In recent years, healthcare institutions have taken multilateral measures to minimize leakage of health information and to protect and ensure the privacy of patients, such as by establishing guidelines for personal information protection and complying with the implementation of health information protection and security systems as part of healthcare accreditation requirements [1]. As social demand for the protection of patients’ personal information increased, the General Information Protection Act was enacted in March 2011 and implemented in September 2011. In addition, the Ministry of Health and Welfare revised the personal information protection guidelines of medical institutions in 2015, establishing a personal information protection law, and emphasizing the need for appropriate processing of personal information by medical institutions [2].

In Korea, the health information of patients is not only the basic data pertaining to patient care, but also the basis for health insurance claims [3,4]. Health information can also represent basic data for nursing research and education [4]. Recently, as the use of Electronic Medical Records (EMR) has become more common in medical institutions, and the importance of information management is increasing [4], ensuring the privacy of patients’ health information has become a new challenge. As access to health information has improved and become easier, the likelihood of exposure of patient personal information has increased [3].

Nursing students are exposed to various forms of patient information in order to learn patient care. As the roles and responsibilities of nurses with respect to patients' health information increase, nursing students must recognize the importance of protecting their patients' personal medical information and translate this recognition into practice [4]. Therefore, they should learn the ethical responsibilities for patient confidentiality, including the Nurse Ethics Code, Nightingale Oath, Nursing Ethics Principles, and Medical Law [4].

Nursing students undergoing clinical training have been found to have a lower sense of responsibility for protecting health information compared to hospital staff, as nursing students often encounter patients’ information via other medical staff, are only given such information during the training program, and are often not familiar with information security protocols [5-7]. Although it is important for nursing students to understand the importance of protecting health information, there are few studies of information ethics and its influence on health information protection in the context of clinical training [4-7].

Information ethics refers to the ethical problems that occur in an information network during the entire process from information generation to destruction of information [8]. To develop appropriate information ethics, the government revised the guidelines for the information and communication technology education for elementary and junior high schools and strengthened the information-related curriculum in 2011 [8], but there is no mandatory university curriculum. However, most medical institutions manage health information through EMR, and ethical standards for information protection by hospital staff, including nurses, are required. As such, emphasis on health information ethics is needed in nursing colleges.

The information ethics index (IEI) has been developed and used to assess students’ ethics related to personal information encountered in internet use or in other situations in Korean daily life, by measuring the four attributes of temperance, respect, responsibility, and participation [9]. That is, IEI assesses the ability to control one’s unethical behavior (temperance); due regard for the feelings, needs and expectations of others (respect); thinking about the effect of one’s actions on others (responsibility); and sharing valuable information that can be helpful to others (participation)[9]. Despite the high intensity of information ethics education in adolescence, there remain concerns that students lack awareness and consistent practice of information protection when they become adults [10]. Emphasis on ethical behavior among nursing students is particularly necessary as patients’ information protection includes operating with their consent, maintaining their confidentiality, and protecting their personal privacy, trust, and autonomous decision-making, as contained in ethics guidelines [4].

Previous studies have focused on the protection of patients’ health information by health care workers such as nurses, physical therapists, and physicians [11-14]. Only five studies investigated the health information practices of college students in health-related fields with a clinical practice component [4,5,13-15]. Those studies reported patients' awareness of personal information protection or recognition and practice [4,5,13-15]. From the findings of prior studies, it is evident that nursing students with a higher level of awareness of personal information protection can better practice information protection. Although health information protection has been emphasized as an aspect of ethics [10], few studies have assessed the link between ethical norms of information protection and protection of patients’ health information in practices.

In this study, the role of the ethics index and nursing students' awareness of health information protection were examined to determine the current status and to provide basic data regarding factors affecting protection of patients’ health information.

