Volume 11, Issue 3 (2023)
Health Educ Health Promot 2023, 11(3): 373-379 |
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Aljabouri A, Khoobi M, Ahmadi F, Rasekhi A. The Relationship between Nurses’ Moral Sensitivity and Patient Satisfaction in Iraqi Emergency Wards in 2021. Health Educ Health Promot 2023; 11 (3) :373-379
URL: http://hehp.modares.ac.ir/article-5-70521-en.html
URL: http://hehp.modares.ac.ir/article-5-70521-en.html
1- Department of Nursing Education, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
2- Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
2- Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
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Instrument and Methods
Study Design
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Introduction
Patient satisfaction results from a comparison of an individual’s healthcare experiences against one’s subjective standards. Satisfaction is a unique and subjective phenomenon influenced by factors, such as the quality of health care services provided by medical staff and their ability to communicate mentally with patients, age, sex, level of education, lifestyle, previous experiences, future expectations, patients’ individual-social values, and their awareness of their rights [1].
Researchers believe that high satisfaction leads to faster physical and psychological recovery of the patient. In addition, more satisfied patients show better adherence to treatment and are more compliant and cooperative [1]. Dissatisfaction with increased anxiety and irritability in patients causes a delay in their recovery process, which will cause more beds to be occupied in hospitals by lengthening their stay and raising their treatment costs. Patient satisfaction is one of the important indicators for assessing the quality of health services [2]. Since patient satisfaction is tied to nursing performance and care, nursing care is not separated from ethical issues. For example, the development of ethical decision-making in nursing increases the quality of care and provides services based on best practices and scientific learning. In addition, if the moral conflict cannot be resolved, it can affect the nurses’ ability and negatively influence the quality of nursing care [3]. Although studies have shown that nurses’ awareness of their moral responsibilities is increasing, nurses have been ill-prepared to identify moral dilemmas and determine the appropriate method to solve the moral problem.
Moral sensitivity is the first component of the ethical decision-making process in difficult moral situations. Moral sensitivity is the ability to identify the existing moral problem and understand the moral consequences of the decisions made about it [3]. This kind of sensitivity is effective in the detection of moral conflicts, emotional and intellectual perception of vulnerable situations, as well as increasing awareness of moral consequences resulting from making decisions about others. Many barriers affect the moral sensitivity of nurses in practice [4]. Therefore, the attention to moral sensitivity is increasing, especially in nursing as a social profession, because nurses are regularly exposed to situations of conflict and tension caused by moral confusion. The lack of attention of nurses to ethical issues may lead to ignoring these issues in their stressful work environment [5]. Research has shown that nurses can face ethical challenges when they have high moral sensitivity. It is also possible to create moral sensitivity in nurses by creating the right knowledge and attitude. It is in the shadow of such moral sensitivity that the nurse can recognize conflicts and moral dilemmas and provide moral care. Ethical sensitivity increases attention and accurate understanding of the needs of patients and their families, which in turn causes satisfaction [6]. Among nurses working in different departments, emergency nursing differs significantly from other areas of specialization. Healthcare professionals working in emergency services encounter a variety of illnesses, injuries, and problems, and are constantly rushed to attend emergencies due to overworked and overcrowded conditions. Many factors, including providing care for multiple patients at the same time, racing against time for care and treatment, hasty decision-making, frequently facing death, disability, pain, and distressing events, working in shifts, long working hours, fatigue, insufficient nursing staff, problems within the team, difficulty in communicating with patients/relatives, insufficiency of work procedures, and lack of materials and hardware lead to moral issues in the emergency department [7].
Ethical considerations affect nursing care in the emergency departments in various ways. For example, nurses have to respect the autonomy, beneficence, non-maleficence, and justice of the patients, while also balancing the duty of care, consent, restraint, privacy, and confidentiality issues that may arise. Additionally, nurses have to deal with the challenges of triage, crowding, access block, and harm reduction in the emergency setting [7, 8].
Amiri et al. reported that moral sensitivity influences caring behavior, mindfulness, and psychological empowerment of nurses, which affect patients’ satisfaction [4].
In developed countries, many researchers have investigated moral sensitivity and its relationship with care outcomes [8, 9], but unfortunately, in some developing and low-income countries, these issues are not known and were less researched. In Iraq, these issues are new and so far, no research has been conducted in Iraqi hospitals. Therefore, this study investigated patient satisfaction with nursing care in emergency wards and its relationship with nurses’ moral sensitivity.
