Moral sensitivity and related factors in Iranian critical care nurses: A narrative review

Article Type : Reviews

Authors

1 Student Research Committee, Nasibeh School of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran

2 Traditional and Complementary Medicine Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran

3 Pediatric Infectious Diseases Research Center, Communicable Diseases Institute, Mazandaran University of Medical Sciences, Sari, Iran

4 Traditional and Complementary Medicine Research Center, Addiction Research Institute, Mazandaran University of Medical Sciences, Sari, Iran

Abstract

This Review explores moral sensitivity and related factors among critical care unit nurses in Iran. A broad systematic search was performed at the international electronic databases such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex and Scientific Information Database using keywords extracted from Medical Subject Headings such as "Morals", "Ethics", "Moral Sensitivity", "Nurses", and "Critical Care Unit" from the earliest to June 1, 2023. The studies revealed that Iranian nurses working in intensive care units (ICUs), cardiac care units (CCUs), neonatal intensive care units (NICUs), and dialysis units had average moral sensitivity. Factors related to moral sensitivity in Iranian critical care nurses were divided into demographic and moral-professional factors. Demographic factors related to moral sensitivity in Iranian critical care nurses included age, average weekly working hours, work history and clinical experience, gender, marital status, education level, type of work shift, workplace sector, and employment status. Demographic factors related to moral sensitivity in Iranian critical care nurses included respecting the patient's rights, moral intelligence, compassion fatigue, communication with the patient, the dimension of professional knowledge, moral tension, work conscience, virtual training, moral principles in a narrative style, critical care unit nurses require high benevolence, professional knowledge, and skills in delivering bad news. They must also know the history of passing moral courses, handling moral distress, and heavy mental workload. Based on these nurses' moderate moral sensitivity, medical center managers should focus on increasing their moral sensitivity by addressing related factors.

Keywords

1 Introduction

The nursing profession comprises the biggest healthcare provider group within the health system, which is based on ethics and aims to improve healthcare provision [1, 2]. Nursing involves making moral decisions that significantly impact a person's life and daily activities, not just life and death outcomes. Ethics is more important in most jobs, especially in the nursing profession, because it is closely related to the recovery and return of health of patients; from this point of view, nursing is based on ethics [3]. Nurses providing health care face many ethical issues that must be accountable for their behavior [4]. Several factors, including economic and cultural factors, shortage of nursing staff, and injustice in resource allocation, cause challenges in the nursing profession, in which moral sensitivity is highly sensitive in these situations [5].

Moral sensitivity is a behavioral concept that refers to a person's internal ability to differentiate between right and wrong and take appropriate actions accordingly [3, 6]. It also provides a platform for nurses to provide more quality and ethical care, which includes emotions, intentions, actions, and complex perceptions [5]. Nurses considering these points can diagnose client problems quickly and take the best action [6]. Moral sensitivity requires care providers to be aware of and analyze clients' behaviors and verbal and non-verbal signs to understand their needs [7]. It also increases their ability to make ethical decisions about the person and causes trust in the client [3]. Nurses with higher moral sensitivity perform better in health care [2].

In Iran, as in many developing countries, nurses face many challenges, such as low social status, job dissatisfaction, lack of manpower, and the difference between theory and practice, which can affect the provision of services and cause wrong decisions. One of them is ethical decisions and managing ethical issues at the bedside, which requires awareness of moral sensitivity [7]. A study showed that special nurses are associated with more ethical challenges than other nurses because they spend a lot of time with clients [5]. Accordingly, compliance with ethical issues is particularly important, and providing unfavorable care in special care units can cause irreparable effects [3]. However, even exceptional nurses face several ethical decisions daily and can only sometimes rely solely on their knowledge and experience to act. In Farasatkish et al.'s study, the moral sensitivity of cardiac intensive care unit (ICU) nurses was moderate [4]. While in another study, the moral sensitivity of special ward nurses was higher than average [2].

According to the importance of moral sensitivity in nurses and the possible effects on the quality of nursing care of patients, and also taking into account the fact that moral sensitivity is influenced by culture, habits, and cultural conditions, this review study aims to investigate Moral sensitivity and its related factors in Iranian critical care unit nurses.

