Nurses’ caring behaviour and its correlation with moral sensitivity

Abstract

Background

Different and contradictory results have been reported for nurses’ caring behaviour and moral sensitivity.

Aims

The present study aimed to examine the correlation between nurses’ caring behaviour and moral sensitivity.

Methods

The research was a descriptive, correlational study. Data were collected using moral sensitivity (range: 0–100) and caring behaviour (range: 24–144) questionnaires. A total of 250 nurses who worked in the clinical wards of Yasuj teaching hospitals in 2018, were selected by systematic random sampling. The collected data were analysed using SPSS version 19 for descriptive statistics and Pearson correlation tests.

Results

Seventy-four percent of nurses had moderate moral sensitivity (50–74). Nurses’ moral sensitivity and caring behaviour mean scores were reported to be 59.5 ± 11.1 (range: 31–87) (Potential range 0--100) and 110.99 ± 17.99 (range: 69–94) (Potential range 22–144), respectively. The Pearson test showed a positive correlation between nurses’ caring behaviour and moral sensitivity at a 99% level (p = 0.001).

Conclusions

Nurses’ moral sensitivity and caring behaviour were found to be moderate and good, respectively. Furthermore, there was a positive correlation between moral sensitivity and caring behaviour in nurses, that is, nurses provided better caring behaviour as levels of moral sensitivity increased.

Introduction

Nurses’ actions have two behavioural and ethical dimensions – these dimensions are interdependent. Caring, the core of the nursing profession is the primary nursing practice. Various definitions of caring have been presented by nursing theorists due to its abstract nature and therefore, the challenge of accurately describing it (Blasdell, 2017). For instance, Leininger introduces care as a unique natural instinct in human society (Leininger, 1988). According to Watson, caring has an ethical dimension under which the human value system guides nursing staff practice. It is believed that nurses’ caring behaviour has two aspects: expressive and operational activities. Expressive activities are supportive actions employed by nurses, such as honesty, trust, hope and empathy, that affect the human mood. Operational activities provide tangible services to meet basic living needs such as promoting comfort and pain relief (Watson, 2008). Nursing practices are not limited to technical knowledge and skill, they also comprise ethical efforts to judge and ethical decision-making in clinical places (Thorkildsen and Råholm, 2010).

Nurses engage in therapeutic communication with patients (Cavinder, 2014; Sadrollahi and Khalili, 2015). Recently, moral sensitivity has been increasingly emphasised in relation to nurse–patient interactions (Nora et al., 2017). It is a subjective concept that enables individuals to recognise moral conflicts in situations where the patients could be vulnerable (Yasin et al., 2020). Nurses need to be morally sensitive to interpret patients’ verbal and nonverbal behaviours (Schluter et al., 2008). In fact, this is the first stage of ethical decision-making in nursing (Imanifar et al., 2015; Kohansal et al., 2018). Moral sensitivity indicates nurses’ understanding of the ethical consequences of caring decisions (Lützén and Ewalds-Kvist, 2013). Moral sensitivity also helps nurses resolve ethical conflicts in their personal and professional lives (Baykara et al., 2015; Tazakori et al., 2018). It not only guides nurses towards ethical decision-making in facing ethical dilemmas and challenges (Ahn and Yeom, 2014), but also improves the quality of their professional performance (Karimi Noghondar et al., 2016). Results of studies indicate that moral sensitivity is associated with professional competence, high-quality care (Ertuğ et al., 2014), professional responsibility and accountability (Abdou et al., 2010). All such qualities are based on an holistic care approach to respond to patients’ physical, psychological, social and spiritual needs (Udomluck et al., 2010).

Advances in technology and increasing health-related change have raised new professional issues in relation to nurses’ caring behaviour. Caring behaviour, as an essential part of nursing practice (Poirier and Sossong, 2010), refers to actions related to a patient’s well-being (Ehlers, 2008). It was conceptualised as an interactive process (Loke et al., 2015) and includes both expressive behaviours and instrumental activities (Karlou et al., 2015).