Patient satisfaction results from a comparison of an individual’s healthcare experiences against one’s subjective standards. Satisfaction is a unique and subjective phenomenon influenced by factors, such as the quality of health care services provided by medical staff and their ability to communicate mentally with patients, age, sex, level of education, lifestyle, previous experiences, future expectations, patients’ individual-social values, and their awareness of their rights [1].
Researchers believe that high satisfaction leads to faster physical and psychological recovery of the patient. In addition, more satisfied patients show better adherence to treatment and are more compliant and cooperative [1]. Dissatisfaction with increased anxiety and irritability in patients causes a delay in their recovery process, which will cause more beds to be occupied in hospitals by lengthening their stay and raising their treatment costs. Patient satisfaction is one of the important indicators for assessing the quality of health services [2]. Since patient satisfaction is tied to nursing performance and care, nursing care is not separated from ethical issues. For example, the development of ethical decision-making in nursing increases the quality of care and provides services based on best practices and scientific learning. In addition, if the moral conflict cannot be resolved, it can affect the nurses’ ability and negatively influence the quality of nursing care [3]. Although studies have shown that nurses’ awareness of their moral responsibilities is increasing, nurses have been ill-prepared to identify moral dilemmas and determine the appropriate method to solve the moral problem.
Moral sensitivity is the first component of the ethical decision-making process in difficult moral situations. Moral sensitivity is the ability to identify the existing moral problem and understand the moral consequences of the decisions made about it [3]. This kind of sensitivity is effective in the detection of moral conflicts, emotional and intellectual perception of vulnerable situations, as well as increasing awareness of moral consequences resulting from making decisions about others. Many barriers affect the moral sensitivity of nurses in practice [4]. Therefore, the attention to moral sensitivity is increasing, especially in nursing as a social profession, because nurses are regularly exposed to situations of conflict and tension caused by moral confusion. The lack of attention of nurses to ethical issues may lead to ignoring these issues in their stressful work environment [5]. Research has shown that nurses can face ethical challenges when they have high moral sensitivity. It is also possible to create moral sensitivity in nurses by creating the right knowledge and attitude. It is in the shadow of such moral sensitivity that the nurse can recognize conflicts and moral dilemmas and provide moral care. Ethical sensitivity increases attention and accurate understanding of the needs of patients and their families, which in turn causes satisfaction [6]. Among nurses working in different departments, emergency nursing differs significantly from other areas of specialization. Healthcare professionals working in emergency services encounter a variety of illnesses, injuries, and problems, and are constantly rushed to attend emergencies due to overworked and overcrowded conditions. Many factors, including providing care for multiple patients at the same time, racing against time for care and treatment, hasty decision-making, frequently facing death, disability, pain, and distressing events, working in shifts, long working hours, fatigue, insufficient nursing staff, problems within the team, difficulty in communicating with patients/relatives, insufficiency of work procedures, and lack of materials and hardware lead to moral issues in the emergency department [7].
Ethical considerations affect nursing care in the emergency departments in various ways. For example, nurses have to respect the autonomy, beneficence, non-maleficence, and justice of the patients, while also balancing the duty of care, consent, restraint, privacy, and confidentiality issues that may arise. Additionally, nurses have to deal with the challenges of triage, crowding, access block, and harm reduction in the emergency setting [7, 8].
Amiri et al. reported that moral sensitivity influences caring behavior, mindfulness, and psychological empowerment of nurses, which affect patients’ satisfaction [4].
In developed countries, many researchers have investigated moral sensitivity and its relationship with care outcomes [8, 9], but unfortunately, in some developing and low-income countries, these issues are not known and were less researched. In Iraq, these issues are new and so far, no research has been conducted in Iraqi hospitals. Therefore, this study investigated patient satisfaction with nursing care in emergency wards and its relationship with nurses’ moral sensitivity.
Instrument and Methods
Study Design
This descriptive-correlational study was done on nurses and patients in the emergency wards of Al-Hamza General Hospital and Al-Diwaniyah Teaching Hospital, who met the inclusion criteria and were selected by a convenience sampling method. These wards are representative of the general population of emergency wards in Iraq. The study environment in both hospitals included the entire emergency department, which had the title of general and accepted all emergency patients who entered the hospital. Morgan's table was used to calculate the sample size.