 

2 Methods

2.1 Search strategy

A broad systematic search was performed at the international electronic databases such as Scopus, PubMed, Web of Science, and Persian electronic databases such as Iranmedex and Scientific Information Database using keywords extracted from Medical Subject Headings such as "Morals", "Ethics", "Moral sensitivity", "Nurses", and "Critical care unit" from the earliest to June 1, 2023. For example, the search strategy was in PubMed/MEDLINE database including (("Moral Sensitivity") OR ("Ethical Sensitivity") OR ("Morals") OR ("Ethics")) AND (("Nurses") OR ("Intensive Care Nurses") OR ("Critical Care Nurses")). Boolean operators "OR" and "AND" combined keywords. The Persian translation of the abovementioned keywords was used to search Persian internet databases.

 

2.2 Inclusion and exclusion criteria

This Review covers original research written in both English and Persian, exploring the moral sensitivity of critical care unit nurses and related topics. The study excluded letters to the editor, case studies, conference proceedings, experiments, studies with qualitative designs, or reviews.

 

2.3 Study selection

EndNote 8X software was used for the narrative Review's data management. Two researchers conducted the selection of studies based on specific inclusion and exclusion criteria. First performed electronically, then manually, the Review of article titles, abstracts, full texts, and the removal of duplicate studies. The third researcher clarified disagreements and inconsistencies between the two researchers. Finally, references were carefully examined to avoid data loss.

 

2.4 Data extraction

Information was extracted from the articles in this narrative review, including the first author's name, title, sample size, sampling method, questionnaire, and critical results.

 

3 Results

3.1 Moral Sensitivity in Iranian critical care nurses

This Review reviewed 11 Persian and English articles (Table 1). Based on the research conducted, it was determined that Iranian nurses working in ICUs such as cardiac care units (CCUs) and neonatal ICUs (NICUs), and dialysis exhibit an average level of moral sensitivity.

 

3.2 Factors related to moral sensitivity in Iranian critical care nurses

Factors related to moral sensitivity in Iranian critical care nurses were divided into demographic and moral-professional factors.

 

3.2.1 Demographic factors

Demographic factors related to moral sensitivity in Iranian critical care nurses were included age, average weekly working hours, work history and clinical experience, gender, marital status, education level, type of work shift, workplace sector, and employment status.

 

3.2.2 Moral-professional factors

Demographic factors related to moral sensitivity in Iranian critical care nurses included respecting the patient's rights, moral intelligence, compassion fatigue, communication with the patient, the dimension of professional knowledge, moral tension, work conscience, virtual training, moral principles in a narrative style, the area of benevolence, the area of professional knowledge, the history of passing moral courses, the skill of delivering bad news, moral distress, heavy mental workload, and moral distress.

 

Table 1. Basic characteristics of the included studies in this narrative Review.

First author name/ year

Title

Methods

Sampling-sample size

Questionnaire

Key results

Farasatkish et al., 2015 [4]

Critical care nurses' moral sensitivity in Shahid Rajaee heart center hospital

Cross-sectional

Random sampling-181

Kim's moral sensitivity questionnaire and the quality of work life of Brooks and Anderson

The average score of moral sensitivity in nurses was high. The highest score was in the dimension of knowing how to communicate with the patient and the lowest score was related to the dimension of professional knowledge. Among the demographic variables, age, average weekly working hours, and work experience had a statistically significant relationship with nurses' moral sensitivity, in such a way that with increasing age and working experience, moral sensitivity increased, and with increasing average weekly working hours, moral sensitivity decreased.

Mohammadi et al., 2016 [8]

Moral sensitivity and delivering bad news skills: A study on critical care unit nurses

Cross-sectional

Convenience sampling-222

Hun Moral Sensitivity questionnaire for assessing the skill of delivering unpleasant news to the patient Spikes

The average moral sensitivity of nurses was medium to high. The highest average is in the dimension of ethical behavior and the lowest average is related to respect for the patient. A positive and significant relationship was observed between average moral sensitivity and the delivery of bad news to nurses. There was a significant relationship between moral sensitivity and the number of years of service and the age of the participants.

Borhani et al., 2017 [11]

Moral Sensitivity and moral distress in Iranian critical care nurses

Cross-sectional

Census sampling-153

Lutzen Moral Sensitivity Questionnaire

Corly Moral Distress Questionnaire

The average score of moral discomfort and moral sensitivity was average. There was no statistically significant relationship between moral sensitivity and moral distress.

