Clarifying the concept of conscience in nurses' ethical performance in Iran: a concept analysis study.

Although conscience, as an ethical concept, has emerged widely in the field of nursing, its functional meaning and its effects on nurses' performance are not clear. Therefore, the present study aimed to analyze the concept of conscience in the context of Iranian nurses' ethical performance. This study used a hybrid model including theoretical, fieldwork, and final analytic stages. In the theoretical phase, English and Persian articles published up to 2020 and indexed by scientific databases were analyzed. In the fieldwork phase, semi-structured in-depth interviews were conducted on nurse participants. The last two stages were jointly considered to draw the study's conclusions. In the theoretical phase, conscience was considered as a context-dependent concept, an inner voice, and a criterion for distinguishing right from wrong. The fieldwork phase' results were categorized into three themes: "perception of conscience", "commands of conscience", and "obedience to conscience. The final definition was reached by merging the theoretical and field stages. This article aimed at investigating the relevance of conscience to ethical practice in the nursing field. Findings show that conscience is an inner feeling or voice that plays a vital role in providing ethical care by nurses.

Introduction

Ethics is entangled in various aspects of the nursing profession, and nurses frequently face different ethical challenges in providing care to patients (1). During their professional lives, nurses face situations demanding decision-making and judgment based on ethical considerations. In ethically challenging situations, nurses rely on their conscience to resolve them and provide quality care (2). Different definitions for conscience in nursing literature were presented: (i) an inner sense or feeling that helps an individual make the right choice; (ii) an innate force that is the cornerstone of ethics. (3, 4).

Under complicated circumstances, conscience can positively affect nurses’ performance and guide nursing care toward ethical quality care (3). Many studies on the concept of conscience admitted that in ethical decision making based on professional, ethical codes and guidelines, conscience guides nurses to protect both patients and their moral integrity (4-6). For instance, participants in the study by Hasani et al. stated that conscience directed them to provide ethical and comprehensive care to patients. They also felt guilty if they neglected their conscience in providing care to patients (7).

In many studies, including Lamb et al., conscience was introduced as a commanding authority issuing a warning signal depending on the subject’s culture and context (3). Other studies described conscience as the cornerstone of ethics (4, 8). When nurses follow their conscience to provide quality care, their interpretation of conscience is positive; otherwise, conscientious conflict causes a troubled conscience that can be associated with the feeling of guilt (9, 10). Since conscience judges thoughts and deeds, it can help nurses preserve their ethical integrity and provide proper care to patients. If nurses do not follow the path of conscience, they may face various consequences such as guilt, troubled conscience, and stress of conscience (11, 12).

Conscience is a valuable asset that guides nurses towards ethical practice and has a significant impact on nursing care (2, 8, 9). Studies on conscience consider it as a function of structure and culture (3, 8). In Iran, studies on conscience in the nursing field have not focused on the concept of conscience in nurses’ ethical performance. Additionally, conscience does not have a clear definition when considering the role of ethics in the ethical performance of nurses. Hence, the present paper aimed at analyzing the concept of conscience in the context of nurses’ ethical performance in Iran and clarifying this concept from Iranian nurses’ perspective based on Iran’s culture. Clarification of the dimensions and characteristics of this concept can help in future research, educational plans, practice, benchmarking, and evaluation. Moreover, a precise definition of conscience is a step towards the development of context-centered professional knowledge.

Methods

In this study, to analyze the concept of conscience, a hybrid method was used, and comprised of theoretical, fieldwork, and analytical phases (13). This method of concept analysis is one of the methods for processing and developing concepts and theories. In nursing, it is used to remove concepts’ ambiguities and help reduce concepts’ abstract load (13). The major usage of this model is to analyze a topic in nursing as well as in a specific field and context (14).

