Original Article
Chinese nurses’ perceived barriers and facilitators of ethical sensitivity
Nursing Ethics 1–16 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015574925 nej.sagepub.com
Fei Fei Huang Central South University, China
Qing Yang Yale School of Medicine, USA
Jie Zhang Central South University, China
Kaveh Khoshnood Yale University, USA
Jing Ping Zhang Central South University, China
Abstract Background: An overview of ethical sensitivity among Chinese registered nurses is needed to develop and optimize the education programs and interventions to cultivate and improve ethical sensitivity. Aim: The study was conducted to explore the barriers to and facilitators of ethical sensitivity among Chinese registered nurses working in hospital settings. Research design: A convergent parallel mixed-methods research design was adopted. Participants and research context: In the cross-sectional quantitative study, the Chinese Moral Sensitivity Questionnaire–revised version was used to assess the levels of ethical sensitivity among registered nurses, and the scores were correlated with key demographics, training experiences in ethics, and workplace cultural environments (n ¼ 306). In the qualitative study, semi-structured interviews were used to elicit the nurses’ perceptions of the barriers and facilitators in nurturing ethical sensitivity (n ¼ 15). The data were collected from February to June 2014. Ethical considerations: This study was approved by the Institutional Review Boards of Yale University and Central South University. Results: Despite moderately high overall Chinese Moral Sensitivity Questionnaire–revised version scores, the ethical sensitivity among Chinese nurses lags in practice. Barriers to ethical sensitivity include the lack of knowledge related to ethics, lack of working experience as a nurse, the hierarchical organizational climate, and the conformist working attitude. The positive workplace cultural environments and application of ethical knowledge in practice were considered potential facilitators of ethical sensitivity.
Corresponding authors: Jing Ping Zhang, Xiangya School of Nursing, Central South University, No.172 Tongzipo Road, Changsha, Hunan 410013, China. Kaveh Khoshnood, School of Public Health, Yale University, 60 College Street, New Haven, CT 06520, USA. Emails: [email protected]; [email protected]
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Discussion: The findings of this study were compared with studies from other countries to examine the barriers and facilitators of ethical sensitivity in Chinese nurses. Conclusion: This mixed-methods study showed that even though the Chinese nurses have moderately high sensitivity to the ethical issues encountered in hospitals, there is still room for improvement. The barriers to and facilitators of ethical sensitivity identified here offer new and important strategies to support and enhance the nurses’ sensitivity to ethical issues. Keywords China, ethical sensitivity, mixed-methods design, nursing, registered nurse
Introduction Nursing is an ‘‘ethical laden practice.’’1 The nursing staffs play a pivotal role in healthcare because they spend more time with patients and their families than any other type of healthcare professional.2 Providing nursing care is a physically demanding and intellectually challenging process delivered in contexts that are increasingly complex and fraught with ethical issues and dilemmas.3 In order to make the appropriate decisions, nurses need to have ethical sensitivity,4 defined as the ability to recognize the presence of an ethical problem or an ethical dimension in a situation when no ethical conflict is apparent.5,6 Ethical sensitivity helps determine relative importance of different ethical issues for any given situation, promote contextual and intuitive understanding of the patient’s vulnerability, and derive insight into the ethical consequences of any decision made on behalf of the patient.5,6 For healthcare professionals, ethical sensitivity is theoretically a positive attribute, because the recognition of ethically problematic issues is a prerequisite for making the appropriate decisions and engaging in ethical behaviors.7 Heightened ethical sensitivity among nurses encourages better clinical decision-making, more apt