Role of judgment in promoting nurses' decisions and ethical behavior.

BACKGROUND: Ethical decision-making and behavior of nurses are major factors, which can effect on the quality of nursing care. It seems that there is a correlation between demographic variables and ethical decision-making and moral behaviors of nurses. Promoting patients' health is one of the issues related to nurses' ethical behaviors. The aim of this study was to determine the role of judgment in promoting nurses' decisions and ethical behavior.
MATERIALS AND METHODS: This was a descriptive, cross-sectional study in which 260 nurses were selected based on the inclusion criteria. Sampling method was available. The data collection tool was the Hospital Ethics Committee Survey Questionnaire. Data were analyzed by SPSS software version 20.
RESULTS: In this study, judgments and ethical behaviors of nurses were evaluated at the moderate and good level. Gender, marriage status, education level, and nursing position were effective in judgments and ethical behavior of nurses. Age, job experience, and participation in the ethics workshop had no significant effect on ethical behavior and moral judgment. The mean score of moral belief of nurses participating in this study was 181.56 ± 17.60, and their mean moral practice in the real environment was 168.5 ± 17.77.
CONCLUSION: The judgment competencies in ethical situation of nurses should be promoted to a higher level. It seems that more advanced educational methods are needed to achieve this goal. The findings from this study show the necessity of nurses' ability to improve their behavior and moral judgment. It also shows that nurses need more reinforcement based on the demographic variables. Copyright:

Introduction

The nature of health services, which deals with the valuable issue of maintaining life and improving its quality and eliminating or reducing disease and disability, in general, and the field of nursing, in particular, is compatible with this trend and idea in the service management[1] as the largest part of the professional forces at the forefront of service delivery in the healthcare system has numerous and extensive roles and responsibilities.[2]

The nursing profession is a science that at all times (past, present and future) has many ethical aspects in the care system (conscience). The nursing profession is known as a health conscience and plays a key role in improving the care system.[34] They provide nursing care free of discrimination and judgment to all clients. In providing care, respect for human dignity and ethics is an integral part of the healthcare system. Sensitive conscience is needed to guide communication and ethical action, so sensitive conscience is important to healthcare providers.[1] Conscience is the cornerstone of morality and affects private and professional life. On the other hand, the cornerstone and the original principle in performing proper nursing care in today's society and the world of the future is to train nurses who have a conscience of professional ethics. In general, professional ethics competence can be considered equivalent to professional competence. That is, if the nurse acquires this competence and virtue based on the professional ethical virtues, when faced with professional conditions, he/she considers himself/herself bound to do moral and correct work. This leads to the development of ethical virtues in the healthcare profession.[1234]

Nurses are the largest group of healthcare providers.[5] The dynamic and changing conditions of nurses’ work environment, along with the uncertain and changing situation of clients, require them to be competent decision-makers and to be able to combine their technical skills and professional knowledge to make accurate and appropriate clinical judgments about patients’ health status. Nurses identify and solve clients’ problems in the field of nursing by acting in a team and multidisciplinary manner. Nurses’ clinical decision-making ability affects the quality of care more than any other factor. Judging ethical issues is one of the criteria for nurses’ professional competence so that observing ethical standards will be an effective factor in improving the performance of nurses in providing quality care. Therefore, nurses need the effective application of ethics, reasoning skills, ethical judgment and understanding and analysis to develop ethics to identify ethical barriers and appropriate moral decisions, to provide the conditions for satisfaction, motivation and a sense of competence in themselves and the patient. Nurses often face challenging ethical issues in practice, making it difficult for them to make decisions. They are morally responsible and must be held accountable for their behavior. Patient care is an important concept and in fact the art of the nursing profession and requires the personal, social, moral, and spiritual ability of the nurse to be able to provide desirable and ethical care.[45678910]

Demographic factors at the individual level in the organization have a great impact on the type of ethical behavior of employees. Nurses in health organizations, especially in hospitals, are very important factors influencing the ethical performance of the organization because they are professionally in a position to establish the most internal and external communication. Understanding the effects of demographic factors on nurses’ judgment and ethical behavior provides valuable data for nursing managers and hospital managers, based on which they can design programs to improve nurses’ ethical performance. Since there is no complete and proven information about the impact of demographic factors on nurses’ moral performance, studies that focus on the impact of individual factors and abilities on judgment in nurses’ moral decisions and behavior help to better understand the issue. Therefore, this study was conducted to determine the status of judgment in the decisions and ethical behavior of nurses in Yazd, one of the central cities of Iran.

