Abstract
Introduction: The quality of care affects patients’ satisfaction. To provide high quality care, nurses face ethical challenges in daily practice. Moral sensitivity is the first phase in moral implementation. This study aimed to determine the relationship between nurses’ moral sensitivity and patients’ satisfaction in medical wards.
Methods: In descriptive correlational study 198 nurses and 198 patients in 17 medical wards filled out the Moral Sensitivity Questionnaire (MSQ) and Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ), respectively. Nurses were sampled by the census method. For each nurse, a patient was selected randomly from the same ward. Data were analyzed using SPSS version 13.
Results: The highest scores were in the dimensions of “relational orientation” and “following the rules”, and the lowest scores were in the dimensions of “autonomy” and “experiencing moral conflicts”. The highest level of patients’ satisfaction was with “nurses’ professional performance” 3.98 (1.09), and the lowest level was with “nurses’ routine work” 2.69 (1.22). There was no significant relationship between the mean of patient satisfaction and moral sensitivity of nurses.
Conclusion: Considering that nurses had a higher score in dimension of “following the rules” and a lower score in dimension of “autonomy”, it seems ethical performance in the real situation is not merely due to the nurses’ moral sensitivity and it seems the complexity of the organization causes nurses face difficulties in making decisions related to clinical practice; therefore, policy makers in the health system should be able to identify barriers.
Keywords: Moral sensitivity, Nurses, Personal satisfaction, Patients, Care
Introduction
Today’s world approach can be considered as a return to morality and rationality. Mankind after going through different periods uses moral approach to satisfy its material and spiritual needs so morality must be recognized as the center of attention for all future developments in the world.1 Ethics has been defined as a set of moral values or ethical principles which regulate the behavior of an individual or an occupation,2 ethics search the best way of caring for patients as well as the best nursing function. Nurses as one of the health service providers who are responsible for giving care to the patients based on ethical issues.3
Nurses are faced with issues like the right to life and death; the increasing medical interventions in patient care; changes in health requirements and nursing concepts; grows in numbers of elderly people and end of life care; limiting patients autonomy and so on. All of these factors have led nurses to be treated with this situations that require ethical decision-making.4 In a study by Başak et al., in Turkey, 46.7% of nurses in special wards were faced with moral problems, and 35.7% of them were unable to solve their moral problems.5
Moral sensitivity is used to describe the capacity and ability of a person in the process of ethical decision making. In the process of ethical decision making, moral sensitivity definitions as the nurses’ knowledge of patients’ vulnerability and predict the results of moral decision-making in patients, it enables them to make a moral decision for patients.6 Having a capacity to deal with and resolving moral conflicts is essential for providing high-quality nursing care.7 The development of ethical decision-making in nursing increases the quality of care and providing services based on best practice and scientific learning. In addition, if moral conflicts cannot be resolved, it can be affected the nurses’ ability and can benegative impacted on the quality of nursing care.8 Patients’ satisfaction is one of the important indicators for assessing the quality of health services.9
Patient satisfaction is a multi-dimensional complex structure that is the result of a comparison of an individual’s health care experiences against one’s own subjective standards.10 Some have defined patient satisfaction as appropriateness between the patient’s expectations of ideal care and their perception of actual care.11 Researchers believe that high satisfaction leads to faster physical and psychological recovery of patient. In addition, patients who are more satisfied show better adherence with treatment and more compliant and cooperative.12
Patient satisfaction is largely dependent on nursing care.13 Although studies have shown that nurses’ awareness of their ethical responsibilities are becoming increasingly, however nurses have been ill-prepared to identify ethical dilemma and determining the appropriate method to solve the moral problem.14 Various studies have shown that many barriers affect the moral sensitivity of nurses in practice.15
Considering the importance of ethical issues in the provision of care to patients7 and considering the importance of nurses to the delivery of high-quality patient care,16 this study was designed. Although moral sensitivity has been studied in nurses,17 this study was designed to contribute to the body of knowledge by different approach to looking at patients’ satisfaction and moral sensitivity. The purpose of this study was to describe the relationship between nurses’ moral sensitivity and patients’ satisfaction with the nursing care in hospitals affiliated with Tabriz University of Medical Sciences.