Participants
There were 5,000 patients and 300 nurses in the emergency wards of Al-Hamza General Hospital and Al-Diwaniyah Teaching Hospital. Based on Morgan's table the sample size of patients and nurses was 357 and 169, respectively, and considering the attrition of 20%, 428 patients and 202 nurses were selected. It is worth mentioning that after sampling, only 200 out of 202 nurses and only 400 out of 428 patients participated in this research. Nurses and patients who did not fill out the questionnaire completely were excluded. Each nurse in the department also was responsible for the care of two patients. Inclusion criteria for patients were willingness to participate in the research with informed consent, patients in the emergency wards of Al-Hamza General Hospital and Al-Diwaniyah Teaching Hospital with more than 18 years, being hospitalized for at least 24 hours and being on the verge of discharge from hospital, no known cognitive or psychological disorders based on self-reporting and recorded documents, and no physical disability (unable to hear and speak) while completing the questionnaire. Inclusion criteria for nurses were work experience of at least six months in emergency wards, having high school, diploma, bachelor’s or master’s degrees, willingness to participate in the research, and nurses involved in the direct care of the patient in the emergency wards. The exclusion criteria for patients and nurses were failure to complete the questionnaire.
Data collection
Data collection was done from Jan 2021 to Aug 2022. the personal information form for patients and nurses, the Newcastle Satisfaction with Nursing Scale (NSNS) designed by Loiset al. in 1996, and the Moral Sensitivity Questionnaire (MSQ) designed by Lützén et al. in 1995, were used to collect the data. The demographic characteristics for patients included age, sex, marital status, level of education, length of hospitalization, and income level. The demographic characteristics form for nurses included sex, marital status, level of education, love for the profession, satisfaction with the job, and working shift.
NSNS is considered parsimonious and empirically supported. The scale provides information about nursing quality from patients’ perspectives. It includes demographic information, satisfaction with the nursing care scale, and a one-item scale (7-point response scale) on overall patient satisfaction [10]. The satisfaction with nursing care part consists of 19 items. All items are scored on a five-point Likert scale (1=not at all satisfied, 2=barely satisfied, 2=quite satisfied, 4=very satisfied, and 5=completely satisfied). The total score was computed and transformed to yield an overall satisfaction score of 0 to 100, where 100 denotes full satisfaction. The NSNS was found to be valid and reliable in previous studies [11, 12]. The Arabic version of this questionnaire translated into Arabic by Alasad et al. was used in this study [12].
Lützén et al. developed the MSQ, including 30 questions that measure moral sensitivity. It has six subscales, including interpersonal/relational orientation, structuring moral meaning, benevolence, modifying autonomy, experiencing moral conflict, trust in medical knowledge, principles of care/guiding rules, and three items classified under items [13]. The MSQ was translated and validated into different languages, such as Korean. The Korean‑MSQ (K‑MSQ) consisted of only 27 items used to measure the moral sensitivity among general nurses rather than psychiatric specialty as originally intended by Lützén et al. MSQ includes five subscales, namely patient-centered nursing (five items), professional responsibility (seven items), the experience of conflict (five items), structuralizing of moral meaning (five items), and expression of good deeds (five items) [4]. It has a seven-point response scale ranging from “one” indicating “not at all” to “seven” indicating “strongly agree.” The overall possible score ranges from 27 to 189. A higher score indicates a higher nurse’s moral sensitivity and vice versa. The Arabic version of this questionnaire was used in this study [13]. In addition, to confirm validity, the research tool was given to some Arabic expert professors and it was found that there was no difference in vocabulary and meaning in the Arabic questionnaire for Arabs. Its reliability was determined through the analysis of Cronbach's alpha coefficient approach by investigating 40 nurses and 85 patients who met the inclusion criteria. Cronbach’s alpha coefficient was respectively 0.76 and 0.89 for NSNS and MSQ.
The researcher first received written permission from the Vice-Chancellor for Education of Tarbiat Modares University of Medical Sciences and referred to the hospitals with a proposal and permission from the university to obtain a sampling permit. Then, he went to the emergency wards of Al-Hamza General Hospital and Al-Diwaniyah Teaching Hospital in Al-Diwaniyah City to distribute the questionnaire to the nurses and patients in these wards. Before sampling, the nurses were informed about the purpose of the study and guided to complete the questionnaire. In addition, the researcher distributed the questionnaire to the patients after receiving full health care and while completing the questionnaire, the researcher was with the patients to answer their possible questions. The researcher gave nurses enough time to fill out the questionnaire.
Data analysis
Data analysis was conducted using SPSS software version 20. Descriptive statistics, including means, standard deviations (SD), frequencies, and percentages, were used to describe participants’ demographic and clinical characteristics along with study variables. According to the obtained results of the Kolmogorov-Smirnov test, the distribution of patient satisfaction and moral sensitivity data was not normal (p =0.001 and p=0.001, respectively); thus, the non-parametric test (Spearman correlation coefficient and Kruskal-Wallis test were used. To analyze the relationship between nurses ' moral sensitivity and patient satisfaction, we matched one nurse with two patients on the same shift; there were two patients for each nurse in the same shift. For correlation assessment, we averaged the patients' satisfaction score and compared it with the moral sensitivity score.
