Abstract
Aim
This study aimed to: (1) assess the level of moral sensitivity of nurses and the quality of nursing care for patients with COVID‐19 in Iran; and (2) identify the relationship between the moral sensitivity of nurses and the quality of nursing care for patients with COVID‐19 in Iran.
Design
This study was designed as a descriptive, cross‐sectional, and correlational research.
Method
A total of 211 nurses working in four hospitals affiliated with the Hamadan University of Medical Sciences in Iran from December 2021 to April 2022 were selected via the stratified proportional random sampling method. Demographic information, a moral sensitivity questionnaire, and the Good Nursing Care Scale were used for data collection. The data were analysed by SPSS 24 based on descriptive and inferential statistics (Pearson correlation coefficient and multiple regression).
Results
Results revealed that 188 of the nurses (89.1%) had a moderate level of moral sensitivity. Furthermore, 160 of the participants (75.8%) reported a relatively low level of the quality of nursing care. The results of the Pearson correlation coefficient test indicated that there was an inverse and significant relationship between the moral sensitivity of nurses and the quality of nursing care (r = −0.528, p < 0.001). The results of multiple regression indicated that the model of moral sensitivity components explained 27.9% of the variance in the quality of nursing care. The components of moral sensitivity, including relation (β = −0.246, p < 0.001), meaning (β = −0.188, p = 0.003), conflict (β = −0.170, p = 0.008), benevolence (β = −0.153, p = 0.012), and rules (β = −0.144, p = 0.019) had inverse and significant effects on the quality of nursing care.
Conclusion
Since higher mean scores of moral sensitivity reflect lower moral sensitivity, it can be stated that with the increase in moral sensitivity of nurses, the quality of nursing care for patients with COVID‐19 grows.
Keywords: COVID‐19, moral sensitivity, nurses, nursing care quality
1. INTRODUCTION
The COVID‐19 pandemic started at the end of 2019 and can be considered the greatest challenge since World War II (Safdari et al., 2022). The pandemic can be a challenge for nurses who are on the front line of care. In this crisis, they play an important role in facing complex COVID‐19 cases that require hospitalization. Thus, they work under physical and emotional pressure, putting their lives at risk while fulfilling their duties (Lorente et al., 2021). They faced several problems during COVID‐19, such as high risk of infection, infection transmission to their family members, lack of equipment and human resources, inadequate hospital infrastructure, lack of organizational support, heavy workload, lack of adequate care experience, psychological health problems, and moral distress (Safdari et al., 2022).
Occupational stress, patients flocking to hospitals on a daily basis, low hospital capacity, and an unsuitable nurse‐to‐patient ratio have complicated the care process for patients with COVID‐19 (Karimi et al., 2020). All of these make it impossible for nurses to provide all necessary care to patients. Nurses may ignore, delay, or even eliminate some aspects of care. Therefore, the quality of care may decline in the COVID‐19 pandemic (Safdari et al., 2022). In the review of studies conducted in Iran, Fazaeli et al. (2020) found a significant reduction in the quality of care compared to before the COVID‐19 pandemic. In another study, Nazari et al. (2022) found an average‐high quality of nursing care in nurses caring for elderly patients with COVID‐19. The findings of a qualitative study by Rezaee et al. (2020) showed that nurses expressed that there is a risk of declining quality of nursing care and an absence of a holistic care approach for patients with COVID‐19.
The quality of nursing care for patients with COVID is a major challenge. The pandemic period, in which ethical issues may be encountered, requires the development of nurses' ethical sensitivity for ethical decisions (Mert et al., 2021). High moral sensitivity not only helps in professionalization but also directly affects the quality of nursing care (Jiang et al., 2021; Mert et al., 2021). Moral sensitivity refers to recognizing the existence of ethical issues and making correct decisions by evaluating the patient's condition and level of vulnerability, and the ethical consequences of decision‐making (Jiang et al., 2021). Moral sensitivity increases attention to ethical considerations, improves the ability to make moral decisions, and leads to the acquisition of problem‐solving skills during ethical dilemmas (Hajibabaee et al., 2022; Nazari et al., 2022).