Theoretical phase

A systematic method was used, and a protocol was utilized involving the following: selecting review questions, inclusion criteria, search strategy, study selection, data extraction, and quality assessment. Literature was reviewed using articles from creditable databases including PubMed, ISI, Scopus, ScienceDirect, and Persian databases SID and Magiran. The keyword "conscience" was searched in paper titles, and "nurs*" was searched in the title and abstract of the papers indexed in English and Persian electronic databases. No limitation was applied to publication date as well as to selecting original and review articles, including qualitative and quantitative. The inclusion criteria involved considering articles relevant to the concept under study, English and Persian languages, full- text availability, and non-duplication. The search yielded 212 papers, including 40 reports from Persian databases and 172 articles from English databases. Given the overlaps of articles and that only original articles on conscience were included, 22 articles (16 English articles and 6 Persian articles. Diagram 1 shows the article selection process details. A domain-based evaluation, a component approach, was used to evaluate the quality of quantitative studies. Each study was assigned a specific code considering randomization, sample size, blinding, and random sampling. The Critical Appraisal Skills Programme (CASP) evaluation tool was used in the qualitative studies; a 10-item evaluation tool designed by the UK Evidence-Based Medical Center (15). In addition, two faculty members of Tehran University of Medical Sciences (TUMS) confirmed the quality of the studies. Conventional qualitative content analysis was used to analyze the texts, and data analysis was performed using Graneheim and Lundman's method, 2004 version (16). The text was read several times to achieve a general overview. Then, the meaning units were extracted, and the extracted concepts were compressed. Concepts and definitions extracted from the theoretical phase were transferred into the fieldwork phase.

Fieldwork phase

The fieldwork phase’s objectives were to improve and refine the concept resulted from the theoretical phase. In terms of time, the fieldwork phase overlapped with the theoretical phase and focused on the experimental component. This stage was investigated in TUMS’ affiliated hospitals, and nurses in those hospitals were invited to participate in the study. Inclusion criteria were having a bachelor’s degree or higher in nursing as well as the willingness to share the experiences regarding the concept of conscience.

Based on the theoretical phase’s results, a semi-structured questionnaire was designed; purposeful sampling was used; and, face-to-face interviews were conducted to collect data. At this phase, the interviews’ guiding questions included the following: “how does your conscience help you in clinical practice?”; “What does a conscientious nurse do while caring for a patient?” Then, questions starting with "Why" and "How" were asked, and, each interview lasted 30 to 60 minutes, on average. The written informed consent of participants was initially obtained, and the time and place of interviews were scheduled according to their convenience. After receiving participants’ permission, the interviews were audio-recorded. After eight interviews, data saturation was reached and sampling was completed.

Data collection and analysis were performed simultaneously, conventional qualitative content analysis was used to analyze the interviews, and data analysis was performed using Graneheim and Lundman's method, 2004 version (16). The interviews were transcribed and read several times to form a general overview of the interviews and concepts; then, meaning units were extracted, and the extracted concepts were compressed. The extracted concepts were categorized considering similarities and differences, and a suitable title was chosen for each category. Analysis and management of data were performed using MAXQDA software, version 10. To enhance data quality in this phase of the study, the researchers used Lincoln and Guba 1985 to increase the trustworthiness of the data and findings. Trustworthiness includes various dimensions such as credibility, transferability, confirmability, dependability, and authenticity (15). In this study, the researcher tried to increase the credibility of the data by long-term involvement in the field and establishing appropriate communication with the participants to access their actual experiences. Peer checks were used to confirm the findings; the meaning units with the extracted codes were provided to observers, and their comments were applied.

Final analytic phase

The data from the literature review and the codes obtained from the field study were compared to develop the concept of conscience in the nursing field in Iran, and then the meaning and specifications of this concept were discovered and reported.

Ethics considerations

This article resulted from a research project approved by the Nursing and Midwifery Research Center of TUMS and has a code of ethics from TUMS (IR.TUMS.FNM.REC.1399.142). Written informed consents were obtained from the participants after full disclosure of the study’s goals. Maintaining anonymity and confidentiality were observed and participation was voluntary.

Result

Theoretical phase

According to studies, conscience is an inner sense of right and wrong and acts as a guide to human behavior (8,12). The word conscience was derived from the Latin word "conscientia", rooting in the Greek word "synderesis". The word’s meaning is twofold: to share knowledge and awareness as well as to Apprehension.

Conscience is also used to convey a sense of mind or thought (17). Conscience is the bedrock of ethics, an inner voice functioning as a moral compass as well as an integrated set of personal values guiding human beings in living and behaving (2, 4, 18,19). Jensen and Lidell quoted from Alden that conscience in theology is a manifestation of faith or a perspective of life, and if so, it has to do with ethics and ethical feelings. Conscience in religious texts was defined as God’s voice (20). However, from a philosophical perspective, conscience is a theoretical construct that depends on personal emotions and thoughts (3). From a psychological viewpoint, according to Juthberg et al., quoted from Freud, conscience acts subconsciously and is rooted in the integrity of human beings' values (21).