Ethical considerations
The Medical Research Ethics Committee of Tarbiat Modares University (IR.MODARES.REC.1400.269) approved this research. Also, the participants were assured that the information would be kept confidential and anonymous. They were told to participate in the study freely and if they did not want to, they could leave the study. The first author gave adequate information about the purpose, and benefit of the study in a language understandable to the patients and nurses. Necessary permits were obtained from the related organizations in Iraq.
Findings
Demographic information of the nurses and patients is shown in Tables 1 and 2. Only 200 nurses and 400 patients completed the questionnaires.
Table 1) Nurse's socio-demographic information (n=200)
Table 2) Patients' socio-demographic information (n=400)
There was a positive correlation between patient satisfaction and moral sensitivity (r=0.662; p<0.001), which means patient satisfaction depends on the moral sensitivity of emergency nurses. The higher moral sensitivity, the higher the patient's satisfaction, and vice versa. There were no significant differences in moral sensitivity among emergency nurses concerning their gender, marital status, and education level. Also, the analysis of variance confirmed significant differences in moral sensitivity among emergency nurses concerning work shifts (p<0.001); nurses working in the afternoon had significantly low moral sensitivity. In addition, love for the profession had a significant relationship with moral sensitivity (p<0.001). Satisfaction with the job had a positive relationship with moral sensitivity (p<0.001). Also, there were no significant differences in satisfaction among patients regarding their socio-demographic characteristics except the length of hospitalization was significantly associated with patient satisfaction (p =0.047); longer stay in the hospital decreased the level of patient satisfaction. Table 3 shows the relationship between nurses’ moral sensitivity and its dimensions and patient satisfaction with received care in emergency wards.
Table 3) Association between Nurses’ moral sensitivity dimensions and overall level of patient satisfaction with received care in emergency wards
Discussion
This study aimed to investigate the relationship between nurses' ethical sensitivities and patient satisfaction with the care received in emergency departments in Iraq. The ethical sensitivity and patient satisfaction were positively correlated; therefore, the moral sensitivity of emergency nurses is essential for patient satisfaction. Although the results showed a positive and significant correlation between moral sensitivity and patient satisfaction, this correlation did not imply causality. This means that moral sensitivity is related to patient satisfaction, but it is not necessarily the only determinant of patient satisfaction. In addition, in the literature review, nurse's behavior reflects their morals attitudes, and sensitivities, which can affect care and as a result, patient satisfaction.
We found that emergency department patients were satisfied with person-centered care, including the patient's desires, values, family situations, and unique needs. When nurses treat each patient as a whole individual and collaborate to develop treatment, the quality of care improves. According to Shahvali et al., person-centered care can have a significant impact on care quality [14]. According to Amiri et al., patient-centered care improves the patient's experience of care and makes them feel more satisfied [4]. The nurses' moral sensitivity is demonstrated by their belief in patient-centered care [15, 16].
Our findings are consistent with those of Araç et al. and Borhani et al. in terms of professional responsibility and patient satisfaction [17, 18]. What leads emergency department nurses to get a high professional responsibility score is directly tied to the patient's satisfaction with the care received. One of the examples of a sense of responsibility is the emphasis on the need to perform appropriate and ethical care measures by nurses in the emergency department. Ethical decision-making in giving care also demonstrates that the nurse has arrived at the professional conclusion that she/he should do what is right and moral for her/his patient, especially in stressful emergencies.
Unlike the previous subscales of moral sensitivity, the nurse's experience of moral conflict has an inverse and meaningful relationship with patient satisfaction with the care received in the emergency department, which is consistent with the results of Huang et al. and Ye et al. [19, 20]. Ethical conflicts arise when an emergency nurse is unsure of what to do in a difficult situation. Because emergencies are so much more challenging, one of the ethical conflicts in emergencies is that you must provide the best patient care in the shortest possible time, even if the patient disagrees [20]. In our study, the inverse and meaningful relationship also means that reducing ethical conflicts leads to better performance of care and patient satisfaction.
