Ethical Sensitivity in Nursing Ethical Leadership: A Content Analysis of Iranian Nurses Experiences.

BACKGROUND: Considering that many nursing actions affect other people's health and life, sensitivity to ethics in nursing practice is highly important to ethical leaders as a role model.
OBJECTIVE: The study aims to explore ethical sensitivity in ethical nursing leaders in Iran.
METHOD: This was a qualitative study based on the conventional content analysis in 2015. Data were collected using deep and semi-structured interviews with 20 Iranian nurses. The participants were chosen using purposive sampling. Data were analyzed using conventional content analysis. In order to increase the accuracy and integrity of the data, Lincoln and Guba's criteria were considered.
RESULTS: Fourteen sub-categories and five main categories emerged. Main categories consisted of sensitivity to care, sensitivity to errors, sensitivity to communication, sensitivity in decision making and sensitivity to ethical practice.
CONCLUSION: Ethical sensitivity appears to be a valuable attribute for ethical nurse leaders, having an important effect on various aspects of professional practice and help the development of ethics in nursing practice.

INTRODUCTION

Making the right decision on nursing requires sufficient sensitivity to ethical issues [1], and failure to handle ethical issues in caring may result in neglecting ethical principles and values of nursing [2]. In workplaces where employees constantly receive many different messages, ethical messages can be overlooked, and the ethical leader can bring ethics to the attention of followers (employees) through frequent contacts and salient ethical messages [3].

Ethical sensitivity is an attribute that enables the identification of ethical challenges and emotional and mental perceptions of vulnerable situations of people, and awareness of ethical outcomes of decisions made by others [1, 4, 5]. Ethical sensitivity is defined as an “attention to the ethical values involved in a conflict-laden situation and a self-awareness of one’s own role and responsibility in a situation” [7]. It is a personal predisposition guiding ethical decision making [8] and involves cognitive capacity, including feelings, sentiments, moral knowledge and skills and an interrelational process [1]. Research evidence shows that ethical sensitivity in nursing is defined and measured in at least three different ways: identification of numbers of ethical issues, recognition of the unique characteristics of situations and persons receiving care, and attitudes to issues such as the use of restraints and forced medication administration [5]. Ethical sensitivity requires nurses to recognize patients’ needs by learning and interpreting their verbal and non-verbal behaviors [9]. Development of ethical sensitivity creates an attitude and ethical response in nurses, which enables providing effective and ethical care for patients [1, 5, 6] Ethical sensitivity is therefore particularly important for nurses as ethical care providers [10], and this leads to ethical decision making that favors the patients [1].

Iran is generally a religious country, and religious attitudes and beliefs have spread into every dimension of Iranians’ lives, including the health system and nursing profession [11, 12], such that respect for human and ethical values has a special place in Iranian culture and among nurses [13, 14]. In Iran, the subject of ethics in nursing has attracted greater attention in recent years, such that various studies have been conducted, and experts have developed guidelines, such as the Nursing Code of Ethics provided in 2011 by the Iranian Nursing Organization [15].

On the other hand, challenges faced by Iranian nurses affect their attention to ethics in practice [16]. These challenges are mainly due to the shortage of nurses, job dissatisfaction, poor social position, and curriculum shortfalls with regard to ethics [12, 17, 18], which can lead to increased ethical distress in nurses and subsequent burnout and higher turnover [16, 18]. Within the Iranian nursing context and knowledge of professional values and problems, an ethical leader can act as an ethical role model for nurses, and thus creates ethical sensitivity and develop ethical decision-making and help the development of ethical nursing performance, from which patients, nurses, workplace, and nursing profession can all benefit.

