The Relationship between Moral Sensitivity, Ethical Climate, and Job Strain with Patient Privacy from Viewpoint of Operating Room Staffs.

BACKGROUND: The privacy of patients in the operating room is in particular importance. The results of previous studies have shown that various factors are affecting in this context. The aim of this study is to evaluate the relationship between moral sensitivity, ethical climate, and job strain with respect to patients' privacy in operating rooms.
MATERIALS AND METHODS: All of operating rooms nurses of teaching hospitals affiliated to Ardabil University of Medical Sciences were entered into this descriptive-analytical study with census sampling method in 2019. To collect data, standard surveys of moral sensitivity, ethical climate, job strain, and privacy were used. Data were analyzed by SPSS15 software using descriptive and analytical statistics methods (independent t-test, ANOVA, Pearson correlation, and regression analysis).
RESULTS: There was a positive significant relationship between moral sensitivity and privacy (r = 0.56, p < 0.001) and ethical climate and privacy (r = 0.60, p < 0.001), too. But, there was an inverse and significant correlation between job strain and privacy (r = -0.69, p < 0.001). The results also showed that moral sensitivity is the best predictor of patients' privacy.
CONCLUSIONS: Despite the predictability of all variables, results showed that moral sensitivity is the most important component in patients' privacy. In this regard, by increasing the moral sensitivity of nurses, the privacy of patients can be improved. Copyright:

Introduction

In the present, with the emphasis on human values, privacy has been more important in health care settings.[1] Privacy has physical, psychological, social, and informational dimensions,[2] which means, privacy not only includes personal space, freedom of choice and decision-making, and respect for the people dignity,[3] but also includes matters such as confidentiality and protection of patients' personal and medical information.[4] In operating room ward, because of the patients' anesthesia, privacy is more sensitive.[5] Teamwork and interdisciplinary collaboration, the variety of procedures in the operating room, workload, large and heavy responsibilities, the speed of action and the high precision, the rapid entry and exit of patients, the unpredictability of work in many cases, occurrence of acute and severe emergency situations, simultaneous occurrence of dangers in the operating room, and simultaneous and the specific culture governing the environment can affect ethical climate and patients privacy in the operating room.[6]

Although respect for patients' privacy is one of the nursing codes of ethics,[7] but only awareness of the codes of ethics does not sufficient and one must be sensitive enough to enforce them.[8] Moral sensitivity of nurses is a feature that enables them to recognize ethical conflicts, analyze the situation appropriately, and make appropriate ethical decisions in patient care.[9] Another important factor that affects patients' privacy is providing appropriate ethical climate in the workplace.[10] Ethical climate in the hospital setting is described as nurses understanding of deal with ethical issues.[11] King states in his study that the operating room nurse demonstrates his/her commitment to ethics principles by preventing harm to patients.[12] Job strain is another factor that affects patients' privacy,[13] so that shortage of time and high fatigue due to job strain is mentioned as one of the most important barriers to patient privacy.[14] When there is no balance between the nurses' job demands and their potency to satisfy them, job strain is created.[15] Because the operating room technicians experience more stress than other nurses in this settings[16]; this matter doubles the importance of job strain assessment in these staff as one of the most important sources of stress.

In two studies which are conducted in Iran, results showed that privacy of patients in operating rooms is not in desirable condition.[1718] Also, as mentioned before, different factors can affect patients' privacy in operating rooms. Thus, the present study was conducted to determine the relationship between moral sensitivity, ethical climate, and job strain with patients' privacy in operating rooms of teaching hospitals affiliated to Ardabil University of Medical Sciences and predict the most important factor.

Materials and Methods

This descriptive-analytical study was performed on operating room nurses of teaching hospitals affiliated to Ardabil University of Medical Sciences with census sampling method in 2019.

The inclusion criteria included: a minimum of six months job experience, an associate, bachelor's, or master's degree in nursing, anesthesia, or surgical technology and employment in the operating room during the research period. Unwillingness to participate in the research and incomplete answering to the study instruments were the exclusion criterion. Finally, 132 questionnaires were completed and analyzed based on inclusion and exclusion criteria.

The data were collected using a self-administered five-section questionnaire including demographic information, Lautzen's moral sensitivity questionnaire, Olson's ethical climate, Glendon and Litherland job strain and Nourian et al. patient privacy questionnaires.