Professional ethics can guide these processes and activities (Leuter et al., 2018; Leuter et al., 2013). In other words, moral sensitivity is necessary to ensure the quality of nurses’ caring behaviour (Hassanpoor et al., 2011). A literature review found variable levels of moral sensitivity in nurses: they were moderate in some studies (Nora et al., 2017; Kim et al., 2013; Yeom et al., 2017; Dalvand et al., 2019) and high in others (Tazakori et al., 2018; Karimi Noghondar et al., 2016; Mousavi et al., 2015; Ohnishi et al., 2019). This variation may be due to different social and cultural contexts as effective factors in promoting nurses’ moral sensitivity (Robinson et al., 2014).

Based on the results of published studies and available evidence, we surmised first that few studies have been conducted on the correlation between nurses’ moral sensitivity and caring behaviour. Second, nurses’ caring behaviour, especially expressive activities, can be influenced by social, cultural, belief and value systems, even economic factors. Therefore, due to the different social and cultural contexts of Iranian nurses and their possible impact on caring behaviour, the present study aimed to determine the correlation between nurses’ caring behaviour and moral sensitivity. The two main questions in this study were,

1. What are the levels of nurses’ moral sensitivity and caring behaviour?

2. Is there a correlation between nurses’ caring behaviour and moral sensitivity?

Method

Design and sample size

The present study was a descriptive, correlational study. The statistical population consisted of nurses who worked in the clinical wards of three teaching hospitals in the city of Yasuj, in southwestern Iran, in 2018. The sample size for this study was estimated to be 250 nurses based on the statistical formula (N =  $(\frac{{\text{Z}}_{(1-\alpha )}^2*{\text{S}}^2}{{\text{d}}^2})$ . Nurses were selected through a systematic random sampling method. Based on the number of nurses in each hospital, 100 were selected from Shahid Beheshti Hospital, 100 from Imam Sajjad Hospital, and 50 from the social welfare hospital. Inclusion criteria were: working in clinical wards, having at least a year of work experience, not working in a profession other than nursing, and willingness to participate in the study. Unwillingness to participate in the study and non-completion of questionnaires were considered the exclusion criteria.

Instruments

Data were collected using moral sensitivity and caring behaviour questionnaires. The Moral Sensitivity Questionnaire (MSQ) was originally developed with 30 items (Lützén et al., 1997). However, three of these items were deleted by the researchers due to them being related to psychiatric nursing contexts, leaving a questionnaire that can measure nurses’ moral sensitivity in a more general way (Han et al., 2010). Six subscales were defined: modifying autonomy, patient-oriented care, professional responsibility, conflict, meaning, and benevolence. Two items of the original 27-item version were deleted for reasons of cultural adaptation in the Persian version of MSQ. This 25-item MSQ with a five-point Likert scale (0 = have no idea, 1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree) has frequently been used by Iranian researchers to measure nurses’ moral sensitivity. Six subscales were defined in the Iranian version of the MSQ: modifying autonomy (3 items), patient-oriented care (5 items), professional responsibility (2 items), moral conflict (3 items), moral meaning (5 items), and benevolence (7 items). The range of the MSQ was 0–100, with higher scores indicating a greater degree of moral. A score of 0–50 indicates low moral sensitivity, 51–75 moderate moral sensitivity, and 76–100 high moral sensitivity. The validity of the Persian version was confirmed with a Cronbach’s alpha coefficient of 0.81 (Borhani et al., 2016). We again checked for our study and found a result of r=0.89.