According to Bandura’s Theory of Social Learning [19], ethical leadership is defined as “the demonstration of normatively appropriate conduct through personal actions and interpersonal relationships, and the promotion of such conduct to followers through two-way communication” [3]. In other words, an ethical leader influences ethical behavior of followers by setting and observing high ethical standards and the use of reward and punishment [3, 20]. In the organization, employees as an ethical leader’s followers can learn ethical behaviors via observation and imitation of ethical leaders as their role model [3]; thus an ethical leader can help the develop the ethical performance in employees. In a way, everyone working in nursing can act as an ethical leader [21] for example, nurses in their everyday work demonstrate a commitment to ethical practice and can act as ethical role models for others. Nurse managers such as matron, supervisors, and head nurses are responsible for influencing their employees and for acting as mediators between organizational and professional values [21]. Despite the importance of the subject, no study has yet been conducted on ethical sensitivity in nursing ethical leadership in Iran. As part of a larger qualitative study on ethical leadership in nursing, the present study explores ethical sensitivity in ethical nursing leaders in Iran. Qualitative methodology was used because the ethical leadership process is complex and both of ethical leadership and ethical sensitivity are likely to have a symbolic and subjective component [9, 22] which is understood and interpreted by everyone based on his/her lived experiences and then these may be difficult to be captured by other methodologies [22]. This approach can provide a valuable tool for describing the experiences of a group of people and thus help better understanding their life experiences [23].

Objective: The present study aims to explore ethical sensitivity in ethical nursing leaders in Iran. It intends to know how the Iranian nurses perceive ethical sensitivity in ethical nurse leaders.

MATERIAL AND METHODS

Design

Qualitative content analysis was used to explore ethical sensitivity in ethical nursing leaders in Iran because it allows for the subjective interpretation of data [24] and helps better understand human emotions and the meanings underlying everyday experiences [25]. The conventional approach to content analysis was then used because ethical leadership is a recent concept and there is not enough former knowledge about it in Iranian nursing context. This type of design is appropriate when the existing theory or research on a phenomenon is limited [26, 27]. In this way, the researchers intend to gain an insight into the ethical sensitivity of an ethical leader from the perspective of Iranian nurses.

Sample

For accessibility reasons, the participants were selected from among the employees of different hospitals affiliated with Mashhad University of Medical Sciences in Mashhad, Iran. Because of everyone in nursing can be an ethical leader [21] or can have had experiences about at least one ethical leader in his/ her professional education the period or work, all nurses who were currently working full-time in these university hospitals were considered as potential participants. The participants who consented to share their experiences of ethical leadership were interviewed. They were introduced to researchers by other employees and nurses as whom compliance with ethics in their practices. To achieve maximum variation sampling, the nurses were chosen from various nursing experiences in terms of the period of experience, type of ward and position in nursing.At first, data collection began with nursing managers consisted of head nurses, supervisors and matrons and then continued with nurses. A total of 20 nurses were ultimately interviewed, including two matrons, five supervisors, four head-nurses, eight nurses and one M.Sc. student in nursing who were also working as a supervisor. Overall, nursing experience ranged between six and 29 years. Table presents the demographic information of the participants.

Data Collection

The participants were chosen using purposive sampling. This is a judgmental sampling that involves the conscious selection by the researcher of certain subjects or elements to include in a study [28].The interviews were conducted within a nine-month period from September 2014 to May 2015. All the interviews were conducted at a time and place most convenient for the participants. One of the researchers who was responsible for conducting the interviews first introduced herself to the participants and continued with a brief explanation about the subject and objectives of the study. If the candidate consented to participate, she collected demographic information of the participant. The interviews were in-depth and semi-structured. Semi-structured interviews allow for better understanding of the participant’s views on a given topic. In addition, it allows participants to think more critically about the subject matter. A consistent set of initial questions and topics also makes it easier to replicate the interview. The main interview questions were developed by research team three of whom were faculty members in nursing and expert in qualitative research and nursing ethics. At the beginning of each interview, the participants were asked to “describe their experiences about one of their ethical leaders” and then were asked to explain their own perceptions and experiences of the ethical sensitivity of their ethical leaders. For instance, they were asked:

“Describe your experience of your ethical leader’s ethical sensitivity in nursing”.

“How did your ethical leader induced ethical sensitivity in nurses?”

“As an ethical leader, how do you apply ethical sensitivity in your work?”

“As an ethical leader, how do you induce ethical sensitivity in others?”

The interviews lasted from 30 to 100 minutes and had a mean duration of 45 minutes and were recorded with participants' permission. No new information was gained during the last four interviews, at which time the data were considered to be saturated. It occurred with the 20th interview when new concepts were no longer emerged [29].

