Ethical Attitudes of Intensive Care Nurses during Clinical Practice and Affecting Factors.

Background: Technological advances in critical care contribute to patient survival, but healthcare professionals working in these units, which require technical expertise, experience highly challenging ethical decision-making processes. Aim: The aim of this study is to determine the attitudes of intensive care nurses toward ethical problems they face during clinical practice and the affecting factors. Method: The study included a total of 294 nurses working in the intensive care units at a city hospital. Data was collected using the Personal Information Form and Ethical Attitude Scale for Nursing Care. Findings: About 58.8% of the participants were females and 71.1% had undergraduate degrees. The total scale score was 56.48 ± 15.98. A statistically significant difference was found between participants' gender, weekly working hours, ethical definition status, and scale score averages.
Conclusion: More than half experienced frequent ethical problems and tried to solve them on their own. Trainings aimed at developing ethical sensitivity and participation in symposiums/conferences that address ethical issues specific to intensive care are recommended. How to cite this article: Işik MT, Özdemir RC, Serinkaya D. Ethical Attitudes of Intensive Care Nurses during Clinical Practice and Affecting Factors. Indian J Crit Care Med 2022;26(3):288-293.

Introduction

Intensive care units (ICUs) are specialized units developed for the treatment and follow-up of life-threatening health problems and equipped with high technology for close observation and rapid intervention of acute and chronic diseases. Problems within the multifaceted and complex structures of intensive care range from patient admission to determining the limits of treatment applied to the costs of intensive care.

Technological advances in critical care contribute to patient survival. But healthcare professionals working in these units, which require technical expertise, experience highly challenging ethical decision-making processes.[1],[2] In this context, ethical issues in intensive care are mostly related to ICU patient admission/fair sharing of medical resources, clinical research, whether to tell the truth or not, privacy/confidentiality, HIV and AIDS, problems related to cardiopulmonary resuscitation decision, not providing and terminating treatment, brain death, organ transplantation, and questioning in connection with the quality of life.[3]

There are professional ethical codes that nurses are obliged to follow. The creation of nursing ethical codes is a guide in understanding the process of professional conduct.[4] These codes are a practical and specific guide for all, increasing commitment to the profession and making nurses adopt a philosophy of care. For example, the ethical principles of the International Council of Nurses (2012) and the Turkish Nurses Association (THD)[5],[6] in our country state the ethical principles and responsibilities for becoming a professional nurse.

It is important that nurses who provide 24-hour continuous care in accordance with patient needs have professional ethical competence and sensitivity.[2],[7] Ethical principles in nursing can be ranked as autonomy, beneficence, nonmaleficence, veracity, confidentiality, justice, and fidelity.[8] In this context, basic issues, such as professional competence of the nurse in practice, roles and responsibilities of teamwork, respect for the patient's honorable life, respect for the right to privacy, attention to autonomy, avoidance of discrimination, and providing services with respect to patient rights, can be discussed.[8],[9] For nurses working in ICUs, having ethical awareness and sensitivity is effective in identifying ethical problems, managing the ethical decision-making process correctly, and making the most beneficial decision for the patient. In this context, it is important that holistic patient care continues to be provided adhering to ethical values, especially in complex ICUs.

Aim

This study is planned to determine the ethical attitudes of ICU nurses in patient care and the factors that influence these attitudes.

Methods

Research Design

The research was conducted as a descriptive cross-sectional study.

Location and Characteristics of the Study

This research was carried out with nurses working in ICUs at a city hospital in Southern Turkey. ICU nurses work in three shifts: 08:00 am-04:00 pm, 04:00 pm-08:00 am, and 08:00 pm-08:00 am.

Study Universe

Three hundred fifty nurses working in internal medicine, surgical, and pediatric ICUs between August 3, 2020, and January 3, 2021, at a city hospital formed the universe of this study.

Study Sample

The sample size planned was at least 52 nurses to allow for a moderate relationship between the scales used with 5% type I error and 90% test reliability.[10] The sample consisted of 294 volunteer nurses who worked in the internal medicine, surgical, and pediatric ICUs of a city hospital. Fifty-six nurses were not included in the study because 26 were on leave during data collection, 16 filled out the data collection form incompletely, and 14 did not agree to participate in the study.

Data Collection Tools

Data were collected using the personal information form and the ethical attitude scale for nursing care (EASNC).