The standard questionnaire of moral sensitivity has been developed by Lautzen et al. The questionnaire consists of 25 items on a 5-point Likert scale ranging from strongly disagree to strongly agree. It is composed of six dimensions: Experiencing moral conflict, following the rules, relational orientation, expressing benevolence, modifying autonomy, structuring moral meaning. The mean of the total score of the questionnaire is 0-100 (0-50: Low, 51-75: Moderate, 76-100: High). In Borhani et al. study Content Validity Index (CVI) was found to be 0.97 for this questionnaire.[19] Izadi et al. Confirmed the validity of the questionnaire and calculated its internal consistency reliability by Cronbach's alpha (0.89).[20] Also, in our study, the internal consistency reliability of the questionnaire was confirmed by measuring the Cronbach's alpha value (α = 0.87). The validity of this questionnaire and three more questionnaires was measured using the content validity method through implementing the modifications proposed by ten faculty members of Ardabil University of Medical Sciences who reviewed the items.

The standard ethical climate questionnaire, developed by Olson, contains 26 items in five dimensions (communication with colleagues, physicians, managers, patients, and hospital). Each item scores 1-5 and the mean of the total score of the questionnaire is 26-130. Olson determined the validity of the questionnaire using content validity index at 87' and its reliability at 91' using Cronbach's alpha.[21] Also, the internal consistency reliability of this questionnaire was reported 0.92 in Mobashar et al. research[22] and 0.9 in Abdollahzadeh et al. research in Tabriz operating rooms.[23] In this study, the internal consistency reliability of the questionnaire was calculated as 0.93 by Cronbach's alpha.

The Glendon and Litherland job strain questionnaire measures perceptions of job strain in two dimensions: perception of time and perception of workload. This scale consists of 4 questions, based on a 5-point Likert scale. The reliability of this scale in Glendon and Litherland research was calculated 0.86.[24] The validity of this scale has been confirmed in Iranian studies. Also, reliability of the questionnaire was reported in Kiani et al. research 0.71[25] and in this study for reliability, Cronbach's alpha was 0.78.

Patient privacy questionnaire is designed by Nourian et al. in 2015 to measure patients' privacy in the operating room. The questionnaire consists of 18 items in three dimensions of physical, informational, and social privacy. Each item scores 1-3 and the mean of the total score of the questionnaire is 18-54 (18-30: Poor, 31-42: Moderate, 43-54: Good). The content validity of the questionnaire was confirmed, and its' reliability was calculated by Cronbach's alpha (0.81).[17] Also in this research, the reliability of the questionnaire by Cronbach's alpha was calculated 0.84.

Data were analyzed by SPSS software version 15 (produced by IBM SPSS Statistics) using descriptive statistics including frequency, percentage, mean, and standard deviation. The variables were compared between groups by independent t-test and ANOVA. Pearson correlation and regression analysis were conducted to assess the factors affecting patients' privacy.

Ethical considerations

This study was approved by the Ethics Committee of Ardabil University of Medical Sciences, with the code of ethics IR.ARUMS.REC.1398.047. After obtaining initial permissions, receiving the ethics code, the researchers participated in various work shifts in the research environment. Prior to distributing the questionnaires to the participants, informed consent was obtained for voluntary participation in the study. They were also ensured of the confidentiality of the data and the voluntary nature of participation in the study.

Results

The mean (SD) age of participants was 33.99 (5.85) years, 69.70% were female, 81.10% were married, and 54.50% had an associate degree. 59.10% of nurses had surgical technology and 40.90% had anesthesia degree. The majority of participants (53%) were contractual employed. 70.50% of the participants stated that they had previously participated in workshops on professional ethics. In terms of the surgery type, the majority of nurses respectively participated in orthopedic surgery (18.90%) and general surgery (17.40%).

According to the results, there was a direct and statistical significant relationship between moral sensitivity and privacy variables (r = 0.56, p < 0.001). Also, there was a positive and significant relationship between ethical climate and privacy (r = 0.60, p < 0.001). Statistical analysis also indicated that there was an inverse and significant correlation between variables of job strain and privacy (r = -0.69, p < 0.001) [Table 1].