The Caring Behaviors Inventory, or CBI-24, was originally developed by Wolf (2003) in the context of caring theory. The CBI-24’s theoretical definition is focused on the perception of nurses’ caring. In other words, it is used to explore the perception of the frequency of caring behaviour, as practised by nurses or received by patients. It defines four subscales: assurance of human presence (8 items), which refers to actions to meet the needs and expectations of others; knowledge and skill (5 items), which includes actions viewed as proficient and skilful to others; respectful deference to others (6 items), which refers to actions that involve the validation of others’ feelings; and positive connectedness (5 items), which refers to providing prompt ongoing support (Papastavrou et al., 2012). The items are rated on a six-point Likert scale (6 = always, 5 = almost always, 4 = usually, 3 = occasionally, 2 = almost never, 1 = never). The total score ranges from 24 to 144. The higher the mean of responses, the more frequently caring behaviour is perceived. This inventory has frequently been used by Iranian researchers (Asadi and Shams, 2014; Mohammadi et al., 2014). We again checked that its reliability was verified by our study and found a result of r=0.93.

Data analysis

The collected data were analysed using SPSS version 19 (IBM Corp, Armonk, NY, USA) employing descriptive statistics including frequency, and percentage for categorical variables such as gender, marital status, education level and clinical setting. Means and standard deviation were calculated for continuous variable such as age, work experience, and working hours. Pearson’s correlation test was used to test for a correlation between moral sensitivity and caring behaviour at a 99% confidence interval. Because the score distributions of both variables were normal, the result of Pearson test was reported.

Results

In the current study, 55 male (22%) and 195 female nurses (78%) participated with an overall mean age of 32.6 ± 4.9 years (range: 22–48), mean work experience of 67.6 ± 34.4 months (range: 7–300 months), and mean working hours of 44.4 ± 7.6 hours per week (range: 32–70 hours) (Table 1).

Table 1.

Nurses’ demographic data.

Age	Mean + standard deviation	32.6 ± 4.9
Gender N (%)	Male	55 (22)
	Female	195 (78)
Marital status N (%)	Single	113 (45.2)
	Married	137(54.8)
Education N (%)	Associate Degree	22 (8.8)
	Bachelors Science	214 (85.6)
	Master Science	14 (5.6)
Clinical setting N (%)	Medicine	48 (19.2)
	Surgery	52 (20.8)
	Emergency	59 (23.6)
	Paediatric/nursery	39 (15.6)
	Intensive care	42 (16.8)
	Gynaecology/obstetrics	10 (4)

The findings indicates that 70.4% of nurses had a moderate level (scores of 50–74), 18% a low level (scores of 0–49), and 11.6% of them had a high level of moral sensitivity. The total mean score of moral sensitivity was 59.5 ± 11.1 (range: 31–87, and quartiles 25, 50, 75; reported as 52, 58 and 65, respectively). According to the mean per item of the MSQ subscales, nurses rated trust in medical knowledge and principles of care (2.43) to be the most valued subscale, followed by structuring moral meaning (2.40), experiencing moral conflict (2.39), modifying autonomy (2.38), interpersonal orientation (2.34) and lastly, benevolence (2.33) (Table 2). No significant difference was observed in female and male nurses’ moral sensitivity.

Table 2.

Mean scores of nurses’ moral sensitivity subscales.

Moral sensitivity subscales	Items summation of subscales			Per item
	Mean ± SD	Observed range	Possible range	Mean	Observed range	Possible range
Modifying autonomy (3 items)	7.1 ± 2.3	0–12	0–12	2.38	0–4	0–4
Patient-oriented care (5 items)	11.7 ± 3.4	3–20	0–20	2.34	0.6–4	0–4
Professional responsibility (2 items)	4.9 ± 1.9	0–8	0–8	2.43	0–4	0–4
Moral conflict (3 items)	7.2 ± 2.5	0–12	0–12	2.39	0–4	0–4
Moral meaning (5 items)	12 ± 3.2	3–19	0–20	2.40	0.6–3.8	0–4
Benevolence (7 items)	16.3 ± 3.8	5–27	0–28	2.33	0.7–3.8	0–4
Total MSQ-25 items	59.5 ± 11.1	31–87	0–100	2.38	1.4–3.4	0–4

Mean scores of nurses’ caring behaviour were 110.97 ± 17.99 (range: 69–144, and quartiles 25, 50, 75; reported as 97, 109 and 122, respectively). According to the mean per item of the CBI-24 subscales, nurses rated knowledge and skills (4.87) to be the most valued subscale, followed by connectedness (4.62), respectfulness (4.53), and assurance (4.53) (Table 3). No significant difference was observed in female and male nurses’ caring behaviour.