application of the codes of conduct, and less stress.7,8 Ethical behavior can have a positive impact on healthcare quality.9 On the other hand, inadequate ethical sensitivity can predispose nurses to experience ethical conflicts and jeopardize patient care.3,10–13 Ethical conflicts are a source of psychological distress and burnout, and may even lead to nurses leaving the profession.14,15 Ethical sensitivity is influenced by many factors, such as religiosity, education, and life experience, resulting in individual differences.16 Moreover, cultural values play an important role in shaping the ethical experience among healthcare professionals.17 For example, Chinese nurses are more inclined to understand ethical responsibilities in terms of virtue (a sense of responsibility to make judgments based on how to provide the best possible care for patients), while American nurses tend to rely on ethical principles (justice, beneficence, respect for person, etc.).11 China had 2.49 million registered nurses as of 2012.18 With the increased awareness of the importance of ethical sensitivity in nursing practices globally,1,7,19,20 it is imperative to examine the ethical sensitivity among healthcare providers, particularly nurses, in Mainland China. The leadership in nursing education in China has also increased emphasis on ethical sensitivity,21 which can be cultivated through training and education.22 Understanding the existing levels of ethical sensitivity among healthcare providers is the key to informing changes to education. To the best of our knowledge, no such empirical study has been carried out. Consequently, there is limited insight into how to provide and improve ethical training programs for nurses in China. Ethical sensitivity is a dynamic process of interpretation and decision-making based on the unique context of the situation.19,20 Understanding this complex process requires an in-depth qualitative approach.23,24 Mixed-methods studies can effectively and comprehensively provide insight into ethical sensitivity. While quantitative analysis offers relatively objective measurement, qualitative interviews explore the contextual depth and details of ethical problems, which can be used to triangulate the quantitative data to provide additional insight and validate or repudiate the quantitative data.17
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Ethical sensitivity has been examined in Western and other Asian countries (e.g. Japan, Korea, and Europe) among nurses,7,8,13,16,19,22 physicians,15 physiotherapists,25 and health professional students.23,26,27 We found only one mixed-methods study exploring the ethical sensitivity of undergraduate and graduate nursing students, which was conducted in the United States.26 Most previous studies were cross-sectional and used structured (e.g. Moral Sensitivity Questionnaire) or unstructured (e.g. clinical scenarios) questionnaires. Additionally, many studies emphasized the low level of ethical sensitivity among health professionals and the necessity to strengthen ethical sensitivity to meet the needs of patients.24 Therefore, an overview of ethical sensitivity among Chinese registered nurses is needed to develop and optimize the education programs or interventions to cultivate and improve ethical sensitivity.
The purpose of the study The main aim of this study was to explore the levels of ethical sensitivity among Chinese registered nurses working in the hospital setting, to examine the association between ethical sensitivity and demographic, cultural, and professional factors, and to identify the barriers and facilitators in the development of ethical sensitivity.
Methods Design A convergent parallel mixed-methods research design was adopted,28 and the quantitative and qualitative components of the study were conducted concurrently from February to June 2014. In the crosssectional quantitative study, self-administered questionnaires were used to assess the level of ethical sensitivity of the registered nurses and collect information on key demographics, ethics training experiences, and characteristics of the workplace cultural environment. In the qualitative study, semi-structured interviews were used to elicit the nurses’ perceptions of the barriers and facilitators in nurturing ethical sensitivity.
