Keywords: Ethical sensitivity; Ethical decision–making; Nursing students
Today, health and sanitation professions’ objective is to secure the healthiness and safety of the individuals in need of medical treatment and nursing protections; so, such occupations have been introduced and described as ethical professions . By paying more attention to the ethical problems and challenges in catering and health protection environments, the health caterers find themselves in intricate and complicated situations that originate from the ethical problems . Nursing is also an occupation with great many ethical codes. The ethical action arouser, which involves thinking, acting, and accepting one’s own responsibilities, can turn out to have a lot of problems in nursing due to the conflicting values extant in such a profession . Everyone believes that ethical decision-making is one of the necessary elements integrated to the nursing occupation [4,5]. Factors such as medical technological advances, resource allocation, expenditures increase, the increase in old-aged individuals, paying attention to individual’s rights, and the shift created in the nurses’ role can result in ethical conflicts . Nurses require an ethical challenges recognition competency and proper decision-making ability. They are held accountable for nursing decision-making regarding certain problems for certain patients . Ethical decision-making should be applied as an organized form of ethical thoughtfulness for solving the ethical conflicts . Nurses as professional individuals should be familiar with the ethical decision-making and they should respect patients’ ethical rights without risking their own conscience [7,9].
Because the ethics principally deals with correct and pertinent decision-making and distinguishing right from wrong, the professional behavioral qualifications based on ethics can be considered as equal to the professional qualification. That means that if a nurse acquires such a competency or qualification based on professional behavioral virtues and in confrontation with the occupational conditions and at the time for making a decision, he or she can distinguish right from wrong and bounds him- or herself to do the right thing and avoid the wrong, and his or her actions lead to the development of such virtues in the occupation of protecting others’ health . Inability in confronting with the ethical problems makes some of the nurses quit their job of nursing. And the studies have shown that ethical depression directly affects the nursing occupation and 25% of the nurses apply for a change in their occupational position due to ethical depression .
Despite the frequent emphasis on the necessity of attending to the ethics in all of the phenomena, what is seen as an outcome is the doubtfulness regarding the nurses’ occupational competencies for making decisions, which has been criticized by health system authorities and from outside . Unfortunately, the health care ethics area, during the four recent decades, has not paid a careful attention to the nursing occupation’s concerns or its growth, and, in theory, research and practice have shown superficial or partial tendencies to various ethical problems that nurses are facing and the problems experienced by them in their roles as the ethical problems . The results of the conducted studies regarding the ethics also signify that there is weakness in nurses’ ethical decision-making . The results of a study in Iran showed that the nurses do not appropriately apply the ethical principles in their decision-making . In nursing training and education, the nursing students get to know the ethical decision-making and after graduation they are faced with tensions between what has been taught to them and what is really existing in their work environment. And they are to show their clinical competences and ethical sensitivity in confrontation with such tensions and stressors. Therefore, there is the need for measuring the students’ method of treating such ethical problems and their ethical sensitivity extent in the gamut of nursing jobs. Sufficient evidences are still to be found regarding the relationship between the nursing knowledge and nurses’ ethical sensitivity with the nursing students . Therefore, we felt that there is a need to perform a study aiming at the survey of the ethical sensitivity extent in students’ decision-making.
The current study is a descriptive-analytical research, which dealt with the survey of ethical sensitivity in decision-making of nursing students of Zahedan University of Medical Sciences, all of whom have been studying nursing in 2016. The entrance priority was given to those students who have spent at least one year studying nursing major; that was because they were supposed to have spent some time in clinical environments in order to be able to have experienced conditions for which they had needed to make an ethical decision and to have a proper understanding of the concept. The present study was performed on 93 nursing students who were selected randomly. The number of university students according to the total number of the study population was 37 individuals/semester 4, 40 individuals/term 6, and 43 individuals/semester 8, which totally becomes 120 individuals. Hence, according to Morgan Table the study sample was estimated to be 92 people. To gather information required there was made use of a questionnaire made up of two parts, the first part of which dealt with the demographic characteristics (age, gender, and marital status) and the second part was related to the standard questionnaire of nurses’ ethical sensitivity in decision-making. This questionnaire was compiled by Lutzen et al. in Sweden and then it was used in various countries, such as in Iran. The questionnaire’s validity was evaluated in Iran by Hasanpoor et al. in Kerman and its reliability was obtained as equal to 0.81 . Also, Cronbach’s alpha was used in the present study and the reliability was calculated as equal to 0.76. The questionnaire poses 25 questions, which measured the nurses’ ethical decision-making status while offering clinical services, and each question was scored according to the Likert Spectrum from completely agree (4), relatively agree (3), relatively disagree (2), completely disagree (1), and abstain (0). The maximum possible score would be 100 and the lowest possible score was 0. Based on this, in case that the total score for each of the samples was obtained as between 0 and 50, the sample indicates low ethical sensitivity, 75-50 indicates intermediate sensitivity, and 75-100 is an indicator of having high ethical sensitivity. The questionnaire has six ethical sensitivity dimensions, and from the perspective of the respect for the help-seeker, the maximum score was calculated to be 20 and the minimum score was 0. And it included five questions. The dimension of the nurses’ awareness of the way the patients should be treated had a score of maximum 12 and minimum 0, and it included three questions. The professional knowledge dimension had a maximum score of 20 and minimum of 0, and it posed five questions. In the dimension of having prior ethical problems and challenging issues experiences, the maximum score was calculated to be 20 and the minimum score was 0, which consisted of five questions. The dimension of applying ethical concepts in ethical decision-making was scored at most 20 and at least 0 and it consisted of five questions. And the dimension of honesty and benevolence had a score of maximum 8 and minimum 0 and it incorporated two questions.