Previous studies in Iran have shown that moral sensitivity is desirable among nurses (Amiri et al., 2019). However, in the COVID‐19 pandemic, limited studies have investigated the level of moral sensitivity of Iranian nurses. For example, Nazari et al. (2022) showed in their study that the majority of the nurses (55%) had low moral sensitivity. In another study by Hajibabaee et al. (2022), moral sensitivity of 78.3% of the nurses was moderate during the COVID‐19 pandemic.
Understanding and awareness of the factors contributing to the enhancement of nursing care are critical to the development and promotion of nursing services and client satisfaction (Hassanian et al., 2019). The literature examining the relationship between the moral sensitivity of nurses and the quality of nursing care for patients with COVID‐19 has gaps that require research. First, most of the existing studies have determined the relationship between the moral sensitivity of nurses and the quality of nursing care or nurses' caring behaviour before the COVID‐19 pandemic (Afrasiabifar et al., 2021; Gholjeh et al., 2015; Mert Boğa et al., 2020; Shahvali et al., 2018; Taylan et al., 2021). Therefore, limited studies have been conducted during the COVID‐19 pandemic (Jiang et al., 2021; Nazari et al., 2022). Second, it was found that there are discrepancies in these studies. Several studies have indicated that nurses' moral sensitivity is associated with nursing care quality or nurses' caring behaviour (Afrasiabifar et al., 2021; Gholjeh et al., 2015; Khodaveisi et al., 2021; Mert Boğa et al., 2020; Nazari et al., 2022; Shahvali et al., 2018; Taylan et al., 2021). The findings of several studies showed that there is no relationship between moral sensitivity and nursing care quality (Amiri et al., 2019). Third, limited studies have measured the quality of nursing care for patients with COVID‐19 (Nazari et al., 2022). Based on the above arguments, this study aimed to: (1) assess the level of moral sensitivity of nurses and the quality of nursing care for patients with COVID‐19 in Iran; and (2) identify the relationship between the moral sensitivity of nurses and the quality of nursing care for patients with COVID‐19 in Iran.
2. METHODS
2.1. Study design
This study was designed as a descriptive, cross‐sectional, and correlational research.
2.2. Sample and setting
The present study was conducted in four hospitals affiliated with Hamadan University of Medical Sciences in West Iran. The research population included all nurses working in these hospitals from December 2021 to April 2022. The inclusion criteria were: a BSc. in nursing, willingness and consent to participate in the research; having at least 1 month of clinical experience in the COVID‐19 ward; having at least 6 months of clinical practice background, no acute crisis in the person's life over the past 6 months based on their own self‐expression, including the death of a family member. Failure to return the questionnaires or fill them out incompletely was considered the exclusion criterion.
The sample size was calculated using the formula N = [(Z α + Z β )/C]2 + 3, where C = 0.5 * ln[(1 + r)/(1 − r)]. The r (correlation coefficient) was 0.14 according to a previous study (β = 80%, α = 0.05; Amiri et al., 2019), and taking into account the 10% sample attrition. Using the stratified proportional random sampling method, 220 nurses were chosen as the study sample in terms of their hospital and ward of service. In this way, taking into account the number of nurses in each hospital (hospital A, n = 366; hospital B, n = 208; hospital C, n = 191; hospital D, n = 205), the contribution of that hospital to the total sample was determined. Then, by considering the ratio of nurses in each ward to their total number throughout the entire hospital, the sample size in each ward was determined. Using a list of the names of the nurses, a random number table was used to choose the appropriate sample size from each ward. A total of 220 questionnaires were distributed among the four hospitals. After collection, 211 questionnaires were included for analysis. Nine questionnaires were eliminated because they were either not given back to researchers or filled in incompletely. The retrieval rate of the questionnaires in the study was 95.90%.
2.3. Data collection tools
For data collection, a demographic information questionnaire (age, gender, marital status, level of education, and years of experience in nursing), a moral sensitivity questionnaire (MSQ), and a Good Nursing Care Scale (GNCS) were used.