Participants and setting Participants were recruited from three tertiary hospitals (500þ beds each) and one secondary hospital (300– 500 beds) in Changsha, Hunan Province, by cluster random sampling. A total of 90 full-time registered nurses from each hospital were randomly selected from the staff directory using computer-generated random numbers. The nurses had worked at the study hospital for at least 12 months. Nurses who completed the survey were invited to voluntarily and freely share their thoughts on ethical sensitivity. We intentionally selected nurses of different backgrounds (age, gender, ward, working experience, ethics training experience, etc.) for the semi-structured individual in-depth interviews. A total of 15 eligible nurses participated in the interview. This sample size met the criteria for theoretical saturation after coding.29
Data collection Questionnaires. The Chinese Moral Sensitivity Questionnaire–revised version (MSQ-R-CV),30 together with a background questionnaire, was distributed to 360 nurses and individually collected by the researchers. MSQ-R-CV is a self-administered questionnaire incorporating a 6-point Likert-scale (1 ¼ ‘‘I totally disagree’’ and 6 ¼ ‘‘I totally agree’’). The MSQ-R-CV consists of nine items representing the two main factors
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of ethical sensitivity—sense of moral burden (four items) and moral responsibility and strength (five items). The ratings of the items are added to generate the total score, which ranges from 9 to 54. A higher total score indicates increased ethical sensitivity. The reliability and validity of MSQ-R-CV were confirmed previously.31 The Cronbach’s alpha was 0.82. The Spearman–Brown coefficient was 0.75. Item-total correlation values ranged from 0.52 to 0.72. Exploratory factor analysis showed that the two-factor model explained 56.4% of the overall variance. Confirmatory factor analysis yielded w2/df ¼ 1.22, comparative fit index (CFI) ¼ 0.99, root mean square error of approximation (RMSEA) ¼ 0.03, and Tucker–Lewis Index (TLI) ¼ 0.99. This is consistent with adequate reliability and validity. The additional personal and professional background information collected included age, gender, marital status, level of education, religion, position, professional title, experience working as a nurse (years), institution, ward, ethics training, and workplace culture. Semi-structured interview. The individual interviews were conducted in private at a mutually convenient time for each participant. All interviews were conducted by the first author. A thematic question guide (Appendix 1) covered the following topics: the participant’s understanding of the concept of ‘‘ethical sensitivity’’, his/her ability to recognize or become aware of ethical problems or dimensions, and factors impeding/facilitating the recognition of ethical problems. An average interview lasted 40 min. The responses were transcribed verbatim and translated from Chinese into English and discrepancy checked by two authors (F.F.H. and Q.Y.).
Ethical considerations This study was approved by the Institutional Review Boards (IRB) of Yale University and Central South University. Verbal informed consent was obtained from the survey participants after explaining the purpose, risks, and benefits of the study. Participation was voluntary and anonymous. No personally identifiable information was collected. The participants in the semi-structured interviews gave written consent before the start of the interview. All participants were assured confidentiality and informed about the right to withdraw at any time.
Data analysis The quantitative data were analyzed with SPSS 16.0 (IBM, Chicago, IL). Descriptive analysis was provided for the MSQ-R-CV scores and background characteristics. Continuous variables were assessed for homogeneity of variance and normality. The scores of different groups were compared with student’s t-test and one-way analysis of variance (one-way ANOVA). Multiple linear regression was performed to assess the association between background characteristics and ethical sensitivity scores. The dependent variable was ethical sensitivity. Independent variables were the demographic, cultural, and professional factors shown to have significance in the t-test or one-way ANOVA. All variables were entered in a stepwise fashion. Statistical significance was established at p < 0.05. The qualitative data were entered into ATLAS.ti for thematic content analysis.32 To increase the validity and reliability of the qualitative data, two authors (F.F.H. and J.Z.) independently read the interview transcripts line by line, and performed inductive coding based on categories in the question guide. Both authors discussed and compared the preliminary coding and re-examined the original transcripts as discrepancies arose, until a consensus was achieved. Then, the similar codes were summarized to generate the final themes. To increase the validity and interpretability of the overall study, a ‘‘pure mixed interpretative’’ approach was used.31 Equal weight was placed on both qualitative and quantitative findings, and the main points of interface between the results from the two methods were further interpreted. Finally, both the
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quantitative and qualitative data were used in the interpretation of the results, and three categories were devised based on the research aim: ‘‘Comprehension of ethical sensitivity,’’ ‘‘Barriers to ethical sensitivity,’’ and ‘‘Facilitators of ethical sensitivity.’’
Results A total of 306 (response rate 85%) registered nurses completed the questionnaires. Their demographic, cultural, and professional characteristics were summarized in Tables 1 and 2. The overall sample was overwhelmingly female (96.4%), young (82.4% under age 36), and had received collegiate education (72.7% had a Bachelor’s degree or above). Of the 15 nurses who were interviewed individually, 80% were female. Their age ranged from 24 to 53 years and their work experience ranged from 2 to 30 years. One-third was unit managers. Slightly less than half (45%) reported having had ethics education.