Table 1

Mean, standard deviation and correlation coefficients of relationship between moral sensitivity, ethical climate, and job strain with patient privacy in operating rooms

Variables	Mean (SD)	r	p
Patient privacy
Physical	21.77 (6.59)
Information	7.30 (2.37)
Social	3.65 (1.43)
Total	32.73 (10.02)
Moral sensitivity
Experiencing moral conflict	13.14 (2.09)	0.59	<0.001
Following the rules	11.71 (1.47)	0.61	<0.001
Relational orientation	8.86 (1.96)	0.48	<0.001
Expressing benevolence	14.56 (3.18)	0.54	<0.001
Modifying autonomy	10.65 (2.07)	0.57	<0.001
Structuring moral meaning	6.34 (2.13)	0.43	<0.001
Total	81.41 (20.22)	0.56	<0.001
Ethical climate
Patients	3.16 (0.81)	0.57	<0.001
Hospital	3.24 (0.76)	0.53	<0.001
Physicians	3.28 (0.79)	0.59	<0.001
Managers	3.20 (0.78)	0.57	<0.001
Peers	3.20 (0.81)	0.59	<0.001
Total	3.22 (0.75)	0.60	<0.001
Job strain
Perception of time	8.12 (4.11)	-0.58	<0.001
Perception of workload	9.02 (4.01)	-0.67	<0.001
Total	8.73 (4.04)	-0.69	<0.001

Also, multiple regression analysis showed that all three variables of moral sensitivity, ethical climate and job strain can be used to predict patients' privacy. The regression coefficient of determination was 0.58, which means that 58% of the changes in privacy variable were due to predictor variables. The results of stepwise regression analysis also showed that moral sensitivity is the best predictor of patients' privacy [Table 2].

Table 2

Multiple correlation coefficients of predictive variables (moral sensitivity, ethical climate and job strain) and patient’s privacy with entry and stepwise methods

Method	Predictive Variables	Unstandardized Coefficients		Standardized Coefficients	t	p
		B	SE*	Beta
Entry	Moral Sensitivity	1.32	0.06	0.53	5.88	<0.001
	Ethical Climate	0.08	0.07	0.16	3.29	<0.001
	Job Strain	-0.04	0.13	-0.07	-1.57	<0.001
Stepwise	Moral Sensitivity	1.38	0.20	0.59	6.97	<0.001

*Standard error

Discussion

According the results, there was a positive and significant relationship between nurses' moral sensitivity and patients' privacy, also this was more predictive variable than others for patients' privacy. Previous researches has emphasized on nurses' favorable moral sensitivity to respect patients' privacy. For example, Mahdiyoun et al. reported that, nurses who are more sensitive ethically, are more likely to respect patients' rights than other nurses.[26] In a study in South Korea, researchers also emphasized that it is necessary to increase nurses' moral sensitivity to patient privacy in hospitals.[9] The point that nurses' moral sensitivity is the most important factor on patients' privacy in the operating rooms is a new point that should be considered more than other factors. So, in order to improve patients' privacy in the operating room, staff awareness of the codes of professional ethics, patients' rights and also awareness of the duties that staffs have ethically towards patients should be assessed periodically and, if necessary, staff training in this field should be done.

In this study, the operating room nurses showed a high level of moral sensitivity. Also, of all the dimensions of moral sensitivity, “expressing benevolence” received the highest, and “structuring moral meaning” the lowest scores. This result is consistent with Borhani et al. study results. In the moral sensitivity questionnaire, “expressing benevolence” refers to concepts such as honesty and trust[19], while in operating rooms is more important in sterile principles, because nurses in this ward play an important role as the patient's infection control advocate. Also, “structuring moral meaning” is a dimension of moral sensitivity related to issues about which decisions are made without the patient's participation.[19] This dimension received the lowest score in the present study; this finding may be due to the fact that in operating rooms, unlike other wards, nurses have little time to communicate with the patient and important decisions about the patient are made before surgery.

According to the results, there is a positive and significant relationship between ethical climate of operating rooms and patients' privacy variables. In a study by Lin et al. in Taiwan, they found that creating suitable ethical climate in the workplace can improve respecting for patients' privacy.[10] Allari also noted in his research in Jordan that patient privacy, as one of the professional values in nursing, was significantly influenced by the hospital's ethical climate.[27] According to the findings of this study, in the dimensions of ethical climate, “relationship with physicians” received the highest, and “relationship with patients” the lowest scores. But in Allari research “relationship with managers” had the highest, and “relationship with physicians and hospital” had the lowest scores.[27] This difference was not unexpected; because in operating rooms, due to teamwork, nurses have a closed relationship with physicians and a large part of their duties to patients is summarized in working with physicians, so they have less understanding of patient communication.