Regarding the moral sensitivity of emergency nurses, we believe that mutual understanding is required for an efficient ethical relationship between nurses and patients. As a result, moral sensitivity and reciprocal perception have a direct relationship. Mutual understanding and benevolence, which are both necessary for moral sensitivity, increase the patient's trust in the nurse and reinforce the patient's sense of satisfaction. Although the findings of Amiri et al. and Brannon et al. are consistent with ours, and there is a positive and significant relationship between the nurse-patient relationship and patient satisfaction [4, 21], Palazoğlu et al. reported inconsistent findings. Their reason for the non-significance relationship between the nurse-patient relationship and patient satisfaction is that nurses in critical and emergency departments are forced to decide and take quick action before establishing a proper relationship with the patient [22].
Another subscale of moral sensitivity was the expression of good deeds. There was no significant relationship in this study between expressing good deeds in nursing and patient satisfaction similar to the study by Amiri et al. [4]. According to the findings of Asmaningrum and Tsai, the highest score of moral sensitivity was related to expressing good deeds, which contradicts our findings. According to Asmaningrum and Tsai, there is a positive and significant relationship between the expression of good deeds and patient satisfaction [23]. The dimension of expressing benevolence denotes honesty, sympathy, patient-nurse trust, attention to patients' reactions to health care, and patients' insight into and awareness of their disease [24]. As a result, establishing appropriate and compassionate relationships, as well as honesty and benevolence, provides the foundation for patients' and nurses' trust and confidence. According to Asmaningrum and Tsai, the expression of good deeds reflects nurses' sensitivity to patients, and when patients understand this type of nurse sensitivity, they are satisfied with the received care [23]. The discrepancy in our results and those of Asmaningrum and Tsai can be differences in the research environment and samples. Nurses in emergency rooms do not have many opportunities to express their emotions compared to the general wards.
Regarding the last dimension of moral sensitivity (guiding rules), in the present study compared to the study by Lützén and Kvist, nurses had a higher score [16]. When nurses are faced with a difficulty, guiding rules inform them what they should do. For example, in emergencies where it is difficult to determine what is appropriate for the patients, nurses consult with their colleagues about what they should do. Also, our result is inconsistent with the findings of Amiri et al. regarding no statistically meaningful association between nurses’ moral sensitivity in the dimension of guiding rules and patients’ satisfaction with the nursing care provided [4]. They claimed that guiding rules possibly lead the nurse to the routine work-based approach in practice, which reduces the quality of care and patient satisfaction.
The author encountered some obstacles when carrying out the research. Nurses are overworked and unresponsive to some patients in the emergency department, resulting in time-consuming data collection. Government agencies between the two countries need a long process to agree on data collection. Also, this study was done in a small area. More large-sample, multicenter studies are recommended in other provinces of Iraq. Another problem in data collection was the COVID-19 outbreak and physically filling out the questionnaires was very time-consuming and sometimes they were incomplete, which led to the elimination of the samples. Since this study was conducted on clinical nurses in two hospitals, the generalizability of the study’s results is limited.
Conducting an ethics education course in the form of continuing education, ethics seminars, and journal clubs enhances the moral sensitivity of nurses, thus, clinical managers should plan for nurses and encourage them to take part in these courses. For future practice, we suggest further studies on patient satisfaction in the emergency department to clarify other factors influencing patient satisfaction in the emergency department.
Conclusions
Nurses frequently face difficult situations while caring for patients in emergency departments. In order to face these conditions and make ethical decisions, the nurse must have acceptable moral sensitivity. They should be sensitive to ethical issues because this will help them respect their patients' rights, establish appropriate therapeutic relationships with them, and better manage situational challenges. When nurses are morally sensitive to patient care, the patient recognizes the nurse's sense of responsibility in providing care, and his/her mutual understanding and satisfaction from receiving nursing care increases.
Acknowledgments: This research is a part of the master's thesis in nursing. The researchers of this study would like to thank all the participants in this research and the Research Deputy of the Faculty of Medical Sciences of Tarbiat Modares University.
Ethical Permission: The Ethics Committee of Tarbiat Modares University authorized the research protocol (Register number: IR.MODARES.REC.1400.269).
Conflict of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Aljabouri A (First Author), Introduction Writer/Original (20%); Khoobi M (Second Author), Methodologist/ Assistant Researcher (30%); Ahmadi F (Third Author), Assistant Researcher/Discussion Writer (25%); Rasekhi AA (Fourth Author), Assistant Researcher/Statistical Analyst (25%)
Funding/Support: This study was supported by the Tarbiat Modares University.