Comprehension of ethical sensitivity The overall score of ethical sensitivity among Chinese registered nurses was 40.22 + 7.08 (range ¼ 20–54) based on the MSQ-R-CV (Table 3). The factor score for ‘‘moral responsibility and strength’’ was higher (23.85 + 4.40) than for ‘‘sense of moral burden’’ (16.37 + 3.75). However, in the interviews, 15% of nurses could not verbalize their understanding of the concept of ethical sensitivity. Among those who attempted to express their understanding, only 10% gave the correct definition. In addition, many nurses voiced that they do not consciously think about ethical issues in their day to day work. Well, I don’t know what ethical sensitivity is. I have never heard of this term. I’ve been working as a nurse for several years now. For the day to day work, I’m just trying to do my best to fulfill the patient care responsibilities. I might have encountered ethical issues, but even then I never consciously acknowledged them. Therefore, I don’t know what type of problems would count as ethical problems. When I make decisions in my work, I never thought about whether something involves ethics, I just make intuitive judgments. (32 years old, internal medicine)
Barriers to ethical sensitivity What are some of the underlying causes for the failure to recognize the presence of an ethical problem or ethical dimension for Chinese nurses? The following major barriers emerged from our study, in no particular order: the lack of knowledge related to ethics, lack of working experience as a nurse, hierarchical organizational climate, and the conformist working attitude. Lack of knowledge related to ethics. In the survey, nurses who have had education in nursing ethics, no matter in what form (formal ethics education, seminar, or self-study), showed higher ethical sensitivity (t ¼ 3.115, p ¼ 0.002) (Table 4). Consistently in the interviews, participants reported that insufficient exposure to ethics education programs and inadequate knowledge about ethics contributed to poor ethical sensitivity in clinical practice. The majority (85%) of nurses knew of the four basic ethical principles by name (respect for autonomy, nonmaleficence, beneficence, and justice),33 but they could not explain the meanings and connotations or how to use these principles in the daily practice. The lack of ethical knowledge may contribute to confusion about the ethical aspects of the situations encountered in practice:
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Table 1. Nurses’ demographics data.
Characteristics Age (years) 25 26–35 36 Missing Experience working as a nurse (years) 1–5 6–10 11–20 21 Missing Gender Female Male Marital status Single Married Divorce Widowed Level of education Certificate (technical school) Diploma (associate’s degree) Bachelor’s degree Master’s degree or above Missing Religion Buddhist Christian No religious faith Declined to answer Missing Institutiona Tertiary (level 3) hospital Secondary (level 2) hospital Ward Surgery Internal medicine Obstetrics and Gynecology Pediatrics Operating room ICU Emergency Assistb Position General nurse Unit manager
Survey (n ¼ 306)
Interview (n ¼ 15)
N (%)
N (%)
107 (35%) 145 (47.4%) 47 (15.4%) 7 (2.3%)
2 (13.3%) 8 (53.4%) 5 (33.3%)
133 (43.5%) 80 (26.1%) 61 (20.9%) 22 (7.2%) 7 (2.3%)
3 (20%) 6 (40%) 4 (26.7%) 2 (13.3%)
295 (96.4%) 11 (3.6%)
12 (80%) 3 (20%)
127 (41.5%) 173 (56.5%) 5 (1.6%) 1 (0.3%) 3 (1%) 80 (26.2%) 217 (71.1%) 5 (1.6%) 1 (0.3%)
1 (6.7%) 4 (26.7%) 9 (59.9%) 1 (6.7%)
21 (7.1%) 2 (0.7%) 260 (88.4%) 11 (3.7%) 12 (3.9%) 224 (73.2%) 82 (26.8%) 56 (18.3%) 72 (23.5%) 6 (2%) 10 (3.3%) 33 (10.8%) 61 (19.9%) 55 (18%) 13 (4.2%)
2 (13.3%) 2 (13.3%) 2 (13.3%) 2 (13.3%) 2 (13.3%) 2 (13.3%) 1 (6.7%) 2 (13.3%)
284 (92.8%) 22 (7.2%)
10 (66.7%) 5 (33.3%) (continued)
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Table 1. (continued)
Characteristics Professional title Primary nurse Junior nurse Senior nurse
Survey (n ¼ 306)
Interview (n ¼ 15)
N (%)
N (%)
96 (31.4%) 194 (63.4%) 16 (5.2%)
ICU: intensive care unit. a Tertiary hospital (500þ beds) and Secondary hospital (300–500 beds). b Includes the Nuclear medicine department and Outpatient chemotherapy infusion center.