Data Collection

Personal Information Form: There are 21 questions to determine the demographic data and participants’ approaches related to ethics in general, such as age, gender, years of work in the intensive care unit, weekly working hours, and the state of having ethical problems in the clinic.[9,11,12]

Ethical attitude scale for nursing care (EASNC) was developed by Özçiftçi and Akin. The Likert scale (1: Strongly agree, 2: Agree, 3: Undecided, 4: Disagree, and 5: Strongly disagree) consists of 34 expressions and has a single subdimension. An increase in the total score of the scale reflects a positive ethical attitude, while a decrease in the average score reflects a negative ethical attitude. The minimum score possible is 34 and the maximum is 170. Lower average scores indicate negative ethical attitudes. The Cronbach's alpha coefficient of the scale is 0.968.[12] For our study, Cronbach's alpha coefficient was 0.977 which indicates a high level of internal consistency.[13]

Application of Data Collection Forms

Nurses who met the inclusion criteria were asked to fill out the data collection form after being informed about the purpose of the study. It took about 10 minutes to complete the form.

Ethical Aspect of Research

Written permission was obtained from the university's clinical research ethics board (decision of the board dated May 8, 2020, and numbered 562/16). In addition, participants were informed about the study, and their consent was obtained.

Data Analysis

Data analysis was conducted using STATISTICA 13.5.0.17 program. Descriptive statistics are given in minimum, maximum, average, and standard deviation for age, duration of work in the profession and in the ICU, average number of patients cared for, and total scale score. Descriptive statistics for other categorical variables are given in the form of number (n) and percentage (%). The suitability of the data for normal distribution was evaluated using the Shapiro-Wilk test. Mann-Whitney U and Kruskal-Wallis tests were used to compare the total scale score and the questions contained in the scale. Spearman's correlation was used to determine the relationship between age, occupation and duration of work in ICU, and the total scale score. The R-value in the correlation was evaluated as <0.20 very weak, 0.20–0.39 weak, 0.40–0.59 medium level, 0.60–0.79 high level, and 0.80–1.00 very high level relationship.[14] All results obtained were considered statistically significant when p is <0.05.

Results

The average age of the participants was 30.55 ± 6.40 (min: 19, max: 50). About 58.8% of the participants were females and 52% were single. And 71.1% had an undergraduate degree, 14.6% had an associate degree, 7.5% were high school graduates, and 6.8% had a graduate degree. The amount of time worked in the profession was 104.82 ± 80.06 (min: 2, max: 366) and in the ICU was 70.44 ± 61.53 (min: 2, max: 312) months. About 54.4% of the nurses worked in surgical, 28.2% in internal medicine, and 17.3% in children's ICU. The number of patients cared for in the unit worked in was 2.79 ± 1.00 (min: 1, max: 6). 96.3% of intensive care nurses worked as clinician nurses and others as lead nurses. 70.4% of the participants did not receive ethics-related training outside of school, and 68.4% did not attend a symposium/conference on ethics. 93.2% worked both during the day and night, 4.8% during the day, and 2% in night shifts. 11.6% worked for 40 hours a week in the ICU, 49% for 48 hours, and 39.5% for 56 hours. 88.4% stated the number of caregivers, 84% the number of nurses, and 69% said that care supplies and medical equipment were not enough.

About 62.2% of the participants had frequent ethical problems while providing care, 19% had no ethical problems, and 18.7% were unaware of ethical problems. When they encountered ethical problems, 59% solved them by themselves, 30.1% with the help of colleagues, 5.5% with the help of other health professionals, and 5.5% failed to solve the ethical problem. When asked to define ethics, 15.6% defined it as ethical principles (justice, providing benefit-not harm, and autonomy), 14.3% professional ethics, 13.3% being fair, 12.9% ensuring the well being of the patient and patient rights, 11.6% working within the framework of love and respect, 5.4% privacy, and 2.7% professional rules. One percent of respondents stated that ethical values have been forgotten because they focus on their work, while 23.1% did not answer the question. 84.4% of the participants stated that there is no written text about nursing ethics in our country, and 62.9% provided care to a patient diagnosed with COVID-19.

A statistically significant difference was found between gender and mean score (p = 0.043). Male participants were found to have higher scores than female participants. A statistically significant difference was found between the hours worked in 1 week and mean score (p <0.05). A statistically significant difference was found between the average score of employees that work 56 hours, 0-40 hours (p = 0.020), and 48 hours per week (p = 0.027) (p <0.05). A statistically significant difference was found between participants who defined the concept of ethics and those who did not respond (p <0.05) (Table 1).