Data Analysis

The present study used a conventional content analysis described by Graneheim and Lundman [54]. The interviews were transcribed verbatim and the transcripts were read and reread in order to understand the meaning within the context of significant words or phrases. The texts were read through several times to obtain a sense of the whole. Sections (meaning units) that corresponded to the aim were underlined, condensed, and coded [29]. Initially, the authors read and analyzed the texts independently. The first author analyzed the total data, while the three authors compared the codes, and minor disagreements were resolved after discussion. Then the codes (and meaning units) were read several times and compared to the context. The codes were grouped together to form subcategories and categories. The final six categories were examined by the authors, in order to ensure a clear difference between them. Meaning units within all subcategories were checked for accuracy. Minor revisions were made thereafter. After categorization of the data at the group level, the researchers returned to the individual level to ensure that the categories were differentiated at an equal level of abstraction. This constant comparative analysis was an inductive process, and the goal was to create a detailed description and a list of categories related to the subject under investigation, that is, ethical sensitivity in ethical nurse leader.

Rigor

As per Lincoln and Guba’s criteria, the credibility of the data was ensured through individual interviews, choosing participants from various nursing experiences, and peer checking. To facilitate transferability, a clear description of culture and context, characteristics of participants, data collection, the process of the analysis, and providing enough quotes were used to ensure that the findings fit the data. To ensure the conformability of the data, the comments made by qualitative research experts with an experience in nursing ethics were implemented. The dependability of the data was ensured through a constant comparative analysis of the data, clarifying the data analysis process and peer review [25].

Ethical Considerations

The present study was approved by the Ethics Committee of Kerman University of Medical Sciences under the code k/93/488. To comply with the code of ethics, the participants were first briefed on the objectives of the study and then ensured of the confidentiality of their data and their right to withdraw from the study at any point in time and were also informed about the process of accessing the final results. They then submitted their informed written consents to participate in the study.

RESULTS

A total of 138 codes and 22 subcategories were extracted from the interviews after eliminating the repetitive and integrating the similar codes; the constant comparison and analysis of the codes ultimately led to 14 subcategories and five main categories (Table ). The extracted themes express the nurses’ perceived concepts and meanings with regard to the ethical sensitivity in ethical nurse leaders.

Sensitivity to Care

The subcategories in this category include sensitivity to all aspects of patient’s condition, emphasis on care issues, and monitoring proper performance.

Sensitivity to All Aspects of Patient’s Condition

According to participants, ethical leaders are sensitive to matters related to patient and constantly monitor all aspects of his/her condition.

One supervisor commented her nursing experience: “In emergency department our head nurse never allowed us to be indifferent to the patient’s condition, and he himself was never indifferent… Also, we had to attend to all patients coming there straight away. We were all very sensitive to admission, discharge and all issues of the patient”.

According to participants, ethical leaders, even consider the patient’s financial problems and costs they have to pay. They try to solve patient’s problems and encourage everyone else to do the same.

A matron stated: “Everything about the patient was important to her; his/her physical and mental state and even his/her financial problems. When she talked with a patient, she tried to identify his/her problems and then did her best to resolve them. With such behaviors, she was a role model for us”.

Emphasis on Care Issues

According to participants, ethical leaders clearly emphasize on patient care to all team members.

One nurse stated: “My nursing teacher always reminded us that we should visit and attend the patient all the time, and he/she should be at the center of our work. He was like this himself, and his focus was on the patients”.

A participating student: “Our nursing teacher was very strict about caring for patients, and of course she performed them herself, even small tasks. She emphasized that we should do the same”.

Monitoring Proper Performance

Ethical leaders constantly and continuously monitor and assess the performance of the employees, and ask them about proper care.

A participating matron: “A while after I relaxed my control, the staff began to perform the tasks in their way. To ensure proper performance, I had to continue my monitoring, and realized that monitoring must be continuous and ongoing to produce results”.

Sensitivity to Error

This category included three subcategories: sensitivity to medical errors, error prevention, and correction of errors.

Sensitivity to Medical Errors

According to participants, ethical leaders are sensitive to errors made by the medical team and do not ignore any errors made by doctors, nurses and others, and warn them or their superiors about their errors.

A participating nurse: “Yesterday a patient came to emergency department presenting with loss of consciousness due to the drug overdose. The doctor administered interacting medications, and before administering them to the patient I warned the doctor about his mistake and wanted to correct it. I ask all my colleagues to warn even them if they see mistakes are being made. We should not allow any harm to patients”.