Table 2. Nurses’ ethics training and workplace culture data (n ¼ 306). Characteristics
N (%)
Ethics training Received ethics education Yes No Missing Setting of ethics educationa Nursing education at school Continuing education in the workplace Seminars outside of workplace Self-study Application of ethical knowledge in practice Yes No Workplace culture Have support system to promote continuing education Yes No Have well-developed continuing education system Yes No Facilitate academic discussion and exchange of views Yes No Accept and encourage nurses’ participation in medical decision-making Yes No Nurses have opportunity to exchange views with other medical professionals Yes No Nurses with ethics training can share experience with others Yes No a
Multiple choice.
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161 (53.1%) 142 (46.9%) 3 (1%) 84.8% 29.1% 40% 8.5% 140 (87.2%) 21 (12.8%)
293 (95.6%) 12 (4.4%) 246 (80.5%) 60 (19.5%) 285 (93%) 21 (7%) 245 (80.1%) 61 (19.9%) 248 (81%) 58 (19%) 191 (62.4%) 115 (37.6%)
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Table 3. Chinese nurses’ responses on MSQ-R-CV. Rank order
Factor
Itema
Mean + SD
1 2 3 4 5 6 7 8 9
Moral responsibility and strength Moral responsibility and strength Moral responsibility and strength Moral responsibility and strength Sense of moral burden Moral responsibility and strength Sense of moral burden Sense of moral burden Sense of moral burden
#1. Feel responsibility #9. Rules and regulations #2. Ability to sense #5. Sense not good care #7. Balance between good and harm #3. Ability to talk #8. Feel inadequate #4. Sense need #6. Suffering
5.15 + 1.13 4.93 + 1.21 4.89 + 1.15 4.47 + 1.14 4.45 + 1.17 4.41 + 1.16 4.24 + 1.31 4.07 + 1.24 3.61 + 1.50
MSQ-R-CV: Chinese Moral Sensitivity Questionnaire–revised version; SD: standard deviation. a Item title abbreviations adapted from Lu¨tze´n et al.1
I didn’t learn much about ethics in school. I am not exposed to much ethics know-how at work, either. Because of the lack of knowledge, I am not aware of the ethical aspects of clinical practice or the roles I play. (24 years old, pediatrics)
Lack of working experience as a nurse. We compared the ethical sensitivity scores of nurses from different demographic and professional backgrounds. Those who are older than 36 years of age or have worked for more than 21 years displayed higher level of ethical sensitivity than their younger and less experienced colleagues (F ¼ 3.963 and F ¼ 3.328, respectively, p ¼ 0.02). Seniority and experience was also mentioned in the interviews. For example, one interviewee (26 years old, surgery) said, After graduation, I have worked in the thoracic department for two years. Compared with the senior nurses with rich clinical experiences, I feel that my sensitivity to ethical issues is relatively low. In my daily work, if I encounter ethical conflicts or problems, I frequently consult with the more experienced nurses.