Table 1

Comparison of ethical attitude scale scores of participants according to their individual characteristics

Characteristics of participants		n	Min-Max [Median]	Q1-Q3	Mean ± SD	Test statistics (Z[*], H[**])	p
Gender	Female	173	34-93 [57]	40-68	54.58 ± 14.15	2.02[*]	0.043[***]
	Male	121	34-102 [64]	43.75-68	59.21 ± 18.00
Weekly working hours	0-40 hours	34	34-99 [47.5]	36-66	52.26 ± 17.94	0.58[**]	0.013[***]
	48 hours	144	34-102 [59]	39-68	55.08 ± 15.51
	56 hours	116	34-102 [64.5]	48-68	59.47 ± 15.57
Definition of ethics	Did not answer	68	34-102 [67]	54.5-68	64.37 ± 16.82	26.81[**]	<0.001[***]
	Ensuring well-being of the patient and patient rights	38	34-88 [67.5]	40-68	57.82 ± 15.21
	Being fair	39	34-93 [54]	46-68	55.74 ± 14.49
	Ethical principles (justice, providing benefit-not harm, autonomy)	46	34-81 [44.5]	34-64	49.00 ± 14.45
	Working within the framework of love and respect	34	34-102 [65.5]	41-68	58.18 ± 17.27
	Privacy	16	34-69 [53.5]	47.5-68	55.00 ± 11.67
	Professional ethics	42	34-71 [49]	38-68	51.98 ± 13.89
	Professional rules	8	34-77 [47.5]	34.5-65.5	50.75 ± 16.32
	Ethics forgotten	3	47-59 [51]	48-57	52.33 ± 6.11

Mann-Whitney U Test;

Kruskal-Wallis;

Statistically significant

No statistically significant difference was found between scale score and the following factors: marital status, position worked in the ICU, status of ethics training, participation status in symposium/ conference about ethics, shift worked in, number of nurses, number of caregivers, having adequate medical equipment, unit worked in, status of having ethical problems, and the status of knowing text related to ethical values for a nursing profession on a national scale (p >0.05).

There was no statistically significant difference between the status of care for patients diagnosed with COVID-19 and the scale score (p >0.05). The scores of those who did not care for a patient diagnosed with coronavirus were higher.

There was no statistically significant difference between the state of solving the ethical problem experienced by participants and the scale scores (p >0.05). Participants who stated that they could not solve the ethical problem experienced had a very low average score compared to those who solved the ethical problems.

There was no statistically significant difference between the educational status of the participants and the scale score (p >0.05). Nurses with undergraduate degrees had the highest average score.

The total scale score average was 56.48 ± 15.98 (min: 34, max: 102). No statistically significant correlation was found between age and duration of work in the profession and in the ICU and the total scale score (p >0.05) (Table 2).

Table 2

Correlation between ethical attitude scale score and age, time worked in the profession, and time worked in the intensive care unit

	N	Mean ± SD	Min-Max
Ethical attitude scale total score	294	56.48 ± 15.98	34–102
	Age	Time worked in the profession	Time worked in the ICU
Ethical attitude scale total score r	−0.06	−0.09	−0.02
p	0.27	0.10	0.66

r, Spearman's correlation coefficient

Five statements on the scale in which the participants received the highest scores were “I identify ethical problems experienced in nursing care,” “I believe that it's necessary to receive ethics training in order to solve ethical problems encountered in nursing care,” “I allow individual autonomy in nursing care,” “I solve problems that occur when providing nursing care with an ethical approach,” and “I inform the individual about the procedures to be performed during nursing care” (Table 3).

Table 3

Top five items in which participants received the highest and the lowest scores on the ethical attitude scale in nursing care (n = 294)

	n	Mean ±	SD Min	Max
Top five items in which participants received the highest scores on the ethical attitude scale in nursing care
1. I identify ethical problems experienced in nursing care.	294	1.81 ± 0.58	1	4
2. I believe that it is necessary to receive ethics training in order to solve ethical problems encountered in nursing care.	294	1.79 ± 0.68	1	4
3. I allow individual autonomy in nursing care.	294	1.78 ± 0.64	1	5
4. I solve problems that occur when providing nursing care with an ethical approach.	294	1.74 ± 0.62	1	4
5. I inform the individual about the procedures to be performed during nursing care.	294	1.74 ± 0.67	1	5
Top five items in which participants received the lowest scores on the ethical attitude scale in nursing care
1. I give importance to holistic care in nursing care.	294	1.53 ± 0.58	1	4
2. I take care not to harm the individual in nursing care.	294	1.53 ± 0.59	1	4
3. I think it is a known and expected behavior in nursing care to approach the individual with empathy.	294	1.57 ± 0.57	1	4
4. I care for the privacy of the individual when offering nursing care.	294	1.59 ± 0.57	1	3
5. I would like nursing care to be targeted toward the individual's well-being.	294	1.59 ± 0.59	1	4

Participants received the lowest scores on the following items: “I give importance to holistic care in nursing care,” “I take care not to harm the individual in nursing care,” “I think it's a known and expected behavior in nursing care to approach the individual with empathy,” “I care for the privacy of the individual when offering nursing care,” and “I'd like nursing care to be targeted toward the individual's well-being” (Table 3).