Mahdiyoun et al., 2017 [2]

Correlation between the nurses, moral sensitivity, and the observance of patients' rights in ICUs

Cross-sectional

Convenience sampling-260

Lutzen's moral sensitivity questionnaire

Researcher-made questionnaire for patients' rights

The level of moral sensitivity of nurses in special care units and their respect for patients' rights by them was above average. A significant direct relationship was observed between the moral sensitivity of nurses and the level of compliance with patients' rights by them in special care units.

Mohammadi et al., 2017 [10]

Moral Sensitivity and moral distress in critical care Unit Nurses

Cross-sectional

Convenience sampling-257

Hun Moral Sensitivity Questionnaire-Corly Moral Distress Questionnaire

No significant relationship was observed between moral distress and moral sensitivity in nurses. The mean of moral distress and the mean of moral sensitivity were high. There was a statistically significant relationship between moral distress and age, the number of years of service, and the type of service department.

Azadehjo et al., 2018 [3]

The relationship between compassion fatigues and moral sensitivity in critical care nurses

Cross-sectional

Census sampling-200

Figli's Compassion Fatigue Questionnaire

Huhn's Moral Sensitivity Questionnaire

There is an inverse and significant correlation between nurses' moral sensitivity and compassion fatigue.

Imani et al., 2018 [5]

Evaluation of the effect of work conscientiousness and moral sensitivity with ethical stress in nurses working in ICUs in educational and therapeutic centers affiliated with Zahedan University of Medical Sciences

Cross-sectional

Census sampling-105

McCar's Work Conscientiousness Questionnaire

Corelli's Moral Tension Questionnaire

Lutzen's Moral Sensitivity Questionnaire

There is a positive and moderate correlation between conscientiousness and moral tension. But there is no correlation between work conscience and moral sensitivity. Also, there is a positive and moderate correlation between moral sensitivity and moral tension.

Dehghani et al., 2020 [1]

Relationship between moral sensitivity and moral intelligence in nurses working in ICUs

Cross-sectional

Census sampling-112

Moral Intelligence Questionnaire

Lutzen Moral sensitivity questionnaire

No significant relationship was observed between the overall score of moral intelligence and moral sensitivity. While there was a positive and significant relationship between the overall score of moral intelligence and the dimension of awareness of how to communicate with the patient as one of the sub-fields of moral sensitivity.

Hosseinabadi et al., 2020 [7]

Moral sensitivity and its dimensions in Iranian critical care nurses

Cross-sectional

Census sampling-153

Modified Moral Sensitivity Questionnaire

Nurses had a moderate level of moral sensitivity. Among the dimensions of moral sensitivity, they obtained the highest scores in the field of benevolence and the lowest in the field of professional knowledge. Among the demographic variables, age had a positive and significant correlation with moral sensitivity.

Nasiriani et al., 2020 [6]

The Effect of Virtual Narrative Ethics Education on Moral Sensitivity in Critical Care Nurses

Quasi-experimental

Quota sampling-60

Lutzen Moral sensitivity questionnaire

The moral sensitivity of nurses was average at the beginning of the study, but after the intervention, an improvement was noticed, but the control group was still average.

Zahednezhad et al., 2021 [9]

Does a heavy mental workload affect moral sensitivity among critical care unit nursing professionals? a cross-sectional study

Cross-sectional

Random sampling-181

Lutzen Moral Sensitivity Questionnaire

NASA Index for psychological workload assessment

There was no statistically significant difference between the mental workload and moral sensitivity of special care nurses. While clinical experience had a positive and significant relationship with moral sensitivity.

 

4 Discussion

A review study was carried out to examine the moral sensitivity of Iranian nurses working in critical care units and the associated factors. The study revealed that moral sensitivity is linked to demographic characteristics and moral-professional factors.

According to Mohammadi et al.'s study, a clear and significant correlation exists between a nurse's age and their level of moral sensitivity [4, 7, 8]. Based on Farasatkish et al.'s study, moral sensitivity increases as one gain more work experience, years of service, and clinical practice. [4, 8, 9]. Furthermore, a statistically significant correlation existed between nurses' moral sensitivity and average weekly working hours. In this way, with the increase in the average working hours, moral sensitivity was reduced [4].