Materials and Methods
This is a descriptive correlational study. The research conducted in hospitals affiliated with Tabriz University of Medical Sciences. The first target population was nurses working in 17 medical wards, whose inclusion criteria were: (1) bachelor’s degree or higher, (2) nurses who are involved in the direct care of the patient in one of the medical wards, (3) having at least 6 months of clinical work experience and (4) willingness to participate in the research. After obtaining a research license from the ethics committee of Tabriz University of Medical Sciences, and after obtaining permission from the head of the hospitals and department authorities, the researcher would attend in wards. Then, after obtaining the cooperation of the nurses, the researcher gave them the questionnaires to complete.
The second target population was patients admitted 17 medical wards of hospitals affiliated with Tabriz University of Medical Sciences. The inclusion criteria were: (1) being at least 18 years of age, (2) not suffering from any known cognitive or psychological disorders, (3) being hospitalized in one of the medical wards of the hospital, (4) receiving care from all nurses in that ward, (5) lack of pain and nausea and lack of tiredness while completing the questionnaire and (6) willingness to participate in the research. The researcher went to the wards in the middle of the shift and, after introducing herself to the patients and explaining the goals of the study completed the questionnaire herself by interview. It should be noted that it was explained to the patients that, while answering the questions, they had to consider all nurses taking care of them during the hospitalization period. Data were collected for three months from July to September 2016. Before information was collected, nurses and patients were informed about the goals and methods of the study, the confidentiality of the information, and the right to withdraw from the study if desired, and then informed consent was obtained. Nurses participating in the study were informed that their participation or lack thereof would not affect their job performance evaluation.
Using the results of a study by Mousavi et al.,18 and considering the confidence coefficient 95%, d = 0.05, and standard deviation of 0.41, the sample size was calculated as 259 nurses. The census method was used due to the limited number of nurses in the medical wards of Tabriz. In all, 198 qualified nurses were considered as the final sample size. In this study, for each nurse, a patient was selected from the same ward. A simple random sampling method was implemented by using lottery method. Since providing care in the wards under study was not the case method, patients were informed to consider all nurses and not focus on a particular nurse while answering the questions on the questionnaire. They were also reminded that this questionnaire was intended solely to examine the nurses’ caring behaviors and caring behaviors of other personnel in the wards were not intended.
The demographic characteristics form and Moral Sensitivity Questionnaire (MSQ) were used to collect nurses’ data. The demographic characteristics form included gender, age, marital status, work experience, employment status, education level, and type of working shift. The MSQ was developed by Lützén et al., in Sweden and then used in various countries such as Iran.19,20 The questionnaire has 28 questions, which are scored on a 7-point Likert scale from completely agree (7) to completely disagree (1). The total score of the questionnaires varies from 28 to 196. The questionnaire has six dimensions including respect for “autonomy”, “relational orientation”, “following the rules”, “experiencing moral conflict”, “structuring moral meaning”, and “expressing benevolence”. In this study, a score in the range of 28–84 was considered as low moral sensitivity, a score in the range of 85–141 was considered as moderate moral sensitivity, and a score in the range of 142–196 was considered as higher moral sensitivity. To confirm the face and content validity, the questionnaire was given to 10 faculty members of Tabriz University of Medical Sciences, and their corrective comments were applied. To assess the reliability of the questionnaire, after gathering information from 20 nurses, internal consistency was calculated, obtaining a Cronbach’s alpha coefficient of 0.7.
The Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ) was designed by Laschinger et al.,21 This questionnaire consists of 22 questions, and the answers to the questions are graded on a 5-option Likert scale from excellent to poor. The score range is from 22 to 110. In this study, the scores 22–51 show low satisfaction, 52–81 shows medium, and 82–110 shows high satisfaction. In the present study, 10 faculty members of Tabriz University of Medical Sciences were asked to complete the questionnaire to determine face and content validity, and their corrective comments were applied. Twenty patients were interviewed to assess the reliability of the questionnaires. The internal consistency of the questionnaire was calculated using Cronbach’s alpha coefficient, obtaining a value of 0.95.
Data were analyzed by SPSS (version 13; SPSS Inc., Chicago, IL, USA). Using descriptive statistics (mean and standard deviation, frequency and percent) and inferential statistics (Pearson correlation coefficient), data were analyzed at the significance level of 0.05. There were two different statistical groups (nurses and patients); therefore, to determine the correlation between patients’ perception of nursing care and moral sensitivity of nurses, medical wards were considered as the research unit. Then, the mean score of patients’ satisfaction of nursing care and nurses’ moral sensitivity were calculated for each ward. Finally, the relationship between these two variables was investigated using the Pearson correlation test. The Shapiro–Wilk test showed that the two variables were normally distributed.