Materials and Methods

This descriptive study was performed on nurses of selected hospitals in Yazd, Iran. The sample was 260 nurses. Sampling method was available. The study units were selected from four educational hospitals. Sampling was performed in the internal, surgical, emergency, children, women, and surgery wards.

The data gathering tool was Nursing Decisions Judgment Questionnaire. The questionnaire was designed by Shake Ketefian in 1981 and it was revised in 2007.[8] The questionnaire consists of six stories and two short scenarios. The questionnaire has 48 questions. Subjects respond to each question in two separate columns according to the five-point Likert scale (completely agree = 5, agree = 4, neutral = 3, disagree = 2, and completely disagree = 1). The first column is related to the ethical belief of the individual, and the second column specifies his/her performance scores in the actual work place. The sum of scores for each column can range from 48 to 240. For the Nursing Decisions Judgment Questionnaire, the validity of the instrument was re-evaluated. Thus, the main questionnaire in English was translated into Persian by two people with a master's degree in English translation. The Persian translations were changed to English again, and finally, the translations were reviewed by fluent English speakers. After preparing the tools, the questionnaire was given to 10 faculty members of Razi School of Nursing and Midwifery in Kerman and Shahid Sadoughi School of Nursing and Midwifery in Yazd. Content validity index was calculated in three areas of simplicity, comprehensibility, and relevance, which was set in the range of 1–4. Using the opinions and guidance of professors, the questions of the questionnaire were examined in terms of content and its ambiguities were removed to confirm its validity. After collecting the suggestions and making the necessary corrections, the final questionnaire was modified and prepared. For the questions of this questionnaire, the average validity coefficient of 0.89 was obtained from a score of one. In this study, the internal correlation method was used to determine the scientific reliability of data collection tools (questionnaire of judgments about nursing decisions). For this purpose, the questionnaire was given to 30 nurses, and after completing it, using the internal correlation method, their Cronbach's alpha coefficient for the Nursing Judgment Decision Questionnaire for column A was 0.72 and column B was 0.78.

To determine the validity of the translated tool, ten faculty members of Yazd University of Medical Sciences were consulted. To determine the reliability of the questionnaire, the calculation of internal consistency was used. Thirty nurses completed the translated questionnaire, and then, Cronbach's alpha coefficient was calculated for the questionnaire. The calculated coefficient for column A was 0.72 and for column B was 0.78. These coefficients in the Ketefian study were 0.71 and 0.78, respectively, for columns A and B. Data were analyzed by SPSS software version 20 (IBM, SPSS Inc., Chicago, Illinois, USA). ANOVA and independent t-test were used for data analysis. For all analyses, P < 0.05 was considered statistically significant.

Results

In this study, 260 nurses were examined which included 161 women (61.9%) and 99 men (38.1%). The majority of samples were in the age range of 26–30 years and the mean age was 33.96 years with a standard deviation of 6.83 years. 85% of the samples were married and the average work experience was 10.62 years with a standard deviation of 7.13 years. 96.5% of the samples had BSc degree, and only 3.5% of them had a master's degree. The research units were 82.7, 14.2, and 2.3 of nurses, head nurses, and supervisors, respectively. 76.5% of the study units did not have a history of participation in the ethics workshop.

The mean and standard deviation of ethical behavior and their relationships with demographic variables are presented in Table 1. Ethical behavior related to individual beliefs and performance in the work environment is presented in column A and column B, respectively. The ethical behavior score in each column can range from 48 to 240 (average 144). The mean score of moral beliefs of nurses participating in this study was 181.56 ± 17.16, and their mean ethical practice in the real environment was 168.5 ± 17.77. Among the studied variables, only gender affected ethical beliefs and practice. Men had higher scores in both areas.

Table 1

Mean and standard deviation of ethical behavior of nurses in terms of demographic variables