In the context of evaluating nursing performance, conscience is a base of ethical actions and decisions as well as ethical nursing care (22, 23). In the nursing field, conscience provides a warning signal, higher sensitivity in actions, and an ethical guide in fulfilling patients’ needs (18, 24, 25). Disregarding conscience can lead to troubled conscience and stress of conscience in nurses’ professional life (8,26,27).

The results of studies in Iran showed that conscience is an intrinsic capability in delivering nursing care for Iranian nurses. Such capability provides aspects of self-awareness for an individual (28, 29). Few studies on conscience in the nursing field in Iran concluded that the concept of conscience was a function of culture and religion. In this regard, Hasani et al. defined conscience as an inner and innate asset that can advance under the influence of the environment (7). They believed that conscience monitors human beings’ actions, and if they act contrary to the call of conscience, as a judge of actions, it begins to blame (7, 30). Another study in Iran in the field of nursing considered conscience as a guide that influenced by environmental, occupational, and personal factors. This study found workload, personality type, history of hospitalization (individuals or their relatives) as the factors affecting conscience (31-33) (Table 1).

Table 1

Studies including the concept of conscience in nursing field

Author and year	Type of paper/method	Sample	Setting	Country
Ahlin et al (2012)	Questionnaire Validation	503 HCP	Hospital	Sweden
Saarnio et al (2012)	Quantitative study	350 nurses	nursing homes	Finland
Glasberg et al (2006)	Questionnaire Validation	444 HCP	Hospital	Sweden
Lamb et al (2017)	Concept analysis	N/A	N/A	Canada
Jensen and Lidell 2009	Qualitative study	15 nurses	Hospital	western Sweden
Cleary and Lees(2019)	Review article	N/A	N/A	Australia
Mazaheri et al (2018)	Qualitative study	10 nurses	residential care settings	Sweden
Mazaheri et al (2015)	Qualitative study	10 nurses	residential care settings	Sweden
Genuis and lipp(2013)	Review article	N/A	N/A	Canada
Glasberg et al 2006	Quantitative study	423 HCP	hospital	Sweden
Dahlqvist et al (2007)	Development of questionnaire	444 nurses and physicians	Hospital	Sweden
Ahlin et al (2015)	Quantitative study	488 nurses	nursing homes	Sweden
Juthberg et al (2010)	Quantitative study	146 nurses	hospital	Sweden
Tuvesson et al (2012)	Quantitative study	93 nurses	hospital	Sweden
Zhang et al (2013)	Quantitative study	100 nurses	Hospital	China
Ko et al (2020)	Quantitative study	167 nurses	Hospital	South Korea
Morton and Kirkwood (2009)	Review article	N/A	N/A	Canada
Vanaki and Memarian (2009)	Qualitative syudy	36 nurses	Hospital	Iran
Hasani et al (2013)	Qualitative study	9 nurses	Hospital	Iran
Foolad et al (2019)	Quantitative study	569 nurses	Hospital	Iran
Lak et al (2018)	Quantitative study	193 nurses	Hospital	Iran
Jasemi et al (2018)	Qualitative study	14 nurses	Hospital	Iran
Nasirzadeh (2015)	Review article	N/A	N/A	Iran

The working definition of conscience

From the theoretical phase’s findings, the researchers concluded that conscience, existing since birth, may develop and change under the influence of environmental factors (e.g., family, society, culture, and religion) and during the process of personal growth.

Flow diagram of search process

Conscience, as an inner voice or feeling, testifies to the rightness or wrongness of an action. Conscience is a personal moral compass that governs a person’s thoughts and feelings, judges actions and behaviors, and provides a reference for future needs. In complex moral situations, conscience enables individuals to distinguish right from wrong as well as acts as a motivator and leader in performing morally right nursing care.

Fieldwork phase’s findings

In this study, eight nurses with an average age of 34.99±7.35 years were interviewed. Table 2 shows the participants’ characteristics.