Results
In all, 198 nurses and 198 patients participated in 17 medical wards of hospitals affiliated with Tabriz University of Medical Sciences. The mean (SD) age of nurses was 31.19 (5.89) years, and the majority of nurses participating in the study were female (96.5%). The mean (SD) age of the patients was 54.44 (19.13) years. Table 1 shows detailed information of the demographic characteristics of nurses and patients.
Table 1. Sociodemographic characteristics of respondents (N=198) .
| Variable | Nurses | Patients | |
| No. (%) | No. (%) | ||
| Gender | Male | 7 (3.5) | 106 (53.5) |
| Female | 191 (96.5) | 92 (46.5) | |
| Education | No formal education | - | 65 (32.8) |
| Elementary | - | 46 (23.2) | |
| Secondary | - | 29 (14.6) | |
| High school | - | 42 (21.2) | |
| University | - | 16 ( 8.1) | |
| BSc | 192 (97.5) | - | |
| MSc | 5 (2.5) | - | |
| Marital status | Single | 75 (36.1) | 24 (12.1) |
| Married | 122 (61.9) | 154 (77.8) | |
| Divorced or widow | - | 20 (10.1) | |
| Employment status | Formal | 98 (50.3) | - |
| Plan | 65 (33.3) | - | |
| Contract | 32 (16.4) | - | |
| Income status | Less than living expenses | - | 66 (33.5) |
| Equal living expenses | - | 124 (62.9) | |
| More than living expenses | - | 7 (3.6) | |
| History of hospitalization | Yes | - | 159 (80.3) |
| No | - | 39 (19.7) |
Study results showed that 0.5%, 66.7%, and 32.8% of nurses had low, moderate, and high moral sensitivity, respectively. The lowest scores were in the dimensions of “autonomy” and “experiencing moral conflicts” and the highest scores were in the dimensions of “relational orientation” and “following the rules.” The mean (SD) score of nurses’ moral sensitivity in the dimensions of “autonomy”, “relational orientation”, “following the rules”, “experiencing moral conflict”, “structuring moral meaning” and “expressing benevolence” was 4.31(0.79), 5.45 (0.73), 5.15 ( 0.93), 3.61 (1.06), 4.40 (0 .52), and 4.81 (0 .67), respectively.
The mean (SD) score of satisfaction from the viewpoint of patients was 72.84 (19.07). In all, 27 (13.6%), 100 (50.5%), and 71 (35.9%) of patients reported poor, moderate, and high levels of satisfaction, respectively. The highest satisfaction rate was with the dimension of nurses’ professional performance 3.98 (1.09), and the lowest level of satisfaction concerned nurses’ routine work and a lack of flexibility in their daily care 2.69 (1.22), coordination of care after discharge 2.74 (1.27), the way nurses inform family or friends about your situation and needs 2.82 (1.36), and discharge instructions 2.92 (1.28) (Table 2).
Table 2. Frequency of patient's satisfaction with each item of questionnaire .
| PSNCQQ items | Rating scale | ||||||
|
Excellent
No. (%) |
Very Good
No. (%) |
Good
No. (%) |
Fair
No. (%) |
Poor
No. (%) |
Mean (SD) | ||
| 1 | Information you were given. | 29 (14.6) | 35 (17.7) | 59 (29.8) | 53 (26.8) | 22 (11.1) | 2.98 (1.21) |
| 2 | Instructions. | 39 (19.7) | 38 (19.2) | 57 (28.8) | 44 (22.2) | 20 (10.1) | 3.16 (1.16) |
| 3 | Ease of getting information. | 31 (15.7) | 37 (18.7) | 70 (35.4) | 44 (22.2) | 16 (8.1) | 3.12 (1.16) |
| 4 | Information given by nurses. | 25 (12.6) | 49 (24.7) | 74 (37.4) | 39 (19.7) | 11 (5.6) | 3.19 (1.06) |
| 5 | Informing family or friends. | 21 (10.6) | 34 (17.2) | 58 (29.3) | 49 (24.7) | 35 (17.7) | 2.82 (1.36) |
| 6 | Involving family or friends in your care. | 62 (31.3) | 42 (21.2) | 53 (26.8) | 30 (15.2) | 11 (5.6) | 3.58 (1.23) |