Variable	Mean±SD
	Ethical behavior A	Ethical behavior B
Gender
Female	177.09±14.79	164.54±14.56
Male	188.83±19.37	174.95±20.51
P	<0.001	<0.001
Marriage status
Single	173.49±18.85	166.46±13.89
Married	182.99±17.03	168.86±13.07
P	0.002	0.348
Education
BS	181.95±17.51	168.71±17.85
MSc	170.78±17.76	162.89±15.09
P	0.061	0.335
Position
Nurse	181.45±18.17	168.61±17.09
Head nurse	183.54±14.68	171.19±18.56
Supervisor	175.37±14.27	153.37±26.26
P	0.483	0.035
Attending to ethic education workshop
Yes	178.75±14.02	167.85±18.51
No	182.43±18.51	168.71±18.28
P	0.154	0.743
Age (years)
>25	180.53±22.41	168.53±15.35
26-30	177.75±14.26	164.98±15.01
31-35	182.55±18.91	168.90±18.76
36-40	183.69±17.11	171.07±16.84
>41	183.64±16.37	169.80±21.78
P	0.312	0.42
Job experience
>5	178.93±19.23	166.58±15.35
6-10	184.66±19.04	166.28±16.28
11-15	178.57±15.80	171.10±19.06
>16	158.63±15.58	171.27±20.53
P	0.032	0.203

SD=Standard deviation

Discussion

The findings of this study show that the ethical judgment and behavior of Iranian nurses are moderate and good level. Some demographic variables such as sex and marital status had a significant effect on the ethical judgment and behavior. Ethical judgment and behavior are mainly influenced by the intention of behavior that predicts ethical or nonethical behavior. The intention forms according to the way of reasoning and ethical codes that are based more on ethnic, cultural, and religious beliefs. Ethical beliefs develop with nursing education.[9] Ethical beliefs are shaped by nursing education, and they are the source of ethical behavior.[10] Ethical beliefs are less influenced by environmental conditions and organizational climate.[11] The findings from this research also confirmed that ethical behavior is influenced by the organizational–educational factors rather than demographics.

In this study, moral belief and ethical practices of nurses are both higher than average. This finding shows that the score of nurses’ ethical behavior is relatively high. On the other hand, belief in ethical behavior has a higher average in comparison to the actual moral act. This suggests that the nurses in this study did not manage to implement all their ethical beliefs in practice. This finding was also found in previous studies. Various factors are needed to shape ethical behavior and transform the good intention into good practice.[12] In a study conducted in Iran, Iranian nurses have identified individual characteristics, communication challenges, organizational factors, supportive systems, and educational and cultural development as effective factors.[13] The role of nursing managers in pushing nurses into ethical behavior is acknowledged more than other factors.[14] In this regard, the ethical climate of the organization which is influenced by nursing management performance can lead nurses, especially novice nurses, toward ethical behavior.[15]

According to the results of this study, attendance to the ethics workshops did not have a significant effect on the ethical behavior of nurses. The educational factor is mentioned as one of the important factors that influence the moral development of nurses. However, more studies are needed to show what kind of educational content and method can enhance nursing ethical behavior.[16] Educational nursing authorities should design educational methods that have a greater impact on the ethical judgment and behavior of nurses.

Based on the results of this study, gender is an effective factor in moral behavior. Males had higher scores in moral behavior than females. It was thought that women, because of emotional qualities and characteristics, were morally more ethical than men. The findings of this study show that ethical behaviors are not affected by the emotional factor. The impact of gender on ethics in nursing has been studied from different aspects and has shown diverse results. Moral sensitivity in women is reported more than men.[17] Moral reasoning and behavior were equal in the two genders, and in some cases, they were higher in men. Perhaps, this is why women are more emotionally sensitive to ethical issues. Because they are more likely to encounter situations where they want to do something moral but cannot.

Work experience was effective on type A ethical behavior in nurses. People with high work experience had lower moral beliefs than those with less work experience. This finding is also found in the Keteflan's (1981) study.[11] On the other hand, paying attention to mental states, emotions, and desires of people can affect their behavior and performance. This behavior and practice can be effective in promoting effective health care for patients and individuals.[18192021222324]

The level of education did not affect the ethical behavior of nurses in this study. The results of some studies have shown that the higher education level has a positive impact on ethical behavior.

Conclusion

In this study, judgments and ethical behaviors of nurses were evaluated at the moderate and good level. Overall, the findings of this study show that the issue of nurses’ judgment and moral behavior needs to be strengthened and improved. All macro-, intermediate-, and micro-level factors in this process should be considered. The judgment competencies in ethical situation of nurses should be promoted to a higher level. It seems that more advanced educational methods are needed to achieve this goal. The findings from this study show the necessity of nurses’ ability to improve their behavior and moral judgment. It also shows which nurses need more reinforcement based on the demographic variables.

Limitations

One of the limitations of this study is the available sampling, performed in one of the cities of Iran, the use of self-reported method in determining the score of judgment and moral behavior of nurses, and the noninclusion of nurses working in the psychiatric wards in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.