2.3.1. Moral sensitivity questionnaire
For measuring moral sensitivity, the “moral sensitivity questionnaire (MSQ)” was used. This questionnaire was developed by Lutzen et al. in 1995 in Sweden, and has 30 items with six subscales, including rules, meaning, conflict, autonomy, benevolence, and relation. The questionnaire scoring is based on a 7‐point Likert scale ranging from absolutely agreeing (1) to absolutely disagreeing (7). The total score of the questionnaire ranges from 30 to 210. The scores are categorized into three groups: low moral sensitivity (150–210), average (90–150), and high (30–90). Acquisition of a higher score indicates lower moral sensitivity (Lutzen et al., 1997). Since the number of items on the subscales is not equal to each other, for interpretation and comparison of results, the mean and standard deviation of the Likert scale (acquirable scores 1–7) were used.
Hassanpoor et al. (2011) translated and nativized this questionnaire in Iran. For the reliability and validity of the questionnaire, it was first translated from English to Persian based on the cultural conditions of Iran. Then, the exact translation was converted back to the original language and compared with the original text. To acquire face and content validity and to ensure correct translation, the questionnaire containing the translated text alongside its English text was provided to 10 scholars. After making the necessary changes and applying the proposed corrections, the validity of the questionnaire was determined. The mentioned questionnaire was provided to 20 nurses, whereby the Cronbach alpha coefficient was calculated at 0.81 (Hassanpoor et al., 2011). To determine the reliability of the questionnaire, the Cronbach alpha method was used; the Cronbach alpha in the subscales of the questionnaire was reported to be 0.73–0.85. The Cronbach alpha for the total questionnaire was 0.83.
2.3.2. Good nursing care scale
To measure the nursing care quality, the “good nursing care scale (GNCS)” was used. This questionnaire was designed by Leino‐Kilpi in 1998 in Finland and was revised several times between 2008 and 2013. This instrument was psychometrically analysed and employed in different countries, including Finland, Sweden, Lithuania, China, and Turkey, showing desirable psychometric properties (Esmalizadeh et al., 2019; Stolt et al., 2019). This instrument has 40 items evaluating nursing care quality in seven subscales, including characteristics of nurses, nursing actions, preconditions for care, the environment, proceeding of the process, patient management strategies, and collaboration with family members/significant others. This instrument was scored with a five‐degree scale within the 0–4 range (score 4: absolutely agree, score 3: relatively agree, score 2: relatively disagree, 1: absolutely disagree, and 0: have no idea). This scoring shows care quality at very high or very low levels in each of the dimensions. After filling out the questionnaire and obtaining the mean score for each item, scores 1–1.5 represent the lowest level of care quality presented in that item, while scores 3.6–4 indicate the best level of care quality presented in that item. For ranking the care quality, the total scores are classified into six levels: very low (scores 1–1.5), low (1.6–2), relatively low (2.1–2.5), relatively high (2.6–3), high (3.1–3.5), and very high (3.6–4; Stolt et al., 2019).
Esmalizadeh et al. (2019) performed a study to translate and determine the psychometric properties of the Persian version of GNCS in Iran. After determining the face and content validity both quantitatively and qualitatively, all 40 items were kept, and according to the results of confirmatory factor analysis, seven dimensions that had been introduced in the main instruments were confirmed with acceptable values. High correlation among the scores resulting from the main questionnaires and the criterion instrument confirmed the test criteria's validity. The results of the Cronbach alpha (0.907) showed acceptable reliability of the questionnaire. The Persian version of the GNCS has acceptable psychometric indices for Iranian nurses' and it can be used as a valid instrument for evaluating nursing care quality. To determine the reliability of the questionnaire in the present research, the Cronbach alpha method was used, which was reported to be 0.70–0.88 for the subscales of the questionnaire. The Cronbach alpha of the entire instrument was 0.92.