| 7 | Concern and caring by nurses: Courtesy and respect you were given; friendliness and kindness. | 64 (32.3) | 57 (28.8) | 49 (24.7) | 21 (10.6) | 7 (3.5) | 3.76 (1.12) |
| 8 | Attention of nurses to your condition. | 58 (29.3) | 44 (22.2) | 57 (28.8) | 28 (14.1) | 11 (5.6) | 3.56 (1.20) |
| 9 | Recognition of your opinions. | 33 (16.7) | 43 (21.7) | 53 (26.8) | 47 (23.7) | 22 (11.1) | 3.09 (1.25) |
| 10 | Consideration of your needs: Willingness of the nurses to be flexible in meeting your needs. | 24 (12.1) | 44 (22.2) | 63 (31.8) | 54 (27.3) | 13 (6.6) | 3.06 (1.11) |
| 11 | The daily routine of the nurses: How well they adjusted their schedules to your needs. | 19 (9.6) | 31 (15.7) | 55 (27.8) | 55 (27.8) | 38 (19.2) | 2.69 (1.22) |
| 12 | Helpfulness. | 38 (19.2) | 48 (24.2) | 63 (31.8) | 35 (17.7) | 14 (7.1) | 3.31 (1.17) |
| 13 | Nursing staff response to your calls. | 66 (33.3) | 37 (18.7) | 42 (21.2) | 31 (15.7) | 22 (11.1) | 3.47 (1.38) |
| 14 | Skill and competence of nurses. | 88 (44.4) | 45 (22.7) | 40 (20.2) | 23 (11.6) | 2 (1.0) | 3.98 (1.09) |
| 15 | Coordination of care. | 70 (35.4) | 50 (25.3) | 41 (20.7) | 29 (14.6) | 8 (4.0) | 3.73 (1.20) |
| 16 | Restful atmosphere provided by nurses. | 54 (27.3) | 46 (23.2) | 50 (25.3) | 25 (12.6) | 23 (11.6) | 3.42 (1.32) |
| 17 | Privacy. | 89 (44.9) | 42 (21.2) | 31 (15.7) | 28 (14.1) | 8 (4.0) | 3.89 (1.23) |
| 18 | Discharge instructions. | 29 (14.6) | 36 (18.2) | 56 (28.3) | 44 (22.2) | 33 (16.7) | 2.92 (1.28) |
| 19 | Coordination of care after discharge. | 22 (11.1) | 35 (17.7) | 51 (25.8) | 49 (24.7) | 41 (20.7) | 2.74 (1.27) |
| 20 | Overall quality of nursing care you received during your hospital stay. | 51 (25.8) | 47 (23.7) | 61 (30.8) | 29 (14.6) | 10 (5.1) | 3.51 (1.17) |
| 21 | In general, would you say your health is. | 28 (14.1) | 42 (21.2) | 73 (36.9) | 34 (17.2) | 21 (10.6) | 3.11 (1.17) |
| 22 | Based on the nursing care I received, I would recommend this hospital to my family and friends. | 73 (36.9) | 52 (26.3) | 40 (20.2) | 20 (10.1) | 13 (6.6) | 3.77 (1.23) |
The results of the Pearson correlation test showed that there was no significant correlation between the two variables of nurses’ moral sensitivity and patient satisfaction with nursing care (r=0.04, P =0.8). Table 3 shows the relationship between nurses’ moral sensitivity and its dimensions with patient satisfaction.
Table 3. Relationship between nurses’ moral sensitivity and its dimensions with patient satisfaction .
| Moral sensitivity | Total score of satisfaction |
| Experiencing moral conflicts | r=- 0.46, P =0.06 |
| Structuring moral meaning | r=0.35, P=0.1 |
| Relational orientation | r=0.03, P =0.8 |
| Expressing benevolence | r=- 0.02, P =0.9 |
| Autonomy | r=0.25, P =0.3 |
| Following the ‘rules’ | r=0.12, P =0.6 |
| Total | r =0.04, P =0.8 |
Discussion
The results of this study showed that the moral sensitivity of the majority of nurses and the satisfaction of patients with nursing care provided are at desired level. Although it seems that the people’s behavior appears to be somewhat reflective of their morals and sensitivities, which can affect nursing care and subsequently affect patients’ satisfaction. This study showed that there is no statistically significant correlation between nurses’ moral sensitivity and patients’ satisfaction with the nursing care provided.