Table 2

Characteristics of the participants

Variable	N (%)
Gender Male Female	3(37.5) 5(62.5)
Education Level B.Sc. M.Sc.	6(75) 2(25)
Marital Status Single Married Separated	3(37.5) 4(50) 1(12.5)
Work Experience 1-6 years 7-12 years More than 12 years	3(37.5) 3(37.5) 2(25)

Using conventional qualitative content analysis with Graneheim and Lundman's method, 612 initial codes were extracted. After compressing the codes and classifying them, the fieldwork phase’s results were categorized into three categories: “perception of conscience”, “commands of conscience”, and “obedience to conscience” (Table 3).

Table 3

Categories, subcategories and codes of conscience in the field work phase

Categories	Subcategories	Codes
Perception of conscience	Inner voice Superior feeling Guide and observer	Conscience is the voice of God Conscience is the inner inspiring factor Conscience is a transcendental sense Conscience is the supreme inner power Conscience is an inner guide Conscience is a human observer
Commands of conscience	Conflict of conscience Strong commanding center	Conscience is the agent distinguishing right from wrong Conscience is a factor of choosing right from wrong Conscience is a restraining agent Conscience is an inner stimulus
Obedience to conscience	Troubled conscience Clear conscience	Conscience is a blame factor Conscience is a cause of guilt Conscience is a satisfying factor Conscience is a soothing factor

Perception of conscience

This category is related to nurses’ understanding of the concept of conscience, divided into the following subcategories: inner voice, superior sense, guide, and observer. Under the “perception of conscience” theme, most participants defined conscience as an inner voice or feeling that leads nurses to perform the right actions. Moreover, conscience is a superior feeling, guide, and observer that helps nurses perform their professional duties.

In this regard, participant No. 2 stated as follows: "When I get stuck in a dilemma, a voice from within tells me what to do, as if God is talking to me. For example, I have always tried not to fail in my job because my conscience tells me that I have accepted its responsibility. "

Commands of conscience (commanding conscience)

This category referred to the commanding nature of conscience, divided into two subcategories: “conflict of conscience” and “strong, commanding center”. “Conflict of conscience” recommends or prohibits an action as a “strong, commanding center”. Based on nurses’ experiences, conscience motivates nurses to fulfill responsibilities to patients in the best possible way and encourages them to provide quality care beyond their job description. In summary, conscience helps nurses distinguish right from wrong, encourages them to do the right actions, and prevents them from doing the wrong actions.

In this regard, participant No. 4 stated as follows: "I informed anesthesiologists when the patient developed respiratory distress and hypoxia and was in urgent need of intubation. Unfortunately, they arrived too late. It was not my task to intubate the patient, but I did so because my conscience did not allow me to let the patient remain in that state of respiratory distress."

Obedience to conscience

This category is related to submission to conscience, divided into two subcategories: “troubled conscience” and “clear conscience”. Therefore, if individuals follow their conscience, they will enjoy contentment as well as mental and spiritual peace; otherwise, they will feel guilty. Conscience provides a persistent inner warning and once neglected, it starts blaming, and hence conscience acts as an internal stressor. Hence, nurses enjoyed a clear conscience when they appropriately performed their professional duties. When they failed to meet patients’ needs, they suffered from a troubled conscience accompanied by feelings of guilt, incapacity, fatigue, and discomfort. Not to suffer from a troubled conscience and not to experience such painful feelings, nurses should listen to their conscience call in patient care.

In this regard, participant No. 7 said: "I have always tried to do my work such that my conscience stays at ease. Then, I do not feel guilty and upset because patients’ affairs have been abandoned or I have allocated inadequate time to do their related tasks. Last week, when a patient with COVID-19 developed respiratory apnea, we immediately began resuscitating the patient. She was a 39-year-old woman, and although we worked hard to save the patient, she died. I think the patient has taken too much sedative drug and developed apnea. I still have a guilty conscience for not paying enough attention."

Final analytic phase

After merging the results of the theoretical and fieldwork phases, conscience in the context of ethical performance of nurses in Iran was defined to be an internal voice and feeling, guide, and observer of the individual since birth. Conscience develops and evolves under the influence of environmental factors (e.g., family, society, culture, and religion). Moreover, during the personal growth process, various aspects of consciousness are developed: “perception of conscience”, “command of conscience”, and “obedience to conscience”. Due to the nature of commanding and obedience aspects, conscience affects nurses’ ethical performance. Conscience assists nurses to distinguish right from wrong, motivates them to do the right actions, and helps them make the right choices and decisions. If nurses listen to the voice of their conscience and follow it, they can enjoy a clear conscience with inner peace and joy. If nurses fail to follow their conscience, they suffer from troubled conscience and may experience guilt and tension along with despair, powerlessness, and helplessness. To refuse such consequences, they should listen to their conscience call to provide the best ethical patient care.