2.4. Data collection
After coordination and receiving the necessary permissions, the questionnaires were provided to the nurses by the researcher in person and inside envelopes. After explaining the study goals, receiving a written informed consent form, and ensuring confidentiality of information, in case the nurse consented and met the inclusion criteria, they were invited to this study, so that they would be present in the nursing break room in the ward for completing the questionnaires. The questionnaires were completed by nurses throgh self‐reporting. The nurses were asked to fill in the questionnaire at any suitable time and set a time for collecting the questionnaires. A total of 220 questionnaires were distributed among the participants. Nine questionnaires were eliminated from study because of non‐return or incomplete filling. The response rate to the questionnaires was 95.90%.
2.5. Data analysis
The data were analysed by SPSS 24 and based on statistical tests. This research used descriptive statistical methods (frequency, percentage, mean, and standard deviation) and inferential statistics. The Pearson correlation coefficient, and multiple regression were used to investigate the relationship between nurses' moral sensitivity and nursing care quality for patients with coronavirus.
2.6. Ethical considerations
Ethical considerations considered for the present research included receiving the ethics code with the number IR.UMSHA.REC.1400.479 from the ethics committee of the Hamadan University of Medical Sciences, receiving a written informed consent form from the participants, presenting explanations about the research goals, trusteeship in the use of resources and references, complete freedom of nurses in filling the questionnaires or refusal of participation in study, and the confidentiality of questionnaires' information.
3. RESULTS
3.1. Characteristics of participants
A total of 211 nurses participated in this study, including 166 females (78.7%) and 45 males (21.3%). Also, 182 participants (86.3%) had a bachelor's degree in nursing, and 127 participants (60.2%) were married (Table 1). The mean age of nurses was 33.63 years, with a standard deviation of 6.42 years. Further, the mean working background of nurses was 9.70 years with a standard deviation of 6.40 years.
TABLE 1.
Characteristics of participants (N = 211).
| Characteristic | N (%) | Moral sensivity | Quality of nursing care | ||
|---|---|---|---|---|---|
| Mean (SD) | p‐value | Mean (SD) | p‐value | ||
| Gender | |||||
| Male | 45 (21.3) | 128.24 (11.09) | <0.001* | 2.20 (0.22) | <0.001* |
| Female | 166 (78.7) | 107.10 (14.19) | 2.38 (0.18) | ||
| Marital status | |||||
| Married | 127 (60.2) | 107.38 (16.68) | <0.001* | 2.37 (0.21) | <0.001* |
| Single | 84 (39.8) | 118 (12.85) | 2.29 (0.18) | ||
| Level of education | |||||
| Bachelor of nursing | 182 (86.3) | 112.45 (15.37) | 0.58* | 2.32 (0.20) | 0.003* |
| Master of nursing | 29 (13.7) | 106.34 (19.63) | 2.44 (0.24) | ||
Independent t test.
The level of moral sensitivity and the quality of nursing care were significantly higher in female nurses than in male nurses (p < 0.001). Married nurses had a significantly higher level of moral sensitivity and quality of nursing care compared to single nurses (p < 0.001). Nurses who had a master's degree in nursing had a higher quality of nursing care than those who had a bachelor's degree in nursing (p = 0.003; Table 1). The Pearson correlation coefficient showed that age (r = −0.203, p = 0.003) and working background (r = −0.253, p < 0.001) had a negative and significant relationship with moral sensitivity. Higher age and working background are associated with higher moral sensitivity. The Pearson correlation coefficient showed that working background had a direct and significant relationship with the quality of nursing care (r = 0.14, p = 0.04).
3.2. Moral sensitivity of nurses and quality of nursing care for patients with COVID‐19
Based on the obtained results, 188 of the nurses who participated (89.1%) had average moral sensitivity. None of the nurses showed a low level of moral sensitivity. One hundred and sixty of the participants (75.8%) evaluated the quality of care as relatively low. None of the nurses showed very low or very high levels of nursing care quality (Table 2).
TABLE 2.