The Pearson test indicated a positive correlation between nurses’ caring behaviour and their moral sensitivity at a 99% level (p = 0.001, r = 0.4). In other words, nurses who had higher moral sensitivity provided better caring behaviour.

Discussion

The results from this study indicated that Iranian nurses rated trust in medical knowledge and principles of care to be the most valued subscale of the MSQ, followed by structuring moral meaning, experiencing moral conflict, modifying autonomy, interpersonal orientation, and benevolence. Moreover, Iranian nurses reported moderate levels of moral sensitivity. In a similar study in Brazil, the moral sensitivity of 100 nurses was examined using a 28-item modified MSQ questionnaire: Nora et al. (2017) reported nurses’ moral sensitivity to be moderate. Although this finding was congruent with our study, and both studies comprised multicentre samples, they used different questionnaires. Basar and Cilingir (2019) also assessed the moral sensitivity of 160 nurses who worked in surgical intensive care units (ICUs) across six Turkish hospitals.They reported moderate levels of moral sensitivity as well as statistical differences for moral sensitivity according to workplace, years of nursing experience, and duration of working in an ICU (Basar and Cilingir, 2019). Morever, in similar studies conducted with paediatric nurses (Arslan and Calpbinici, 2018), clinical nurses (Aksu and Akyol, 2011) and critical care nurses (Borhani et al., 2017) moral sensitivity was found to be moderate. Although the majority of the studies reported a moderate level of nurse moral sensitivity, in contrast, a high level of moral sensitivity was reported by Mohammadi et al. (2014) for nurses who worked in the ICU.

Table 3.

Mean scores of nurses’ caring behaviour subscales.

Caring behaviour subscales	Items summation of subscales			Per item
	Mean ± SD	Observed range	Possible range	Mean	Observed range	Possible range
Assurance (8 items)	36.3 ± 7.8	17–48	8–48	4.53	2.1–6	1–6
Knowledge and skill (5 items)	24.4 ± 4.7	10–30	5–30	4.87	2–6	1–6
Respectfulness (6 items)	27.2 ± 5.8	10–36	6–36	4.53	1.67–6	1–6
Connectedness (5 items)	23.1 ± 5.3	9–30	5–30	4.62	1.8–6	1–6
Total CBI-24 items	110.97 ± 17.99	69–144	24–144	4.62	2.88–6	1–6

In another finding from the current study, mean item scores for the CBI-24 for Iranian nurses were reported to be 4.62 for knowledge and skills – the most valued subscale – followed by connectedness, respectfulness, and then assurance. Furthermore nurses’ caring behaviour was observed to be at good or high levels. These results were in accordance with studies by He et al. (2013), Izadi et al. (2013) and Yau et al. (2018), but are in contrast to studies conducted by Loke et al. (2015) and Mohammadi et al. (2017). These discrepancies between the studies may be due to one or more of the following: different methodologies, nurses’ characteristics, research environments, or questionnaires applied. Furthermore, the ability to care is closely related to nurses’ values, knowledge, and work experiences (Watson, 2008) as well as social and cultural contexts; even individual belief systems may influence human caring (Robinson et al., 2014).

In this study, a positive correlation was found between nurses’ caring behaviour and their moral sensitivity. In other words, nurses with higher moral sensitivity reported better caring behaviour. As stated in the introduction, no study was found to have reported a correlation between nurses’ caring behavior and moral sensitivity. However, published studies have reported on the correlation between nurses’ moral sensitivity and clinical self-efficacy (Tazakori et al., 2018), patients’ rights (Mahdiyoun et al., 2017), and patient satisfaction (Freitas et al., 2014; Shahvali et al., 2018) that could support the findings of the current study. To explain the observed correlation in the current study, it can be said that moral sensitivity is an important attribute for nurses, which enables them to provide high-quality and safe care in an environment where they may be confronted with ethical issues related to making decisions, fairness in the care provided, and related to patients’ needs, rights, and problems (Muldrew et al., 2019). In other words, moral insensitivity or the inability to identify ethical challenges may lead to inappropriate caring behaviour (Leuter et al., 2018). Moral sensitivity helps nurses to be responsive to patients’ needs or those of their families (Goethals et al., 2010; Mokhtari Lakeh et al., 2014) because the decisions made by nurses depend on the degree of their moral sensitivity (Callister et al., 2009).