Participants
There were 5,000 patients and 300 nurses in the emergency wards of Al-Hamza General Hospital and Al-Diwaniyah Teaching Hospital. Based on Morgan's table the sample size of patients and nurses was 357 and 169, respectively, and considering the attrition of 20%, 428 patients and 202 nurses were selected. It is worth mentioning that after sampling, only 200 out of 202 nurses and only 400 out of 428 patients participated in this research. Nurses and patients who did not fill out the questionnaire completely were excluded. Each nurse in the department also was responsible for the care of two patients. Inclusion criteria for patients were willingness to participate in the research with informed consent, patients in the emergency wards of Al-Hamza General Hospital and Al-Diwaniyah Teaching Hospital with more than 18 years, being hospitalized for at least 24 hours and being on the verge of discharge from hospital, no known cognitive or psychological disorders based on self-reporting and recorded documents, and no physical disability (unable to hear and speak) while completing the questionnaire. Inclusion criteria for nurses were work experience of at least six months in emergency wards, having high school, diploma, bachelor’s or master’s degrees, willingness to participate in the research, and nurses involved in the direct care of the patient in the emergency wards. The exclusion criteria for patients and nurses were failure to complete the questionnaire.
Data collection
Data collection was done from Jan 2021 to Aug 2022. the personal information form for patients and nurses, the Newcastle Satisfaction with Nursing Scale (NSNS) designed by Loiset al. in 1996, and the Moral Sensitivity Questionnaire (MSQ) designed by Lützén et al. in 1995, were used to collect the data. The demographic characteristics for patients included age, sex, marital status, level of education, length of hospitalization, and income level. The demographic characteristics form for nurses included sex, marital status, level of education, love for the profession, satisfaction with the job, and working shift.
NSNS is considered parsimonious and empirically supported. The scale provides information about nursing quality from patients’ perspectives. It includes demographic information, satisfaction with the nursing care scale, and a one-item scale (7-point response scale) on overall patient satisfaction [10]. The satisfaction with nursing care part consists of 19 items. All items are scored on a five-point Likert scale (1=not at all satisfied, 2=barely satisfied, 2=quite satisfied, 4=very satisfied, and 5=completely satisfied). The total score was computed and transformed to yield an overall satisfaction score of 0 to 100, where 100 denotes full satisfaction. The NSNS was found to be valid and reliable in previous studies [11, 12]. The Arabic version of this questionnaire translated into Arabic by Alasad et al. was used in this study [12].
Lützén et al. developed the MSQ, including 30 questions that measure moral sensitivity. It has six subscales, including interpersonal/relational orientation, structuring moral meaning, benevolence, modifying autonomy, experiencing moral conflict, trust in medical knowledge, principles of care/guiding rules, and three items classified under items [13]. The MSQ was translated and validated into different languages, such as Korean. The Korean‑MSQ (K‑MSQ) consisted of only 27 items used to measure the moral sensitivity among general nurses rather than psychiatric specialty as originally intended by Lützén et al. MSQ includes five subscales, namely patient-centered nursing (five items), professional responsibility (seven items), the experience of conflict (five items), structuralizing of moral meaning (five items), and expression of good deeds (five items) [4]. It has a seven-point response scale ranging from “one” indicating “not at all” to “seven” indicating “strongly agree.” The overall possible score ranges from 27 to 189. A higher score indicates a higher nurse’s moral sensitivity and vice versa. The Arabic version of this questionnaire was used in this study [13]. In addition, to confirm validity, the research tool was given to some Arabic expert professors and it was found that there was no difference in vocabulary and meaning in the Arabic questionnaire for Arabs. Its reliability was determined through the analysis of Cronbach's alpha coefficient approach by investigating 40 nurses and 85 patients who met the inclusion criteria. Cronbach’s alpha coefficient was respectively 0.76 and 0.89 for NSNS and MSQ.
The researcher first received written permission from the Vice-Chancellor for Education of Tarbiat Modares University of Medical Sciences and referred to the hospitals with a proposal and permission from the university to obtain a sampling permit. Then, he went to the emergency wards of Al-Hamza General Hospital and Al-Diwaniyah Teaching Hospital in Al-Diwaniyah City to distribute the questionnaire to the nurses and patients in these wards. Before sampling, the nurses were informed about the purpose of the study and guided to complete the questionnaire. In addition, the researcher distributed the questionnaire to the patients after receiving full health care and while completing the questionnaire, the researcher was with the patients to answer their possible questions. The researcher gave nurses enough time to fill out the questionnaire.
Data analysis
Data analysis was conducted using SPSS software version 20. Descriptive statistics, including means, standard deviations (SD), frequencies, and percentages, were used to describe participants’ demographic and clinical characteristics along with study variables. According to the obtained results of the Kolmogorov-Smirnov test, the distribution of patient satisfaction and moral sensitivity data was not normal (p =0.001 and p=0.001, respectively); thus, the non-parametric test (Spearman correlation coefficient and Kruskal-Wallis test were used. To analyze the relationship between nurses ' moral sensitivity and patient satisfaction, we matched one nurse with two patients on the same shift; there were two patients for each nurse in the same shift. For correlation assessment, we averaged the patients' satisfaction score and compared it with the moral sensitivity score.