Level of moral sensitivity and quality of nursing care.
| Level of variables | n (%) |
|---|---|
| Moral sensitivity | |
| High (30–90) | 23 (10.9) |
| Moderate (90–150) | 188 (89.1) |
| Low (150–210) | 0 (0) |
| Quality of nursing care | |
| Very low (1–1.5) | 0 (0) |
| Low (1.6–2) | 8 (8.3) |
| Relatively low (2.1–2.5) | 160 (75.8) |
| Relatively high (2.6–3) | 42 (19.9) |
| High (3.1–3.5) | 1 (0.5) |
| Very high (3.6–4) | 0 (0) |
The mean total score of moral sensitivity among nurses was 111.61, with a standard deviation (SD) of 16.10. The lowest level of moral sensitivity among nurses was related to the subscale of rules (4.33 with SD 0.99), while the highest was associated with the subscale of “relation” (3.35 with SD 1.22). The mean score of nursing care quality was 2.34 with an SD of 0.21. The highest nursing care quality score was found in the subscale of “environment” (2.54 with SD 0.5) and the lowest in the subscales of “patient management strategies” (2.23 with SD 0.40) and “collaboration with family members/significant others” (2.24 with SD 0.45; Table 3).
TABLE 3.
Means, standard deviations and Pearson's correlations for study variables.
| Variables | Quality of nursing care | M (SD) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Subscales | Characteristics of nurses | Nursing actions | Preconditions for care | Environment | Proceeding of the process | Patient management strategies | Collaboration with family members/significant others | Total | ||
| Moral sensitivity | Rules | r = −0.04 | r = −0.165 | r = −0.20 | r = −0.102 | r = −0.174 | r = −0.121 | r = −0.017 | r = −0.255 | 4.33 (0.99) |
| p = 0.49 | p = 0.017 | p = 0.004 | p = 0.138 | p = 0.011 | p = 0.079 | p = 0.811 | p < 0.001 | |||
| Meaning | r = −0.008 | r = −0.217 | r = −0.24 | r = −0.072 | r = −0.124 | r = −0.247 | r = −0.069 | r = −0.306 | 3.47 (0.98) | |
| p = 0.91 | p < 0.001 | p < 0.001 | p = 0.301 | p = 0.071 | p < 0.001 | p = 0.322 | p < 0.001 | |||
| Conflict | r = 0.005 | r = −0.101 | r = −0.10 | r = −0.193 | r = −0.115 | r = −0.241 | r = −0.214 | r = −0.303 | 4.13 (1.03) | |
| p = 0.94 | p = 0.14 | p = 0.148 | p = 0.005 | p = 0.095 | p < 0.001 | p = 0.002 | p < 0.001 | |||
| Autonomy | r = −0.007 | r = −0.097 | r = −0.136 | r = −0.076 | r = −0.031 | r = −0.184 | r = −0.243 | r = −0.244 | 4.15 (1.02) | |
| p = 0.91 | p = 0.161 | p = 0.049 | p = 0.274 | p = 0.656 | p = 0.007 | p < 0.001 | p < 0.001 | |||
| Benevolence | r = −0.16 | r = −0.156 | r = −0.062 | r = −0.132 | r = −0.077 | r = −0.113 | r = −0.092 | r = −0.247 | 3.43 (1.03) | |
| p = 0.019 | p = 0.024 | p = 0.368 | p = 0.056 | p = 0.267 | p = 0.102 | p = 0.182 | p < 0.001 | |||
| Relation | r = −0.146 | r = −0.127 | r = −0.046 | r = −0.179 | r = −0.162 | r = −0.246 | r = −0.241 | r = −0.361 | 3.35 (1.22) | |
| p = 0.035 | p = 0.066 | p = 0.507 | p = 0.009 | p = 0.019 | p < 0.001 | p < 0.001 | p < 0.001 | |||
| Total | r = −0.108 | r = −0.281 | r = −0.263 | r = −0.230 | r = −0.225 | r = −0.348 | r = −0.232 | r = −0.528 | 111.61 (16.10) | |
| p = 0.116 | p < 0.001 | p < 0.001 | p < 0.001 | p < 0.001 | p < 0.001 | p < 0.001 | p < 0.001 | |||
| M (SD) | 2.42 (0.50) | 2.37 (0.45) | 2.35 (0.47) | 2.54 (0.50) | 2.29 (0.43) | 2.23 (0.40) | 2.24 (0.45) | 2.34 (0.21) | ||
3.3. Correlations of moral sensitivity of nurses and quality of nursing care for patients with COVID‐19
The results indicated an inverse and weak relationship between the components of moral sensitivity and the total score of nursing care quality (p < 0.001). An inverse and weak relationship was found between the total score of moral sensitivity of nurses and the components of nursing care quality (except for the characteristics of nurses; p < 0.001). The linear relationship between the total score of moral sensitivity and the total score of nursing care quality was significant, with a Pearson correlation coefficient of −0.528, indicating an inverse and average relationship between these two variables (p < 0.001). Since higher mean scores of moral sensitivity reflect lower moral sensitivity, it can be stated that with the increase in moral sensitivity of nurses, nursing care quality grows (Table 3).