A participating nurse: “I always let people know if they are making a mistake, the first chance I get and in a very friendly manner”.

Error Prevention

Ethical leaders have error prevention approach. For instance, nurses explained that ethical leaders prevent the creation of incorrect routine in the ward or they regularly monitor the performance of new staff to prevent their mistakes, or when errors have occurred, they hold group discussions to prevent errors being repeated. They also support people with the same approach to error prevention.

A participating head nurse: “I put a few experienced staff with new staff and distribute patients in such a way that a new staff is always supported by a more experienced one. Chances of error are reduced in this way”.

Correction of Error

Participants acknowledged that ethical leaders try to modify erroneous behavior or performance. By making offenders aware of the consequences of error and motivating them to correct their error, they give offenders the opportunity to modify their behavior, and then monitor them to see if the error is repeated.

A participating head nurse: “I gave someone a verbal warning, and monitored her to see if she still repeats the same error in the next shift, by asking the charge nurse to keep an eye on her, and followed-up again until the error was corrected”.

According to participants, ethical leaders warned offenders about their erroneous performance many times, and are firm with them.

A participating supervisor: “I warn and warn and warn her properly”.

A participating head nurse: “If the error of my staffs affects a patient, I seriously stand up to that, but if it affects themselves, I give them a warning”.

Sensitivity to Communications

This category includes two subcategories: proper communication with clients and attention to communication with health team members.

Proper Communication with Clients

According to participating nurses, the way nurses communicate with patients and their relatives is important to ethical leaders, such that he/she assesses challenging factors in such communications and takes preventive measures to eliminate them.

A participating head nurse: “A large number of relatives accompanying some patients in the ICU was a major problem. To prevent any inappropriate contact between nurses and relatives, I announced that the ward nurse usually can be answerable to two of the patient’s first-degree relatives, and thus managed to obviate the friction”.

Participating nurses acknowledged that their ethical leader treats patients properly, and considers harsh treatment of patients or their relatives unethical. He/she takes into account feelings of the patient and his/her relatives and tries to calm them and reduce their anxiety.

A participating head nurse: “She interacted so well with patients. I never saw her treating patients or their relatives badly”.

Attention to Communication with Health Team Members

Nurses referred to the ethical leader’s proper communication with nurses and other health team members. According to them, their ethical leader has the skills for communication, implementation of rules and problem-solving and ongoing and friendly interaction with subordinate staff. According to them, their ethical leader attracts others through proper communication.

A participating matron: “I always try to be friendly with the staff. In this way, I can both affect them and learn from them”.

A participating supervisor: “This nurse is really ethical and personable, and she attracts people by the way she relates to them, and others learn to treat her and the same”.

Sensitivity to Making Decisions

There are two subcategories in this category, including ethical decision making and education of ethical decision making.

Ethical Decision-Making

According to participants, ethical leaders make ethical decisions according to their conscience and consultation with ethics-oriented people. and in, ethical leader’s opinion, decision making based on transient and irrational feelings and based on personal gains is unethical. Participants acknowledged that ethical leaders do not put people with unethical performance in decision-making positions.

A participating supervisor: “She would choose according to her conscience, and made decisions according to her conscience”.

A participating head nurse: “I try not to assign too much responsibility to people that cannot make ethical decisions, or give them responsibilities that don’t involve patient-related decisions”.

Education of Ethical Decision-Making

Participants highlighted the need for educating ethical decision making in nursing schools and considered the absence of such education as one of the problems in this area. According to them, ethical leaders teach ethical decision making to others through guiding them and through their own actions.

A participating supervisor: “I don’t recall anyone talking about professional ethics in the course of our academic education, or teaching us about right or wrong decisions”.

Sensitivity to Ethical Practice

This category included four subcategories: work conscience, adherence to ethical principles and values, ethical sensitization, sensitivity to ethics in practice.

Work Conscience

According to participating nurses, the ethical leaders act based on their conscience and believes this would result in job satisfaction.

A participating nurse: “Because of the conditions of the ward, yesterday my colleague had to go to work despite her renal colic, and carried out all patient duties properly and on time. That is [work] conscience”.

By insisting that we should put ourselves in patient’s place, ethical leaders try to promote work conscience in the employees and show them the importance of ethics in practice.