For collecting the required information, after acquiring a letter of research plan permit from the vice-chancellor of Zahedan University of Medical Sciences and acquiring a letter of recommendation, the researcher referred to the obstetrics and nursing department. And after making the necessary coordination with the vice-chancellor of the nursing department, firstly the objective of the study was explained to the students, and after acquiring an oral consent, the needed number of questionnaires was administered to the students from various curriculum semesters. Of course, the questionnaires were administered in hospital to students from term 8 because they did not have theoretical classes. At the beginning of the questionnaire a text had been inserted that indicated that the individuals were aware of their agreement to participate in the research plan by stating that “your cooperation in the research plan is considered as you consciously and fully agreed to participate in the research plan. Also, the information inserted in the questionnaire is confidential and you are not threatened by any means.” After the questionnaires were completed, they were collected and revised by the researcher. And they were returned to the students in case there were imperfections or flaws and the students were asked to complete the incomplete parts. Finally after collecting the questionnaires, the data were analyzed by making use of SPSS 19 and descriptive statistics, Pierson Correlation, and an independent t-test.
The students’ average age was 21.37 ± 3.24, and from among all of the individuals participating in the present study, 50 people (53.8%) were women and 79 people (84.9%) were single. The overall ethical sensitivity mean among the students was 55.79 ± 17.28, which was in an intermediate level according to the questionnaire class, and the ethical sensitivity dimensions’ scores were respectively as follows. In the dimension of respecting the care-seeker’s independence it was 10.20 ± 4.23 (2.04). In the dimension of having ethical problems and challenges it was 10.41 ± 4.13 (2.08). In the dimension of putting ethical concepts into practical use in decision-making the score was 11.33 ± 4.01 (2.26). In the dimension of honesty and benevolence dimension it was 4.49 ± 1.87 (2.24). In the professional knowledge dimension the score obtained was equal to 12.49 ± 4.66 (2.49), and in the awareness of the style of treating the patients the score was obtained as 6.84 ± 2.58 (2.28). Twenty-seven individuals (29.0%) had a low ethical sensitivity in their decision-making, 55 individuals (59.1%) had an intermediate ethical sensitivity in their decision-making, and 11 individuals (11.8%) had a high ethical sensitivity in their decision-making. The relationship between the marital status and age with ethical sensitivity in decision- making and each of its dimensions was not significant (p > 0.05).
The relationship between the ethical sensitivity in decision-making and each of its dimensions has been illustrated in Table 1.
|Dimension||Gender||Mean||Std. deviation||p *|
|Ethical sensitivity in||Woman||54.6582||16.70781||0.012|
|Respecting the care-seeker’s||Woman||10.1139||3.95483||0.173|
|Ethical problems and||Woman||9.9494||3.96749||0.142|
|Applying ethical concepts in||Woman||11.2658||3.94094||0.001|
|Honesty and benevolence||Woman||12.2532||4.50205||0.003|
|The professional knowledge||Woman||6.7468||2.49342||0.048|
|The awareness of||Woman||4.3291||1.85169||0.022|
*p value: Significance level between gender and ethical sensitivity. The relationship between sex and ethical sensitivity was calculated by SPSS 19. Above 0.05 was not significant, but under 0.05 was significant.