Based on the results of the analytical stage, conscience is defined as follows: If nurses do their best professionally and ethically to provide ideal patient care, the internal stimulus that motivates nurses to make such quality effort is conscience. Conscience is an inner voice or feeling that accompanies human beings since birth and forms the foundation of ethics. Conscience can develop depending on the environmental factors (e.g., family, society, and religion) and involves several aspects: “perception of conscience”, “commands of conscience”, and “obedience to conscience.”

Discussion

This study aimed at clarifying the concept of conscience in the context of nurses’ ethical performance. Conscience is a dynamic and innate concept that can affect human beings’ lives depending on their cultural and social conditions. Moreover, conscience helps nurses provide the best possible professional and ethical care to patients. According to the participants, conscience is the bedrock of ethics and a fair judge that helps them in ethical dilemmas. In complex moral situations where ethics may not be observed, conscience warns nurses about the consequences of ignoring conscience call. Several papers in the field of nursing have defined conscience as a basis for ethical undertakings and ethical care for nurses and assisting nurses in clinical situations requiring ethical considerations (3, 4, 8,34).

in this research, conscience is an inner feeling and voice that guides nurses to perform the right actions. In the studies by Lamb et al. and Glasberg et al., conscience is defined as the inner voice, which is the cornerstone of ethics (2, 3). The present study showed that conscience is activated since birth in humans and has a dynamic nature. Conscience is developed and changed throughout human life in three aspects: “perception of conscience”, “commands of conscience”, and “obedience to conscience”. Thus, Alirezaie et al. showed that conscience can be developed and enhanced through education, which can result in performance improvement of staff and organizations (35). Mazaheri et al. also pointed to the dynamic and changing nature of conscience throughout human life. Environmental factors such as family and religion, particularly, affect the growth or development of conscience (8). Lamb et al. also consider conscience as a culturally related concept (3). Dahlqvist et al. defined conscience as an asset, a sensitivity, a responsibility, and a culture-dependent concept (4). Therefore, “perception of conscience”, “commands of conscience”, and “obedience to conscience” can have different meanings in different cultures, and hence their effects vary.

In the present study, an aspect of conscience is the “perception of conscience”, implying that conscience is a superior sense and inner guide forming the base of nurses’ ethics. Imani et al. argued that individuals with a robust professional conscience are more sensitive to negligence in observing ethical codes by their colleagues and tend to react to such behaviors, a sign of their commitment to ethics. Individuals with a strong conscience call and perception of conscience tend to commit more to ethics (36). According to the present study’s results, conscience is a restraining factor. Ignoring conscience commands leads to conflict in nurses’ actions and behaviors, as Ford and Austin emphasized the importance of paying attention to conscience commands (10). Moreover, studies in nursing fields have shown that if the conflict of conscience is repeated in different care situations, nurses will suffer from a troubled conscience, accompanied by guilt, sadness, and helplessness (12, 37) as the consequences of ignoring obedience to conscience. Moreover, studies showed that if nurses follow their conscience call, a sense of clear conscience is attained, obedience to conscience is exercised, and the conscience’s role is perceived positively (8).

Thus, ignoring the aspects of “command of conscience” and “obedience to conscience” leads to the conflict of conscience and troubled conscience, negatively affecting nurses. Studies showed that these consequences can lead to burnout and reduced quality of nursing care (23, 38). Gustafsson et al. found that negligence of conscience eventually leads to tension and job depression (39). Therefore, paying attention to conscience and its role in the nurses’ professional life is crucial.

Conclusion

This study's findings indicated that conscience is an innate voice, inner feeling, observer, and guide; the concept of conscience involves three aspects or dimensions: “perception of conscience”, “command of conscience”, and “obedience to conscience”. Identifying such dimensions can improve the status, importance, and application of this concept in the nursing field. However, concept analysis is an ongoing process, and with increasing knowledge and experience, the concept should be developed and extended further. Since Iran is a country with Iranian Islamic culture and various subcultures, more studies are needed to deeply identify the concept of conscience and its consequences in the Iranian nursing community.