Our findings showed that the IEI domains and awareness of patients’ health information protection were associated with the practice of patients’ health information protection among nursing students. As discussed previously, the IEI comprises four domains (temperance, respect, responsibility, participation); the score of the four domains were above the median. We cannot compare the results of this study to those of other studies as this is the first study to investigate IEI among nursing students. However, it is worth noting that our participants scored highest on the responsibility domain, followed by respect, temperance, and participation. Furthermore, the degree of awareness and practice of patients’ health information protection was higher among nursing students than nurse professionals [3,23]. It is difficult to directly compare differences in the types of items due to differences in constructs, but our finding may reflect the recent strengthening of education on personal information protection in the medical environment. Despite the high score for awareness and practice of patients’ health information protection, scores on items related to communication with nursing staff were lower than other items. In this study, nursing students had limited opportunities for communicating with medical teams on the practice of patients’ health information protection.

This study aimed to identify the factors associated with the level of practice of patients’ health information protection in nursing students. Among personal factors, religion was the factor that most strongly affected nursing students’ practice of health information protection in this study. Generally, religion plays an important role in the formation and maintenance of social norms and religious individuals’ behaviors are often informed by the shared values and moral responsibility embedded in religious codes [22]. Lim [21] found that critical thinking and ethical decision-making were more prominent among religious than non-religious students, similar to the current study. However, in prior studies [19,20], religious individuals also had more experience with ethical conflict than those who were not religious. Although religion might be related to ethical thoughts and decision-making, further research is needed to understand how the practice of patients’ information protection is linked to ethical decisionmaking, and how ethical indices can reflect an individual’s ethical decision-making ability.

Since the development of security policies related to personal information protection is guided by government [2], a health information education system for healthcare professionals has been established in healthcare facilities. However, operation of the education system for students undergoing practical training, including nursing students, differs depending on the environment and institutional culture of the hospital [4,19]. In the current study, approximately 85% of participants had already received education on patients’ information protection, but this did not affect their practice of patients’ health information protection. Kim [4] showed that both hospital- and school-based education on patients’ information protection offered to nursing college students was simplistic or non-specific, and training was conducted uniformly regardless of the ethical index of each student. As noted in a previous study, the content of education for nursing students should be based on their ethical index.

Among the ethical index domains, respect was the important factor in the practice of patients’ health information protection in the current study. Respect refers to an attitude that simultaneously values, acknowledges, and cares for the existence of others; others are considered to have the same dignity as oneself. The respect domain of the IEI applies to communication etiquette and the degree of effort employed to protect personal information [18]. In the current study, respect was associated with the practice of patients’ health information protection. That is, participants’ degree of preventing and protecting other people’s private matters against invasion affected their behavior related to the protection of patients’ information. Consistent with our findings, previous studies have reported that strengthening basic ethics education can contribute to improving health information protection practices among health professionals [24,25]. One possible reason for this can be inferred from nursing education. Although nursing education does not involve separate subjects for ethical education, it is assumed that the overall curriculum emphasizes human respect. However, the IEI domains of temperance, responsibility, and participation are related to nursing students’ behavior in hospitals to protect patient information. Because their ethical responsibilities and duties differ from those of nursing professionals, nursing students may have limited opportunities to act appropriately; namely in a manner that does not exceed one’s own ability to judge situations appropriately (temperance).

Although the current study identified factors associated with practice of patients’ health information protection among nursing students, there are limitations that need to be considered when interpreting our findings. First, the results might reflect healthcare information protection within the participants’ limited geographic area and healthcare environment. Second, when the IEI was developed by Kim [18], the index was used after standardization. Although the sum for each IEI domain was used without standardization with the developer’s permission, measurement error remains possible.

Nevertheless, this study identified the need to improve educational methods related to nursing students’ ethics index. Future research is needed on whether strategies to increase all areas of the ethics index can affect information protection behavior. We further showed that improvement of awareness of patients’ health information protection can be related to its practice in nursing students. Therefore, various education programs should be developed, including the development of possible case scenarios, to prevent unethical behavior among nursing students.

Among nursing students, religion, ethics index, and awareness of patients’ health information protection were important factors in the practice of patients’ health information protection. Nursing students need to be educated to develop awareness of information ethics and to cultivate their ability to act on it. Accordingly, healthcare systems also need to develop practical education programs to improve ethical awareness among students, based on their ethics index. Moreover, future studies should investigate how the ethical index relates to ethical decisionmaking, and which methods could facilitate the improvement of ethical behavior among nursing students.