Ethical considerations
The Medical Research Ethics Committee of Tarbiat Modares University (IR.MODARES.REC.1400.269) approved this research. Also, the participants were assured that the information would be kept confidential and anonymous. They were told to participate in the study freely and if they did not want to, they could leave the study. The first author gave adequate information about the purpose, and benefit of the study in a language understandable to the patients and nurses. Necessary permits were obtained from the related organizations in Iraq.
Findings
Demographic information of the nurses and patients is shown in Tables 1 and 2. Only 200 nurses and 400 patients completed the questionnaires.
Table 1) Nurse's socio-demographic information (n=200)
Table 2) Patients' socio-demographic information (n=400)
There was a positive correlation between patient satisfaction and moral sensitivity (r=0.662; p<0.001), which means patient satisfaction depends on the moral sensitivity of emergency nurses. The higher moral sensitivity, the higher the patient's satisfaction, and vice versa. There were no significant differences in moral sensitivity among emergency nurses concerning their gender, marital status, and education level. Also, the analysis of variance confirmed significant differences in moral sensitivity among emergency nurses concerning work shifts (p<0.001); nurses working in the afternoon had significantly low moral sensitivity. In addition, love for the profession had a significant relationship with moral sensitivity (p<0.001). Satisfaction with the job had a positive relationship with moral sensitivity (p<0.001). Also, there were no significant differences in satisfaction among patients regarding their socio-demographic characteristics except the length of hospitalization was significantly associated with patient satisfaction (p =0.047); longer stay in the hospital decreased the level of patient satisfaction. Table 3 shows the relationship between nurses’ moral sensitivity and its dimensions and patient satisfaction with received care in emergency wards.
Table 3) Association between Nurses’ moral sensitivity dimensions and overall level of patient satisfaction with received care in emergency wards
Discussion
This study aimed to investigate the relationship between nurses' ethical sensitivities and patient satisfaction with the care received in emergency departments in Iraq. The ethical sensitivity and patient satisfaction were positively correlated; therefore, the moral sensitivity of emergency nurses is essential for patient satisfaction. Although the results showed a positive and significant correlation between moral sensitivity and patient satisfaction, this correlation did not imply causality. This means that moral sensitivity is related to patient satisfaction, but it is not necessarily the only determinant of patient satisfaction. In addition, in the literature review, nurse's behavior reflects their morals attitudes, and sensitivities, which can affect care and as a result, patient satisfaction.
We found that emergency department patients were satisfied with person-centered care, including the patient's desires, values, family situations, and unique needs. When nurses treat each patient as a whole individual and collaborate to develop treatment, the quality of care improves. According to Shahvali et al., person-centered care can have a significant impact on care quality [14]. According to Amiri et al., patient-centered care improves the patient's experience of care and makes them feel more satisfied [4]. The nurses' moral sensitivity is demonstrated by their belief in patient-centered care [15, 16].
Our findings are consistent with those of Araç et al. and Borhani et al. in terms of professional responsibility and patient satisfaction [17, 18]. What leads emergency department nurses to get a high professional responsibility score is directly tied to the patient's satisfaction with the care received. One of the examples of a sense of responsibility is the emphasis on the need to perform appropriate and ethical care measures by nurses in the emergency department. Ethical decision-making in giving care also demonstrates that the nurse has arrived at the professional conclusion that she/he should do what is right and moral for her/his patient, especially in stressful emergencies.
Unlike the previous subscales of moral sensitivity, the nurse's experience of moral conflict has an inverse and meaningful relationship with patient satisfaction with the care received in the emergency department, which is consistent with the results of Huang et al. and Ye et al. [19, 20]. Ethical conflicts arise when an emergency nurse is unsure of what to do in a difficult situation. Because emergencies are so much more challenging, one of the ethical conflicts in emergencies is that you must provide the best patient care in the shortest possible time, even if the patient disagrees [20]. In our study, the inverse and meaningful relationship also means that reducing ethical conflicts leads to better performance of care and patient satisfaction.