A participating head nurse: “I always ask my employees to work according to their conscience and think of the patient as a family member. His/her pain is your pain, and his/her problem is your problem”.

Adherence to Ethical Principles and Values

According to participating nurses, ethical leaders in patient care and interaction with colleagues adhere to ethical principles such as honesty, confidentiality, and justice.

A participating head nurse: “Our matron taught me honesty through her behavior. She is honest and straightforward with everyone”.

A participating nurse: “I never lie to a patient, I explain the reason, if something has not been done for him”.

Also, participants asserted that through knowledge of and adherence to professional values, ethical leaders would be able to properly differentiate ethical and non-ethical nursing performance.

A participating supervisor: “We could see how she respects professional values just by watching her work with patients. For instance, she always respected and valued all patients, and was extremely responsible... She could easily recognize the ethical and non-ethical performance of ours”.

According to the nurses, by emphasizing ethical principles and values to the employees and showing adherence to them, he/ she tries to create the commitment to ethical principles and values in other nurses.

A participating head nurse: “These values are important to me, and I emphasize that they should be observed by the staff”.

A participating matron: “My staff will only respect ethical values such as responsibility when they know that I stand by these values myself, and if they sense that these values are not so important to me, they gradually lose interest”.

Ethical Sensitization

Nurses revealed that through setting ethical processes and requiring staff to implement them, ethical leaders draw their attention to ethics in clinical practices and sensitize ethical performance in them.

A participating supervisor talked about her nursing experience: “Our head nurse set processes to make our work ethical, and we had to comply with them”.

A participating supervisor talked about her nursing experience: “Sometimes sensitization is needed. For instance, in the operation room, a new nurse ignored patient’s privacy. I explained to her that her action was not right. She was truly upset and told me that because of the stress of work, she was not at all aware. Afterward, she modified her action”.

Sensitivity to Ethics in Practice

Nurses also described ethical leaders as someone with sensitivity to ethics in practice that considers ethics before and after their actions, and constantly challenges themselves to be ethical. By preferring to have ethics in practice, they attach importance to observing ethics in practice by all health team members and support the ethical performance of employees.

A participating supervisor: “She considers everything through ethics first, and challenges herself before and after every action, to see if her action is ethical or not”.

A participating supervisor: “She prefers ethics to all else, and ethical principles are always the most important thing for her”.

Also according to participating nurses, ethical leaders assess ethical knowledge and ethical performance of staff and are aware of their commitment to ethics in practice.

A participating head nurse: “As I’m working with them(staffs), I can see their performance and I can easily comment on their commitment to ethical values, and I know how important it is to them and how they work”.

A participating head nurse: “I regularly monitor the performance of staff and assess how committed they are to professional ethics”.

DISCUSSION

The results obtained revealed ethical sensitivity of ethical leaders in five categories, including sensitivity to care, sensitivity to errors, sensitivity in communications, sensitivity in decision-making, and sensitivity to ethical practice.

The first domain is sensitivity to care. The present study results showed that ethical leaders are sensitive to patient’s condition and caring issues. They frequently remind other nurses about the implementation of nursing cares and being sensitive to patient’s condition. Furthermore, they consider problems faced by patients and try to solve them. Given that care is the core of nursing performance, the perhaps ethical sensitivity of ethical leaders could be considered related to their sense of dutifulness; an attribute that has been confirmed by various researchers [3, 30]. Other studies have considered this attribute as the part of the ethical sensitivity of nurses [5, 31]. Some researchers consider that ethical sensitivity of caregivers requires identifying and meeting patients’ needs [4, 5, 9].

The second domain is sensitivity to error. The present study showed that ethical leaders are sensitive to errors in care made by health care team members, and try to prevent them through setting proper and clear work processes, and assessing or monitoring of incidence or recurrence of errors. Various studies have pointed out setting ethical standards and principles by ethical leaders and the care they take in applying these principles by themselves and others [3, 20, 32], which agrees with the present study findings. Furthermore, ethical leaders try to modification erroneous behaviors or performance by making people aware of the consequences, motivating people to modify their behavior, and giving them opportunities for learning proper procedures, and also by firmness in dealing with errors. Various studies have referred to ethical approaches to management of errors committed by the health team, including honesty and humility in the disclosure of errors, accountability, and responsibility for the error committed, effort to amend erroneous behaviors, as well as error prevention approach [33-35]. These approaches are in line with statements made by participants about ethical leaders’ approach to errors. By being sensitive to errors, ethical leaders appear to have an ethical approach to management of errors made by the health team.