Discussion

ICUs are units with limited bed capacity where critical decisions are made about a patient and the ethical burden is high due to the heavy burden of care and treatment. Given these situations, health professionals are expected to be more sensitive and aware especially of ethical issues.

In this study, more than half of the participants experienced ethical problems, while about one-fifth did not realize that they had ethical problems. More than half indicated that when they encountered an ethical problem, they tried to solve it without consulting anyone. The proportion of those who received help from colleagues in solving ethical problems was found to be more than one-fourth.

A study conducted with intensive care nurses in Turkey concluded that 60.8% of the nurses experienced ethical dilemmas and about a quarter (27.5%) received help from nurses and physicians to solve the problem.[7] In a study with clinical nurses in Nepal, 80.5% of the nurses stated that they sought help from senior nurses when they could not solve ethical problems.[15]

It has been noted in studies that the joint decision of health professionals in solving ethical problems reduces moral distress in nurses.[16-18] One study found that two-thirds of ICU nurses failed to solve the ethical problems faced.[19] Ethical sensitivity and awareness are of great importance in solving ethical problems. In ICUs, where work dynamics are different, it is important that health professionals make choices that benefit patients when challenged with ethical problems. Also, consultations with others can positively affect the ethical decision-making process.

In this study, participants were asked to define ethics. Three- fourths of the participants explained the concept with phrases like, “Justice, providing benefit-not harm,” “autonomy,” “professional ethics,” “being fair,” “providing benefit to the patient and patient rights,” “working within the framework of love and respect,” “privacy,” and “professional rules.” In a study with intensive care nurses, 64% stated that they had not heard of the moral distress concept.[20] Burkhardt and Nathaniel emphasized that ethics try to answer “What should I do in this situation?” and is derived from the nurse-patient relationship.[8] In this study, there was a significant difference between the group that defined the concept of ethics and the one that did not respond. Those who did not respond had a higher average score. Understanding ethics is important in the nursing profession, especially in the care process. Ethical values guide professional actions and are a deep and complex process by which people live.[21] Participants who did not define ethics were probably avoiding answering this open-ended question since the concept of ethics is detailed.

In this study, most of the participants stated that there is no written text about ethics in nursing in our country. A study conducted with doctors and nurses found that 85.6% of nurses had an insufficient level of knowledge about ethical codes.[15] In 2009, THD published a text called “Ethical Principles and Responsibilities for Nurses” in Turkey.[6] Another written text about the subject is “Nursing Pledge.” First read in 1893, the Florence Nightingale Pledge was revised in 1935 by Elizabeth Gretter and by the International Nursing Council in 1965.[22] Every nurse in our country takes this oath of the profession. Although these topics are included in nursing education programs, it is thought-provoking that most participants note that there is no written text about nursing ethics in our country. In-service training programs are needed to increase participants’ awareness about ethics and ethical responsibilities in Turkey.

In this study, the total scale score is low. Therefore, it is possible to say that the ethical attitudes of nurses are insufficient. The ethical sensitivity of ICU nurses was found to be moderate in other studies.[7,11,20,23] In a study by Schallenberger et al., ICU nurses were found to be morally sensitive. Ethical attitude can be affected by factors, such as the adoption of personal and professional values, vocational education, corporate culture, and work conditions.[24] Having high ethical sensitivity is the desired attitude and improves the quality of care and plays an important role in making the most useful decision on behalf of the patient. In addition, the high patient turnover rate in ICUs during the pandemic leads to many ethical problems and affects ethical sensitivity.

In this study, a statistically significant difference was found between gender and mean scale score. Male participants were found to have higher scale scores than female participants. Similar results were found in other studies.[7,19] One study concluded that women experienced morale difficulties more often in clinics.[25] The reason for these differences might be due to cultural and individual characteristics.