Regarding the moral sensitivity of emergency nurses, we believe that mutual understanding is required for an efficient ethical relationship between nurses and patients. As a result, moral sensitivity and reciprocal perception have a direct relationship. Mutual understanding and benevolence, which are both necessary for moral sensitivity, increase the patient's trust in the nurse and reinforce the patient's sense of satisfaction. Although the findings of Amiri et al. and Brannon et al. are consistent with ours, and there is a positive and significant relationship between the nurse-patient relationship and patient satisfaction [4, 21], Palazoğlu et al. reported inconsistent findings. Their reason for the non-significance relationship between the nurse-patient relationship and patient satisfaction is that nurses in critical and emergency departments are forced to decide and take quick action before establishing a proper relationship with the patient [22].
Another subscale of moral sensitivity was the expression of good deeds. There was no significant relationship in this study between expressing good deeds in nursing and patient satisfaction similar to the study by Amiri et al. [4]. According to the findings of Asmaningrum and Tsai, the highest score of moral sensitivity was related to expressing good deeds, which contradicts our findings. According to Asmaningrum and Tsai, there is a positive and significant relationship between the expression of good deeds and patient satisfaction [23]. The dimension of expressing benevolence denotes honesty, sympathy, patient-nurse trust, attention to patients' reactions to health care, and patients' insight into and awareness of their disease [24]. As a result, establishing appropriate and compassionate relationships, as well as honesty and benevolence, provides the foundation for patients' and nurses' trust and confidence. According to Asmaningrum and Tsai, the expression of good deeds reflects nurses' sensitivity to patients, and when patients understand this type of nurse sensitivity, they are satisfied with the received care [23]. The discrepancy in our results and those of Asmaningrum and Tsai can be differences in the research environment and samples. Nurses in emergency rooms do not have many opportunities to express their emotions compared to the general wards.
Regarding the last dimension of moral sensitivity (guiding rules), in the present study compared to the study by Lützén and Kvist, nurses had a higher score [16]. When nurses are faced with a difficulty, guiding rules inform them what they should do. For example, in emergencies where it is difficult to determine what is appropriate for the patients, nurses consult with their colleagues about what they should do. Also, our result is inconsistent with the findings of Amiri et al. regarding no statistically meaningful association between nurses’ moral sensitivity in the dimension of guiding rules and patients’ satisfaction with the nursing care provided [4]. They claimed that guiding rules possibly lead the nurse to the routine work-based approach in practice, which reduces the quality of care and patient satisfaction.
The author encountered some obstacles when carrying out the research. Nurses are overworked and unresponsive to some patients in the emergency department, resulting in time-consuming data collection. Government agencies between the two countries need a long process to agree on data collection. Also, this study was done in a small area. More large-sample, multicenter studies are recommended in other provinces of Iraq. Another problem in data collection was the COVID-19 outbreak and physically filling out the questionnaires was very time-consuming and sometimes they were incomplete, which led to the elimination of the samples. Since this study was conducted on clinical nurses in two hospitals, the generalizability of the study’s results is limited.
Conducting an ethics education course in the form of continuing education, ethics seminars, and journal clubs enhances the moral sensitivity of nurses, thus, clinical managers should plan for nurses and encourage them to take part in these courses. For future practice, we suggest further studies on patient satisfaction in the emergency department to clarify other factors influencing patient satisfaction in the emergency department.
Conclusions
Nurses frequently face difficult situations while caring for patients in emergency departments. In order to face these conditions and make ethical decisions, the nurse must have acceptable moral sensitivity. They should be sensitive to ethical issues because this will help them respect their patients' rights, establish appropriate therapeutic relationships with them, and better manage situational challenges. When nurses are morally sensitive to patient care, the patient recognizes the nurse's sense of responsibility in providing care, and his/her mutual understanding and satisfaction from receiving nursing care increases.
Acknowledgments: This research is a part of the master's thesis in nursing. The researchers of this study would like to thank all the participants in this research and the Research Deputy of the Faculty of Medical Sciences of Tarbiat Modares University.
Ethical Permission: The Ethics Committee of Tarbiat Modares University authorized the research protocol (Register number: IR.MODARES.REC.1400.269).
Conflict of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Aljabouri A (First Author), Introduction Writer/Original (20%); Khoobi M (Second Author), Methodologist/ Assistant Researcher (30%); Ahmadi F (Third Author), Assistant Researcher/Discussion Writer (25%); Rasekhi AA (Fourth Author), Assistant Researcher/Statistical Analyst (25%)
Funding/Support: This study was supported by the Tarbiat Modares University.
Article Type: Descriptive & Survey |
Subject:
Health Promotion Approaches
Received: 2023/07/15 | Accepted: 2023/08/27 | Published: 2023/09/15
Received: 2023/07/15 | Accepted: 2023/08/27 | Published: 2023/09/15
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