The setting of clinical practice may also play a role in building ethical sensitivity. For example, as shown in Table 4, the average ethical sensitivity score of nurses working in the surgical and gynecological ward was lower than that of nurses working in other departments (p < 0.05). In my opinion, the types of ethical issues encountered, the ability to recognize them, and the approaches to find solutions may depend on specialty. Nurses in internal medicine and surgery have different value systems and work routines. For example, for whatever reason, the surgical nurses tend to withhold prognostic information from the patients more than internal medicine nurses . . . (41 years old, surgery)
Hierarchical organizational climate. It was highlighted in the interviews that the hierarchical organizational climate lower or limit the nurses’ sensitivity to ethical concerns. Nurses often have great responsibilities but little power in making decisions. One interviewee (35 years old, intensive care unit (ICU)) said, When I notice my colleagues behave in ways not meeting the ethical standards, I usually pretend I did not see them and try not to draw attention. Reporting such behaviors would negatively impact my relationship with my colleagues. More importantly, others may view my action as an act of disloyalty to my department or the hospital. I don’t want to take such risks by questioning the action of those in authority.
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Table 4. Total MSQ-R-CV scores and associated background characteristics. Variables
Mean + SD
Demographics Age (years) 25 39.55 + 8.01 26–35 39.94 + 5.83 36 42.81 + 5.98 Experience working as a nurse (years) 1–5 39.26 + 6.43 6–10 40.31 + 7.53 11–20 40.68 + 8.06 21 44.23 + 4.59 Ward Surgery 37.07 + 7.88 Internal medicine 40.56 + 7.24 Obstetrics and Gynecology 36.00 + 4.43 Pediatrics 41.60 + 6.90 Operating room 40.94 + 5.35 ICU 41.69 + 7.28 Emergency 40.04 + 6.14 Assista 44.85 + 5.57 Ethics training Received ethics education Yes 40.56 + 6.31 No 39.92 + 7.92 Application of ethical knowledge in practice Yes 41.22 + 5.83 No 37.11 + 6.40 Workplace culture Accept and encourage nurses’ participation in medical decision-making Yes 40.89 + 5.83 No 37.11 + 6.40 Nurses have opportunity to exchange views with other medical professionals Yes 41.00 + 7.03 No 37.67 + 6.24 Have well-developed continuing education system Yes 40.86 + 7.13 No 38.55 + 6.15 Nurses with ethics training can share experience with others Yes 41.32 + 6.90 No 38.88 + 6.97
t/F
p
3.963
0.02
3.328
0.02
3.36
0.002
3.115
0.002
2.840
0.005
2.288
0.023
3.286
0.001
2.271
0.024
2.938
0.004
MSQ-R-CV: Chinese Moral Sensitivity Questionnaire–revised version; SD: standard deviation; ICU: intensive care unit.
As such, normalization of bad ethical behavior has deleterious effects on workplace culture and professional behaviors. The conformist working attitude. Although not explicitly examined in the survey, an emerging theme when we asked about barriers to developing ethical sensitivity was the conformist working attitude. The majority of nurses interviewed reported that they try to conform to the convention and avoid controversy and believed
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this attitude may hinder their ethical sensitivity. In clinical practice, the nurses were unwilling to challenge the common practice or tradition. One interviewee (40 years old, gynecology) said, . . . Take informed consent for example, conventionally, I prefer to hide the truth from the patient. Especially in the cases of malignant tumors, in order to protect the patient, I would only share the truth with his family. Of course, I understand that doing so violates the ethical principles of informed consent and honesty. But this is what the majority of nursing staff does, so I won’t be blamed for it. I think that right now most nurses like to follow the crowd in their daily practice. They see what others are doing, and they do the same thing. They won’t break the convention, especially in the realm of ethics. (43 years old, pediatrics)