The third domain is sensitivity in communication. According to participants, by having communication skills, ethical leaders properly communicate with patients and team members. They take into account conditions of the patient and his relatives and communicate with them accordingly, and try to prevent challenging incidences between nurses and patients. Weaver also considers communication skills of nurses as important attributes of ethical sensitivity [5]. Lutzen et al. cite trust between nurse and patient as one of the dimensions of ethical sensitivity [4]. According to participants, ethical leaders establish an ongoing and friendly relationship with team members, and especially with nurses to resolve problems of the workplace and patients. The definition of ethical leadership provided at the beginning of this article indicates that ethical leadership is based on proper communication of leaders with followers [20] and ethical leader provides a suitable communicational climate in the workplace [20]. This result is also confirmed in other studies [36, 37]. By being sensitive to communications, ethical leaders pave the way for the ethical performance of nurses in relation to patients and other health team members.

Another domain is sensitivity in decision making. According to participants, ethical leaders regard decision making based on work conscience and not on personal gains as ethical, and try not to assign people with no ethical decision making to positions of making decisions about patients. Researchers believe that attention to ethical principles and values in decision making is a measure taken by ethical leaders to enhance normative ethical behaviors [3, 20]. On the other hand, ethical sensitivity is related to ethical decision making [5, 9, 10], and different researchers consider ethical sensitivity as a dimension of professional decision making [4, 5]. According to Lutzen et al., it is the ethical sensitivity that steers ethical decision-making [7]. It seems that ethical leaders instill others with decision-making based on ethical principles through sensitivity in decision making, and thus develop and steer nursing performance based on ethics.

Participating nurses mentioned the absence of ethical decision-making education in university. The curriculum of nursing bachelor’s courses in Iran lacks ethical education, such that although ethical issues are raised in various subjects, a consistent program for teaching professional ethics or ethical decision making does not exist. Besides, “professional ethics” unit was removed from the curriculum in recent years, and it is now briefly included in another subject as “history of nursing development and ethics” [38-40]. Given the importance and effect of educating ethics at nursing schools in ethical decision making and performance of future nurses, it is essential that this area be reconsidered [39, 41, 42]. Another finding in the present study relates to the role of ethical leader in training ethical decision making to others, and the definition of ethical leadership provided at the beginning of this article indicates the development of ethical performance by the ethical leader through ethical decision-making [3]. According to Brown et al., the ethical leader takes into account consequences of their decisions, and make fair choices, that can be observed and imitated by others [3].

The last domain is sensitivity to ethics in practice. The present study showed that by acting on their conscience, ethical leaders attempt to promote work conscience in others. Many researchers have referred to the ethics-based performance of ethical leaders, and consider their ethics as an attribute that enhances their influence and credibility [3, 43]. Behzady, Naeami and Bashlideh also argue that conscientiousness of ethical leaders is associated with all dimensions of ethical principles and observing these principles [44]. According to Lutzen et al., ethical sensitivity has been used in literature as work conscience [7]. The conscience-based performance of ethical leaders seems to suggest a kind of ethical sensitivity, which enhances their influence and credibility among other nurses.

The present study also showed that ethical leaders are aware of professional ethical values and are able to differentiate between ethical and non-ethical performance. Understanding and awareness of ethical issues have been referred to in various studies as one of the attributes of an ethical leader [3, 20, 22, 45, 46]. Furthermore, the ability to differentiate between ethical and unethical cases has also been confirmed in other studies as part of ethical sensitivity [4, 5, 7, 47, 48]. Kim et al. believe ethical sensitivity requires insight, intuition, and moral knowing, and an ability to identify moral issues in various situations [9]. On the other hand, participants believed that ethical leaders adhere to ethical principles and values such as honesty, confidentiality, and justice. Honesty [3, 20, 22, 43, 46, 49], or justice [3, 20, 45] of ethical leaders have been cited in various studies. It seems that ethical leaders are sensitive to their observation by the nurses, and practically teach these principles and values to other nurses through awareness and adherence to ethical principles and values.