Strengths, limitations and recommendations

The random sampling method was considered to be a strength of the current study. However, we acknowledge that this study also had several limitations. First, this study took place in three hospitals from only one city, which may have different approaches to delivering nursing care. This should be considered in relation to generalisation of the results to the nursing population across Iran. Second, although, the current study sought to use valid questionnaires, a review of existing studies indicated that different questionnaires have been used to assess caring behaviour and moral sensitivity. For example, a 42-item CBI with a four-point Likert scale (Mlinar, 2010); a CBI-42 with a six-point Likert scale (Mohammadi et al., 2014), the CBI-24 with a six-point Likert scale (Karlou et al., 2015) and a CBI-24 with a five-point Likert scale (Rostami et al., 2019) were used by researchers. These differences in the numbers of items and rating scales may not only result in different and sometimes contradictory results but also make it difficult to compare findings. Last, we used a quantitative design to assess both moral sensitivity and caring behaviour by self-reporting. It is acknowledged that this approach is not without flaws; this design is useful but may prevent a more in-depth examination and understanding of nurses’ moral sensitivity and caring behaviour. Therefore, it is suggested that nurses’ caring behaviour should be observed to improve clinical judgement.

Conclusion

The present study determined that nurses had a moderate level of moral sensitivity and a high level of caring behaviour and that nurses were morally sensitive and reported good levels of caring behaviour. Furthermore, nurses provided higher caring behaviour as their level of moral sensitivity increased.

Implications for practice

Nurses – as primary members of the healthcare team – are not only responsible for providing high-quality care to patients and their families but they may also sometimes be required to take action on behalf of their patients. This emphasises that nurses should be morally sensitive in their caring behaviour towards people who are in need of nursing care. We studied the correlation between nurses’ moral sensitivity and their caring behaviour. The results of our study showed that high moral sensitivity contributed to the nurses’ caring behaviour towards patients. Although this study was relatively small, because moral sensitivity is an important nurse attribute in determining and solving the ethical challenges inherent in caring, its results could make a significant contribution to nurses’ everyday practice of moral sensitivity in caring behavior. In addition, nurses need to be guided by clear principles of caring behaviour, including social, communicative, organisational, nursing and technical competences. Therefore, it is important for nurses to understand that nursing practice is affected by their moral values, which influence how they behave towards their patients; moral sensitivity in today’s nursing will help provide good nursing practices.

Key points for policy, practice and/or research

• Iranian nurses considered moral sensitivity when undertaking their caring behaviour.

• Nurses’ caring behaviour was influenced by their moral sensitivity.

• A high moral sensitivity enabled nurses to provide high-quality caring behaviour.

Biography

Ardashir Afrasiabifar is a Professor of Nursing. He is a member of the faculty of Yasuj University of Medical Sciences, Iran. He is the Vice Chancellor for Research at the School of Nursing and has extensive experience in nursing education and research.

Asadolah Mosavi holds a Master of Science in Medical Education. He is an instructor at Yasuj School of Nursing. He is currently a PhD student of medical education and has experience in patient care and nursing education.

Abolfazl Dehbanizadeh holds a Master of Science in Adult Nursing. He is a member of the faculty of Yasuj University of Medical Sciences. He is a nursing instructor and has extensive experience in patient care and nursing education.

Sahar Khaki holds a Master of Science in Psychiatric Nursing. She has extensive experience in patient care and is currently working at Shahid Beheshti Hospital in Yasuj. Her interest is in researching ethical issues in nursing.