A Census method was used for sampling. Inclusion criteria were spending at least one clinical unit and willingness to participate in the study. For data gathering, the data collector referred to the instructors by introducing letter of the head of the school. After obtaining permission from the instructors at the end of the class, he distributed the questionnaires and collected them at the same session (after 15 minutes). He introducing himself and giving a brief explanation about the purpose of the study, anonymity, data confidentiality, and voluntary participation in the study to students before questionnaire distribution.
Data collection Tools: A demographic questionnaire, Clinical Dishonesty questionnaire, and Nursing Student's Clinical Perceived Stress scale were used for data collection.
Demographic Information: Demographic data included age, sex, marital status, school year, student’s clinical work experience, interest in nursing, and the grade point average (GPA) of the previous semester.
Clinical Dishonesty Questionnaire: This was a researcher-made questionnaire, with 12 items designed based on the review of the literature [10, 13]. The answer to each item had 3 parts. The first part measured the frequency of doing dishonest behavior in the previous semester (never, once, twice or more). The second measured the frequency of witnessing clinical dishonest behavior in classmates in the previous semester (never, once, twice or more). The scorings of these 2 parts ranged from 0 to 2, respectively. The third section measured the perceived severity of that behavior as unethical behavior, ranging from 1 to 4 (unimportant, least important, important, and most important). The mean total score of each part was calculated by sum of the responses to the items divided by the number of items. The validity of this questionnaire was confirmed by 10 nursing faculty members. Also, its reliability was determined by Cronbach's alpha for the frequency of doing the dishonest behavior, frequency of witnessing dishonest behavior in classmates, and perceived severity of behavior as unethical behavior, for the archived data of 30 last-year students. The obtained values were 0.79, 0.83, and 0.83, respectively.
Nursing Student's Clinical Perceived Stress Scale: This questionnaire was designed by the first author of another study that has not been published yet. This questionnaire was developed by interviewing first- to fourth-year nursing students, and all its psychometric evaluation (face validity, content validity, exploratory and confirmatory factor analysis) were achieved. This tool has 32 items that are scored based on the 5-point Likert scale, a higher score indicating more clinical stress. The internal consistency of this tool was 0.9.
Data Analysis: Data were analyzed using SPSS version 16. Data normality was assessed by the Shapiro-Wilk test, which showed that data distribution was not normal, thus, the Box-Cox transform was used, which did not normalize the data. Non-parametric tests were used for data analysis. Mann-Whitney U-test was used to determine the relationship between dishonest clinical behaviors and bivariate demographic variables. Further, Kruskal–Wallis test was used to determine the relationship between dishonest clinical behaviors and multivariate demographic variables (If the test result was significant, the follow-up test with Bonferroni correction was used to examine the differences between groups). Also, Spearman correlation coefficient was used to determine the relationship of the frequency of doing dishonest clinical behaviors with witnessing such behaviors, perceived severity of dishonest behaviors as unethical, the stress of nursing students, and the students’ GPA of the previous semester.
After obtaining approval from the ethics committee of the university and the permission of the university authorities, anonymous questionnaires were distributed in classrooms. The questionnaires were collected after being filled out by the students.
Data were collected from November 2018 to January 2019. Questionnaires were collected by a trained MSc nursing student who studied nursing in a different university.
Ethical Considerations: This study was approved by the ethics committee of the university (IR.JMU.REC.1397.31). The questionnaires were anonymous. Also, the confidentiality of the information and the right to withdraw from the study were explained to the participants. Moreover, a written consent form was obtained from all participants. We asked students to submit the signed form and completed questionnaire if they agreed to participate in the study, and to submit the blank form and questionnaire if they did not wish to participate in the study. Despite the voluntary participation in the study, no student refused to participate in the study