Generally, like all organizations, the ethical climate of operating rooms is defined as the values, norms, beliefs, behaviors and habits which influence the performance of the staff.[21] But, in this ward, compared with other parts of hospital, nurses work as a group with people from different professions and are exposed with stressful conditions, which influence it's ethical climate.[28] According to the results of this study, by improving the ethical climate of operating rooms, we can see better patients' privacy in this ward. In this regard, cases such remaindering of occupational and ethical duties, nurses' knowledge enhancement, effective teamwork, strengthening of cooperational spirit and allocating of same sex nurses for each patient are suggested.

Given the results, there was an inverse significant relationship between job strain and patients privacy variables, means that with increasing workload on nurses, the level of privacy of patients is decreased. Also, an inverse significant relationship was found between the dimensions of job strain and patients' privacy which was stronger in perception of workload dimension. Also, though the operating room nurses showed a low level of job strain; in terms of dimensions, the dimension of “perception of workload” received the higher mean score than “perception of time” dimension.

Compared to other wards, reasons like high workload in operating rooms is more visible; especially in emergency surgeries, major surgeries, multistage surgeries. However, most of the reported unethical behaviors in health care take place in the operating rooms.[29] Bakhtiari et al. stated in their research that the uniqueness of working in operating room and job strain of staff in this ward can lead to unethical behaviors[30]; that as observed in this research it can negatively affect patients privacy. Thus, to reduce the job strain in operating rooms and so to improve patients' privacy, the following suggestions are provided: compensating lack of manpower, considering additional staffs for emergency and major surgeries, strengthening the spirit of cooperation and team communications (e.g., when nurses are exposed to job strain, each nurse does her/his duties and patients' privacy is neglected; In such cases, the presence of an additional nurse who does not have surgery in her/his room can be helpful), considering additional payment facilities, avoiding to allocate heavy and burst shifts for staff and considering equipped restrooms.

In this study, patient privacy in operating rooms was moderate from the nurses' point of view. In Norian et al.[17] and Shorje et al.[18] researches, like the present study, patient privacy in operating rooms was moderate. Also, of all the dimensions of patient privacy, “physical privacy” received the highest, and “social privacy” the lowest scores; although all three dimensions were evaluated poorly. In Norian et al. research, patient privacy in the information dimension was better than physical dimension and in the physical dimension, it was better than social dimension.[17] Although both studies used the same tools, the results were different in the dimensions and only in social dimension, patient privacy had paid less attention. Physical privacy refers to cases such maintaining personal space, patient coverage, and touch. Information privacy refers to the confidentiality of the patient's medical records and social privacy refers to the control of the individual in an interaction and privacy in professional relationships.[31] According to the results, it seems that due to the reduction in patient-nurse interaction, short duration of patients' presence and the anesthesia process in operating rooms, respect to physical and information privacy of patients is more visible than social privacy in this ward.

The small size of the sample and the design of the study are among the limitations of this research. Also, in operating rooms, service personnel have an important role in preparing patients and positioning them, so they can affect patients' privacy that is neglected in this research. Therefore, it is recommended that future researchers conduct research on a larger number of samples with randomized sampling methods and do qualitative design researches on service personnel too. Attitudes and beliefs of the surgical team can also be effective on patients' privacy in the operating room, which can be considered in future researches.

Conclusion

Patients' privacy is very important in the operating room. Results of this research showed that respect to patients' privacy in operating rooms is related with nurses' moral sensitivity, ethical climate, and job strain. Also, nurses' moral sensitivity was the most effective factor on patients' privacy; so, in addition to consider impact of all three factors, it is necessary to increase nurses' awareness of ethical issues in operating rooms. For this purpose, holding regular workshops on the nursing ethical codes and the importance of patient privacy in the operating rooms can be helpful.

Financial support and sponsorship

Ardabil University of Medical Sciences

Conflicts of interest

Nothing to declare.