In this study, a statistically significant difference was found between hours worked per week and total scale score averages. Participants’ ethical scores increased as their weekly work hours increased. There may be various reasons for the increase in weekly working hours, but it was not addressed within the scope of this study. Studies have shown that units with an insufficient number of personnel are more likely to experience moral difficulties.[23],[25] Besides work-related factors, such as burnout, workload, and insufficient staff, personal factors can affect the ethical decision-making process and ethical sensitivity in an intensive work tempo. From another point of view, it can be thought that nurses may be more sensitive since long work hours require more attention and care.

In this study, there was no statistically significant difference between the educational level of the participants and the scale scores. Nurses with undergraduate degrees had higher average scores. In studies conducted with intensive care nurses, ethical attitudes of educated nurses were more positive,[17],[20] and trainings on end-of-life care in ICUs and teamwork have been found not to reduce moral distress.[17] These differences can be caused by the level of knowledge and perception of participants due to education, as well as the diversity of sources of access to information.

In this study, scale scores of those who did not care for patients diagnosed with COVID-19 were higher. Gallagher noted that during the pandemic, nurses experienced ethical problems and difficulties in care, which may be due to the limited facilities in institutions and large number of seriously ill patients alone and dying in clinics.[26] During the COVID-19 pandemic, the overflow of patients in intensive care clinics causes many ethical problems and forces health professionals to make difficult decisions.[27]

Our study revealed that about three-quarters of the participants did not receive ethics-related training outside of school, and more than half did not attend a symposium/conference on ethics. There was no statistically significant difference between the participants’ state of receiving ethical training, participation in a symposium/conference related to ethics, and the scale scores. In this study, those who did not receive ethics-related training and did not participate in a symposium/conference had a higher average scale score. One study concluded that two-thirds of ICU nurses had insufficient knowledge of ethical problems in nursing.[19] Moon and Kim emphasized that lack of knowledge or training in health ethics is the common cause of ethical dilemmas that arise in ICUs and that it is important to receive training in bioethics-clinical decision-making processes in clinics.[28] Ethics training, professional autonomy, personal values, effective communication, and leadership skills are important components of nurses’ moral sensitivity and important elements that aid in understanding and solving ethical issues.[24] Having adequate ethical competence is important in increasing ethical sensitivity which can be done through medical ethics trainings.[15,23,29] In line with the results of our study and the literature, it is important to conduct trainings on the ethical problems experienced by nurses and increase the effectiveness of these trainings.

When the scale item scores are evaluated in this study, the most adopted topics are: ethical problems that can be identified during care, the importance of training in ethics to solve ethical problems in nursing, supporting the autonomy of the individual in care, creating solutions to ethical problems using an ethical approach, and providing information about the procedures performed to patients during care. In a study conducted with physicians and nurses, nearly all participants emphasized that it is important to teach medical ethics during vocational training.[15] Bull and Sørlie stated in their study that making decisions on behalf of a patient, convincing a patient, and making decisions on behalf of the patient lead to stress and ethical challenges, and ethical problems caused by supporting patient autonomy should be investigated.[30] In a study, nurses noted that maintaining patient autonomy and dignity in end-of-life care are important ethical issues.[31] As a result of our study, we can explain the parallelism of the ethical principles that participants care about with the common perception of professional ethical principles at an international level.[5]

When looking at the scale item point averages, the issues least internalized by the participants were planning care to increase the well-being of the patient, caring about the privacy of the patient, empathy during care to be known and expected approach, being careful not to harm the patient, and emphasis on the holistic approach in care. In a study conducted with 382 nurses in the ICUs of Iranian hospitals, the most contradictory issue was a violation of privacy (76.9%, n = 294).[32] While there are similar results about the ethical value of compassion in our study, differences in other values might result from differences in the perception of professional ethical principles due to different personal and cultural characteristics.

Conclusion and Recommendations

While ICU nurses had low overall scale scores, there was a statistically significant relationship between long weekly working hours, not answering the definition of ethics question, gender, and ethical attitude score.

ICU nurses with undergraduate education, who could not solve the ethical problem they experienced and who did not care for patients diagnosed with COVID-19, had higher levels of ethical attitude than others.

Ethical attitudes most ignored by ICU nurses while caring for their patients were holistic understanding of care, privacy, care not to cause harm, approach with empathy, and wanting care to be aimed at the individual's well-being. Courses that address ethics should be emphasized during nursing education. Vocational trainings should be organized that address ethical problems specific to intensive care and opportunities should be provided to nurses to share their experiences with ethical problems. In-service trainings should be organized in order to raise awareness of legal regulations and ethical codes.