3.4. Associations of moral sensitivity components with quality of nursing care for patients with COVID‐19
The results of multiple regression showed that moral sensitivity components, including relation (β = −0.246, p < 0.001), meaning (β = −0.188, p = 0.003), moral conflicts (β = −0.170, p = 0.008), benevolence (β = −0.153, p = 0.012), and rules (β = −0.144, p = 0.019) except for “autonomy” had inversely significant effect on nursing care quality. The moral sensitivity components could predict about 28% of the variance of variable of nursing care quality (R 2 = 0.279). Besides, the significance of the F index indicates the goodness of fit of this model (F = 14.57, p < 0.001; Table 4).
TABLE 4.
Regression analysis: moral sensitivity and quality of nursing care.
| Predictor variable | B | SE | β | p‐value | R | R 2 | Adjusted R 2 |
|---|---|---|---|---|---|---|---|
| Constant value | 3.104 | 0.088 | <0.001 | 0.548 | 0.300 | 0.279 | |
| Rules | −0.004 | 0.002 | −0.144 | 0.019 | |||
| Meaning | −0.007 | 0.002 | −0.188 | 0.003 | |||
| Conflict | −0.007 | 0.003 | −0.170 | 0.008 | |||
| Autonomy | −0.008 | 0.004 | −0.114 | 0.064 | |||
| Benevolence | −0.006 | 0.002 | −0.153 | 0.012 | |||
| Relation | −0.014 | 0.004 | −0.246 | <0.001 |
Note: Criterion variable: quality of nursing care.
4. DISCUSSION
This study showed most nurses had a moderate level of moral sensitivity. Based on the obtained results, the components of moral sensitivity of nurses, in descending order were as follows: relation, benevolence, meaning, moral conflict, autonomy, and rules. In line with the present study, the results of Hajibabaee et al. (2022) indicated that the moral sensitivity of most Iranian nurses was moderate during the COVID‐19 pandemic. Furthermore, in this study, the minimum score of moral sensitivity of nurses was related to the component of “following the rules”. This subscale emphasizes observing organizational hierarchy in the healthcare team, obeying nursing instructions and moral principles, and taking help from the knowledge and experience of colleagues. Thus, considering the low moral sensitivity of nurses in the subscale of “following the rules”, it is suggested to consider specialized workshops on “professional ethics, as well as rules and regulations in nursing” in order to enhance the moral sensitivity of nurses in this area.
The results of Jiang et al.'s (2021) study showed that Chinese nurses who took care of COVID‐19 patients had a relatively high moral sensitivity. Furthermore, the nurses acquired high scores in the area of “moral burden”. High “moral burden” may be due to higher psychological pressure, less experience in taking care of COVID‐19 patients, a deficiency in protective equipment, or a high‐risk of infection. In this regard, the findings of Hajibabaee et al. (2022) in Iran indicated the acquisition of a higher score of moral sensitivity in the area of “experience of moral conflicts”, during the COVID‐19 pandemic, which can confirm the greater experience of moral challenges associated with decision‐making, patient participation in the treatment, and patient right of choice. Less participation of the patient in the course of care may be due to the terms of fear and anxiety of nurses, and the acute situation of COVID‐19.