Table 1: The relationship between the gender and ethical sensitivity in decision-making and each of its dimensions (independent t-test)
The results obtained from the present study showed that the ethical sensitivity score mean in making decision for the nursing students was in an intermediate level, and the highest score was related to the professional knowledge dimension and the lowest score was related to the respect for the care-seeker’s independence. In a study performed by Mousavi et al. also the ethical sensitivity score mean was reported to be intermediate to high . In the study performed by Lutzen et al. the highest scores were related to the dimensions of applying ethical concepts and respecting the care-seeker’s independence and the lowest scores were obtained for the dimensions of having honesty and benevolence and experiences in ethical problems and challenges . In a study performed by Comrie the highest score was obtained for the dimension of application of the ethical concepts and the lowest score pertained to the experiences in ethical problems and challenges. And the overall ethical sensitivity score mean was very high in this study . According to the fact that the ethical sensitivity score mean among the students is in an intermediate level, there is a need to help the students increase their ethical sensitivity level via appropriate planning and providing them with proper and convenient programs.
Because the nursing students are faced with serious situations in their profession, which need ethical and legal capabilities in their decision-making, they should be sensitive to the ethical problems regarding their occupation to be able to respect the care-seekers’ rights and manage ethical topics in their work environment and distinguish between personal and vocational values. Ethical sensitivity is subjected to various factors, such as culture, religion, education level, age, gender, experience, and the individual’s upbringing, and it differs from one individual to another. But the research on ethical sensitivity needs to yet get deeper and the results obtained from the previous studies are still constrained and subjective. And there exists a subtle imperfection in the experimental concepts . Nurses believe that they are facing various problems regarding ethical sensitivity on a daily basis, and making decisions based on ethical standards is difficult for them if they are not acquainted with such standards and norms . The results of a study performed in Greece indicated that in spite of the close relationship between the nurses and the patients, the nurses have not been able to play their protective role due to the existence of some barriers, such as the lack of workforce, extensive work hours, and the lack of appropriate training regarding the ethical issues . The nursing students also blend the theoretical and practical principles and bases within their apprenticeship period. Due to the limited knowledge and confidence and independence, they try to choose the more experienced nurses, tutors, and others as their role model. Therefore, the instructional materials and the lesson planning should be in a way that it is augmentative of a special and certain type of thinking method and deliberation. Also, the education environment and the clinical environment should pave the way and be nourishing of the professional ethical values. Moreover, in a study performed on the survey of the nursing students’ perception of the barriers to the acquisition of professional ethical qualification, the results were suggestive of eight motives as the barriers to the acquisition of professional ethical qualification, which are the lack of interest and motivation for the nursing occupation, insufficient self-awareness, the lack of teachers mastering in ethics, lesson plans’ inadequacy, the use of improper methods in teaching ethics, evaluation problems of ethical attributes, the interpersonal relationship weaknesses, and clinical environments’ constraints . It seems that holding ethical courses can influence the improvement of current status, because Sirin et al. indicated in their study results that the students who had passed the ethical courses in comparison to the other group who had not passed the ethical course had a clearly higher ethical sensitivity in decision-making .
The results of the present study showed that the relationship between the marital status and the students’ age with the ethical sensitivity in decision-making is not significant statistically but the relationship between the ethical sensitivity in decision-making and gender is statistically significant. In the study performed by Kim et al. on nurses’ ethical sensitivity in Korean hospitals, it was reported that the age group 25-30 has a higher score respective to the age group below 25 and above 30 . In a study performed by Baghaei et al. there was not observed a significant relationship between the age and the ethical sensitivity in decision-making average score, and the ethical sensitivity in decision-making mean score was higher in the men in comparison to the women . But, because there are only a few number of men in the nursing occupation, the results cannot be generalized to the entire nursing population.
The individuals’ internal fear in responding to the questions, which still had a great effect on the results in spite of assuring the participants of the information confidentiality, was a constraining factor in the present study.
Clinical care is faced with various challenges, and nurses play a significant role in patients’ satisfaction from the treatment services, due to their being perpetually present at the care-seeker’s bed. It is clear that observing the ethical principles in an occupation such as nursing can influence nurses’ performance in treating patients in various aspects to a great extent. Because nurses face serious situations while taking care of patients, which calls for ethical competencies in decision-making and proper performance, it is deemed as necessary for the nurses to be sensitive to the ethical problems of their occupation and to get acquainted with such problems in order to be able to respect the care-seekers’ rights in taking decisions and preserving their independence. Therefore, due to the intermediate level of ethical sensitivity among the students in the present study, it is suggested that the authorities take steps to improve the status quo of the nursing profession, for instance, by holding workshops for the nursing students to make them aware of ethical sensitivities.
This study was the result of a student research project approved at Zahedan University of Medical Sciences. Hereby, we express our deep gratitude to those people who participated and collaborated in this study and research authorities (staff) of Zahedan University of Medical Sciences who helped us in the process of data collection and financial support.