The present study showed that ethical leaders draw people’s attention to observing ethics in clinical practice, and thus sensitize others to ethic-based practices. This result is also confirmed in a study by Brown et al., as they also acknowledged that ethical leaders draw attentions to ethics through salient ethical messages [3].

According to the nurses, ethical leaders attach importance to observing ethics in practice by preferring ethics over other matters, and in other words, they are sensitive to it. Moreover, ethical leaders ensure ethics in practice by regularly monitoring people’s commitment to this issue. It has been confirmed in several studies that ethical leaders are moralist [50-52], and various researchers have acknowledged that ethical leaders possess ethical values and try to spread these values within the organization [22, 53]. Considering that many nursing actions affect other people’s health and life, sensitivity to ethics in nursing practice is highly important to ethical leaders as a role model.

CONCLUSION

Ethical leaders of nurses are sensitive in fifth domains. The first domain is sensitivity to care. Ethical leaders are sensitive to all aspects of patients’ conditions, and monitor proper nursing practice by emphasizing patient care issues. The second domain is sensitivity to errors, such that being sensitive to medical errors, ethical leaders try to prevent errors and modify erroneous practices and behaviors. The third domain is sensitivity to communication. Ethical leaders pay attention to the proper communication of nurses with patients and health team members. The fourth domain is sensitivity to decision making, such that ethical leaders teach ethical decision making to others, especially nurses, by making ethical decisions. The last domain is sensitivity to ethical practice, such that ethical leaders try to promote adherence to ethical principles and values in nurses through work conscience and as well as instilling ethical sensitivity in others, ethical leaders are themselves sensitive to ethics, and monitor adherence to ethics in practice by others.

Given that nursing profession is associated with people’s health and lives, and considering the importance of ethical leader as a role model for nurses, ethical sensitivity appears to be a valuable attribute for ethical leaders, and can have a huge effect on various aspects of professional practice, including commitment to ethical principles and values, patient care, management of nursing errors, communication, decision making and sensitivity to ethics in practice, and thus help in the development of ethics in nursing practice.

Table 1

Demographic characteristics of participants.

Number	Gender	Years of Work experience	Work experience				Current position	Current ward	Last previous ward	Last previous position
			Matron	Supervisor	Head nurse	Nurse
P1	female	13	-				S	Management	ICU	HN
P2	female	10	-		-		S	Management	Emergency	N
P3	female	6	-				HN	ICU	Management	S
P4*	male	10	-				S & NS	Management	Emergency	HN
P5	female	27					M	Management	Management	S
P6	female	25					S	Management	Management	M
P7	female	23					S	Management	Eye operation room	H
P8	female	19	-	-			HN	Open Heart Surgery ICU	Open Heart Surgery ICU	N
P9	female	26	-	-			HN	Nephrology	Open Heart Surgery ICU	HN
P10	female	15	-				N	Poisoning	Trauma	HN
P11	female	12	-	-	-		N	Poisoning	Poisoning	N
P12	female	15	-	-	-		N	Skin	Dialysis	N
P13	female	10	-	-	-		N	Emergency	Emergency	N
P14	female	23	-	-			HN	Urology	Urology
P15	female	15	-	-	-		N	Nephrology	Children	N
P16	female	10	-	-	-		N	Open Heart Surgery ICU	Emergency	N
P17	female	17	-	-	-		N	Open Heart Surgery ICU	Open Heart Surgery ICU	N
P18	Female	28					HN	Operation Room	Management	S
P19	Female	29					M	Management	Operation Room	HN
P20	Female	16		-		-	S	Management	Emergency	N

M: Matron S: supervisor HN: Head-Nurse N: Nurse NS: Nursing Student * P4 was a supervisor and concurrently MSc student in nursing

Table 2

Main categories and subcategories of ethical sensitivity in ethical leaders from the perspective of Iranian nurses.

Main Category	Sub-categories
sensitivity to care	Sensitivity to all aspects of patient’s condition
	Emphasis on care issues
	Monitoring proper performance
sensitivity to errors	Sensitivity to medical errors
	Error prevention
	Correction of error
sensitivity to communication	Proper communication with clients
	Attention to communication with health team members
sensitivity in decision-making	Ethical decision-making
	Education of ethical decision-making
sensitivity to ethical practice	Work conscience
	Adherence to ethical principles and values
	Ethical sensitization
	Sensitivity to ethics in practice