The findings of the present study did not concur with the mentioned studies. The nurses acquired low scores in areas of “autonomy”, and “experience of moral conflicts”. This can indicate low moral sensitivity of nurses in the patient's right of choice and participation in decision‐making. The present study showed the nurses who had better nursing care quality for patients with COVID‐19 in the components of “environment”, “patient management strategies”, and “collaboration with family members/significant others”, had experienced more moral conflicts. Thus, when nurses attempted to improve the care performance for patients with COVID‐19 in areas such as “keeping the patient's privacy, respecting the patient's beliefs and values, keeping the patient's information confidential, preventing the spread of infection, cooperation in establishing security in the environment, supporting family, participation of patient and family in the care, helping the patient cope with the disease, and helping to promote the patient autonomy”, they would experience more moral conflicts. In this regard, the findings of Mert et al. (2021) indicated that the nurses who faced moral conflicts during the coronavirus pandemic showed higher moral sensitivity in the area of “moral conflicts” compared to the nonexposed group. Other reasons for difference with other studies include the acquisition of a total mean score of the quality of nursing care for patients with COVID‐19 and all of its components within the “relatively low” level.
According to Nazari et al. (2022), in Mazandaran, Iran, the moral sensitivity of 55.5% of nurses was reported as low, 26.6% as average, and 19.9% as high. The findings of the present study did not concur with the mentioned study. The reason for this difference is that in the mentioned study, the moral sensitivity of nurses taking care of the elderly in a different population was studied. Furthermore, the results of Khodaveisi et al. (2021) showed nurses reported a high level of moral sensitivity. Despite the similar research population between two studies, these different findings can be attributed to the fact that in the mentioned study, the time of sampling and data collection method were different from the present research; the sampling in this study was done from March 2020 to May 2020 through email or social media.
Most nurses (75.8%) reported relatively low levels of nursing care quality for patients with COVID‐19. In the review of studies conducted in Iran, Nazari et al. (2022) found an average‐high quality of nursing care in nurses caring for elderly patients with COVID‐19. Also, the findings of a qualitative study by Rezaee et al. (2020) showed that nurses expressed ethical challenges in caring for patients with COVID‐19, including the risk of declining quality of nursing care and the absence of a holistic COVID‐19 care approach (poor spiritual care, poor compassionate care, and lack of family‐centred care). The quality of care may decline during critical situations. The findings of the present study were in line with the mentioned studies. Thus, the challenges that occur during the coronavirus pandemic can be an influential factor in how nursing care is provided in Iran. In this regard, the findings of the qualitative study by Safdari et al. (2022) indicated that fear of developing infectious disease, deficits of equipment and workforce, absence of proper infrastructures in the hospital, fatigue and burnout, insufficient care experience, increased working loads of nurses, priority to provide nursing care for very sick patients, ambiguity in responsibilities and roles of different levels of nursing, absence of care protocols and standards, absence of a post‐discharge follow‐up system, a deficiency in providing constant and regular nursing care, and the diversity of symptoms of patients with COVID‐19, have all affected the quality of nursing care. In the study of Jiang et al. (2021), the quality of nursing care for patients with COVID‐19 in China was reported as high among the nurses based on a self‐report method. This difference might be explained by the discrepancies in the places and samples.
In the present study, the highest level of quality was perceived in “environment” and “characteristics of nurses”, while the lowest was reported in “patient management strategies” and “collaboration with family members/significant others”. This result was in agreement with those reported by Gröndahl et al. (2019) for surgical patients in Finland and Bahrami et al. (2020) for cardiac patients in Iran. Improving the quality is still needed, especially in collaboration with family members of significant others and in support patients with COVID‐19 in developing strategies to cope with the disease.