In the present study, patients were the most dissatisfied with “nurses’ routine work.” According to Papes et al., nowadays, routine-centered nursing work is a serious nursing problem, and a general attempt to replace it with methods based on a patient-centered approach has been considered by all nursing experts.22 In fact, a separation of theory and practice in the nursing profession is highly visible, and nurses focus more on dimensions of skill rather than nursing art.23 On the other hand, in the present study, in comparison with the study by Lützén et al., nurses also had a higher score in the dimension of “Following the rules” as one of the dimensions of moral sensitivity.24 It seems that structural defects in support of nurses causes clinical nurses develop a routine work-based approach in practice and refrain from having their own independent intervention.25 A study by Adib-Hajbaghery et al., in Iran showed that the ethical decisions making by a nurse is also based on routine tasks and physicians’ orders.15 Lack of sufficient self-confidence in decision-making is an important barrier to patient independence which causes patients’ dissatisfaction.26 In the present study, nurses had a lower score in the dimension of “Autonomy”. Consideration patient autonomy stands on the opposite side of medical paternalism.27,28 Paternalistic medicine is deeply embedded in Iranian culture.29 It seems in this kind of circumstances the nurses may find themselves disempowered by medical paternalism or ill-equipped in the decision-making process and may increase patient dependency inactive relationships.30
One of the factors affecting patient independence is to facilitate the development of self-care or independence through teaching and education during hospitalization and at the time of discharge31However, in the present study, patients presented low satisfaction with questions related to “patient education”.
Although, in most studies outside Iran, nurses had higher scores in “Structuring moral meaning” as one of the dimensions of moral sensitivity,24,32 in the present study, like other study inside the country,19 nurses scored less in this dimension, and it seems that Iranian nurses are not able to apply ethical knowledge in the clinical environments.29 The results of the research shows that nurses are therefore faced with complex care conditions in which they are expected to autonomously make decisions in delivering good care to patients while often they cannot act according to their own personal values and norms.33 A study in 2017 showed that there was a close relationship between the level of nurses’ decision-making power and their professional autonomy which is acknowledged by other caregivers on the health team.34 In the present study, patients were the most satisfied with technical skills of nurses such as control of blood pressure, giving medication, insertion of venous tract, etc. It seems this result can be related to the greater importance of managers to give to the physical care routine.
This study has a number of limitations. First, the study was performed in four hospitals affiliated with Tabriz University of Medical Sciences, so we have to be cautious in generalizing the results of this study. Second, the probability that nurses will not provide unrealistic responses, which is based on the self-report nature of the MSQ. It is also proposed that a qualitative study be conducted on the barriers to the ethical performance of nurses in Iran.
Conclusion
Although it is desirable for nurses to be morally sensitive, considering that the nurses in this study had a higher score in dimension of “following the rules” and a lower score in dimension of “autonomy”, it seems that ethical decision-making in real situations is not merely related to nurses’ moral sensitivity and it seems numerous organizational complexities make it difficult for nurses to apply their decisions in practice.Furthermore, considering the high level of patients’ dissatisfaction with “nurses’ routine work,” it seems that dutifulnessand work orientation are an obstacle to providing quality care based on ethics. Therefore, policy makers in the health system should be able to change or modify the barriers facing nurses and, along with advances in medical technology, train nurses who are able to provide comprehensive and holistic care.
Acknowledgments
We would like to thanks the authorities, nurses, patients and licensed practical nurses of the Imam Reza, Madani, Sina, and Razi hospitals of Tabriz and Dr. Akram Ghahramanian who have collaborated on the preparation of the article. We would also like to thank the Research Vice chancellor of Tabriz University of Medical Sciences for their financial support given to this research.
Ethical Issues
The present study is part of a research project entitled “Nurses’ moral sensitivity and its relationship with the quality of care and patients’ satisfaction in the medical wards of Tabriz University of Medical Sciences” number 639, which has been approved by the Regional Ethics Committee at the Research Center of Tabriz University of Medical Sciences (IR.Tbzmed.Rec.1395.224).
Conflict of Interest
The authors declare no conflict of interest in this study.
Authors’ Contributions
Study conception and design: EA, HE; Data collection: EA; Data analysis and interpretation: MV, MAJ, EA; Drafting of the article; HE, EA, MV; Critical revision of the article: HE, MV.
Research Highlights
What is the current knowledge?
The quality of care affects patients’ satisfaction. To provide high quality care, nurses face ethical challenges in their daily practice. Moral sensitivity is the first phase in moral implementation.
What is new here?
It seems ethical performance in the real situation is not merely due to the nurses’ moral sensitivity and It seems the complexity of the organization causes nurses face difficulties in making decisions related to clinical practice; therefore, policy makers in the health system should be able to identify barriers.
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