According to Hosseinabadi et al.'s research, gender, workplace sector, employment status, shift work, and history of taking ethics courses did not significantly correlate with moral sensitivity. However, they were related to certain aspects of moral sensitivity [7]. Based on the study by Frost Kish et al., no meaningful correlation was found between moral sensitivity and the type of shift work [4].

The level of moral sensitivity is reported above average in some studies [2] and average in some studies [4, 7, 9]. Mahdiyoun et al. found that nurses' moral sensitivity is directly related to the degree to which they honor patients' rights in special care units [2]. Dehghani et al.'s study showed no significant relationship between moral intelligence and sensitivity. A significant correlation has been found between moral intelligence and the ability to communicate effectively with patients, one of moral sensitivity's sub-fields. Nurses with higher moral intelligence can build better relationships with patients. This, in turn, enhances moral sensitivity [1]. In the study of Azadehjo et al., there was an inverse and significant correlation between moral sensitivity and compassion fatigue of nurses working in ICUs. This means that nurses who have more moral sensitivity are less likely to suffer from compassion fatigue toward the patient [3]. According to Imani et al.'s study, there is a direct correlation between moral sensitivity and tension but no correlation with work conscience [5]. In the study of Nasiriani et al., the use of virtual teaching of ethical principles in a narrative manner improved nurses' moral sensitivity, and this effect continued up to two months after the intervention [6]. In the study of Hosseinabadi and colleagues, Among the different dimensions of moral sensitivity, nurses scored highest in benevolence and lowest in professional knowledge [7]. Mohammadi et al. revealed a positive and potential correlation between moral sensitivity and the skill of delivering bad news to nurses. Nurses with higher sensitivity are more skilled in dealing with moral sensitivity, such as Informing patients and their families of unfortunate news [8]. Mohammadi et al. have demonstrated no notable correlation between moral distress and moral sensitivity among nurses, however, there was a significant correlation between moral sensitivity and the length of service. People who lack sufficient executive power for moral performance may experience moral distress, regardless of their level of moral sensitivity [10]. Zahednezhad et al., have indicated that, the study did not find any significant correlation between the heavy mental workload and the moral sensitivity of exceptional care nursing staff. This significant discovery suggests that nurses follow ethical principles even in challenging circumstances and that their clinical experience has a beneficial and significant correlation with their moral sensitivity. Nurses with more experience have greater moral sensitivity and less psychological burden [9]. In the study of Borhani et al., Experiencing moral distress in clinical settings is not necessarily linked to having a high level of moral sensitivity. However, it is true that all nurses, regardless of their level of moral sensitivity, have experienced moral distress. As nurses gain more experience and become more sensitive to ethical concerns, they can broaden their understanding of ethical issues beyond just their immediate work [11].

 

4.1 Limitations

Language limitations may have resulted from just searching for studies in English and Persian. Additionally, based on this, not all papers in this area may have been considered for the review.

 

4.2 Implications for nursing managers and policymakers

Considering that the moral sensitivity of Iranian nurses is a special department at the average level and is influenced by culture, habits, and cultural conditions. Therefore, it is recommended that the nursing managers and policymakers, taking into consideration the factors related to moral sensitivity, it is important to actively seek ways to improve the moral sensitivity of the nurses working in the special department.

 

4.3 Recommendations for future research

It is suggested that experimental studies be conducted to investigate the effect of various educational interventions on critical care nurses' moral sensitivity.

 

5 Conclusions

Overall, the moral sensitivity of critical care unit nurses was moderate. Therefore, it is recommended that medical center managers consider the factors related to moral sensitivity and make a diligent effort to increase moral sensitivity in critical care unit nurses.

 

Acknowledgements

Not applicable.

 

Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: SMB, FAM, MK, MAL, HJ; Drafting the work or revising it critically for important intellectual content: SMB, FAM, MK, MAL, HJ; Final approval of the version to be published: SMB, FAM, MK, MAL, HJ; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: SMB, FAM, MK, MAL, HJ.

 

Funding

Self-funded.

 

Ethics approval and consent to participate

Not applicable.

 

Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.

 

Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.

 

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (CC BY-NC 4.0).

© 2023 The Author(s).

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Volume 1, Issue 2
July 2023
Pages 78-83
  • Receive Date: 02 June 2023
  • Revise Date: 18 June 2023
  • Accept Date: 24 July 2023
  • First Publish Date: 27 July 2023
  • Publish Date: 27 July 2023