The findings of the present study showed that with an increase in the moral sensitivity of nurses, the quality of nursing care for patients with COVID‐19 would also increase. In this regard, the results of Khodaveisi et al.'s (2021) study in Iran showed a direct correlation between moral sensitivity and safe nursing care among Iranian nurses caring for patients with COVID‐19. Also, according to Jiang et al. (2021), participants with a higher moral sensitivity score had higher scores on their caring behaviours for COVID‐19 patients in China. The findings of studies performed in other care settings also showed that, with an increase in the moral sensitivity of nurses, patient satisfaction with the nursing care quality (Gholjeh et al., 2015; Shahvali et al., 2018) and care behaviour of nurses (Afrasiabifar et al., 2021; Mert Boğa et al., 2020; Taylan et al., 2021) would also increase. In contrast to the present study findings, the study of Nazari et al. (2022) in Iran showed that with an increase in moral sensitivity, the nursing care quality in elderly patients with COVID‐19 decreased (Nazari et al., 2022). Also, in the study of Hajiloo and Torabi (2021) in Iran, there was no significant relationship between moral sensitivity and the nurses' degree of perception about useless care and repeating useless care for patients with COVID‐19 (Hajiloo & Torabi, 2021). Studies performed in other care settings showed that there was no significant correlation between moral sensitivity and the quality of nursing care (Amiri et al., 2019). Nurses played an important role in caring for COVID‐19 patients, and ethical sensitivity was essential for nurses to provide high‐quality care. A high level of moral sensitivity can help nurses feel confident in justifying ethical decisions, be prepared to deal with ethical issues, and feel confident in performing their professional responsibilities (Jiang et al., 2021).
One of the strong points of the present study was the proportional stratified sampling method and use of a GNCS to assess the nursing care quality for patients with COVID‐19. The present study had several limitations. First, the samples were chosen from four hospitals in one city. Thus, generalization of findings to the hospitals throughout Iran should be done with caution. Secondly, although in the present study reliable and valid questionnaires were used, a review of available studies indicated that for assessing the quality of nursing care, QUALPAC, CBI‐42, and CBI‐24 questionnaires were used. These differences in the type of instrument employed may lead to discrepancies in studies, thus complicating comparison with the present study's findings. Finally, the psychological status of participants and its effect on their way of response to the questionnaire items and lack of willingness of some nurses were among the limitations out of the researcher's control in this study.
5. CONCLUSION
The present study showed that the nursing care quality for patients with COVID‐19 has been relatively low and the moral sensitivity level of nurses has been moderate. This study also identified that the perceived high level of nurses' moral sensitivity was associated with high self‐reported care quality. The study suggests that improving nurses' moral sensitivity might improve care quality for patients with COVID‐19. When working with and relating to the patients, nurses should be familiar with and aware of moral issues, and they should employ this awareness during a pandemic to perform better during critical conditions. Moral decision‐making during a pandemic has a considerable effect on nursing care quality and performance. Thus, managers in health systems should be able to identify or correct the barriers to quality nursing care for patients with COVID‐19. It is suggested to focus educational programmes in the form of workshops or seminars on practical and occupational training with moral conflicts. In nursing education, nursing trainers should focus on training ethics so that they could empower students to gain professional ethical knowledge. The presentation of ethical education and its development, and presence of ethical and moral guidelines, can be very useful and effective for nurses during a pandemic. Through evidence‐based decision‐making, they can use the available evidence for developing problem‐solving skills, and teamwork among nurses to handle ethical and moral situations in pandemics. It is suggested to offer moral consultation for the healthcare team during pandemic so that the burden of moral conflicts would decrease.
FUNDING INFORMATION
This study is part of the M.Sc. thesis of the first author at Hamadan University of Medical Sciences (NO.140008257011) in Iran.
CONFLICT OF INTEREST STATEMENT
Nothing to declare.
ACKNOWLEDGEMENTS
The authors would like to acknowledge the participation of the nurses from the investigated hospitals.
Darzi‐Ramandi, M. , Sadeghi, A. , Tapak, L. , & Purfarzad, Z. (2023). Relationship between moral sensitivity of nurses and quality of nursing care for patients with COVID‐19. Nursing Open, 10, 5252–5260. 10.1002/nop2.1763
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.