Facilitators of ethical sensitivity A positive workplace culture was considered the most significant facilitator of ethical sensitivity among Chinese registered nurses. The application of ethical knowledge in practice was also an important facilitator. Positive workplace culture. As shown in Table 4, the positive workplace culture emerged as the most important enabler for nurses’ awareness about ethical issues. The positive qualities we identified include accept and encourage nurses’ participation in medical decision-making, well-developed continuing education system, opportunity to exchange views with other medical professionals, and opportunity for nurses with ethics training to share their experiences with others (p < 0.05). Similar results emerged in the interviews. Nurses paid attention to sharing thoughts and obtaining support from coworkers or organization when they faced with overwhelming ethical situations. In particular, open and honest communication was considered helpful for increasing the nurses’ sensitivity to ethical dimensions: It is helpful to communicate with others, such as my colleagues or the experts. For example, our hospital regularly holds interdisciplinary team discussions, which is great for sharing experiences. In the meetings, we not only hear from the expert ethics scholars, but we also exchange opinions with our colleagues on ethical issues. (45 years old, emergency medicine)
In addition to communication, a well-developed continuing education system was also reported as important for cultivating the nurses’ ethical sensitivity: I often feel confused and at loss when faced with ethical issues involving the interests of the patient. I think the majority of the nurses in clinical practice needs continuing education, but there are very few educational programs on ethics. If the hospital can organize some ethics forums or seminars, I will definitely attend, because it would be really helpful and useful to me. (34 years old, assist ward)
Application of ethical knowledge in practice. Our survey revealed that registered nurses who use ethical knowledge in practice scored higher on MSQ-R-CV than nurses who do not (t ¼ 2.840, p ¼ 0.005). In the interviews, many nurses also considered the application of knowledge as an important enabler for recognizing ethical problems. One interviewee said, Well, I think ethics knowledge can be very helpful in practice. Applying ethics knowledge, I am more aware of my own lack of ethical sensitivity, I want to learn more about ethics, and I have a better opportunity to reflect on ethical issues . . . (50 years old, assist ward)
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Table 5. Independent predictors for the level of ethical sensitivity in Chinese nurses (n ¼ 306). Predictors Nurses have opportunity to exchange views with other medical professionals Nurses with ethics training can share experience with others Experience working as a nurse (years) Application of ethical knowledge in practice
Standardized beta
t
p
0.152 0.150 0.118 0.114
2.736 2.673 2.114 2.052
0.007 0.008 0.035 0.041
Adjusted R2 ¼ 0.56.
Finally, Table 5 highlights the four factors that could predict the level of ethical sensitivity among Chinese registered nurses: (a) nurses have the opportunity to exchange views with other medical professionals, (b) nurses with ethics training can share experiences with others, (c) longer working experience as a nurse, and (d) application of ethical knowledge in practice. These factors accounted for 56% of the total variance (adjusted R2 ¼ 0.56) in ethical sensitivity scores. These four predictors further confirmed the barriers to and facilitators of ethical sensitivity mentioned above.
Discussion To our knowledge, this is the first mixed-methods study to provide an overview of ethical sensitivity among Chinese registered nurses. The findings, both from the survey and the interviews, revealed that although the Chinese nurses’ ethical sensitivity levels were moderately high, they remain in need of improvement. Moreover, the barriers to and facilitators of ethical sensitivity reported here offer new and important strategies to support and enhance nurses’ sensitivity to ethical issues. In our sample, the average score of participants on MSQ-R-CV was 40.22 + 7.08, similar to Western healthcare providers’ ethical sensitivity (mean ¼ 40),1,8 and higher than psychiatric nurses34 and physiotherapists.25 The moderately high ethical sensitivity of Chinese nurses particularly reflect on the dimension of ‘‘moral responsibility and strength.’’ Driven by virtue, after the policy of ‘‘High Quality Nursing Care’’35 was adapted, more Chinese nurses have become aware of the importance to be morally responsible, which includes acknowledging moral problems from the perspective of the patient, having the courage to take actions, and justifying their actions on behalf of the patients instead of themselves. As the ‘‘positive’’ dimension of ethical sensitivity, moral responsibility and strength plays an important role in nurses’ recognition and judgment when faced with ethical issues in everyday practice. In contrast, moral burden is considered the ‘‘negative’’ dimension, which is brought on by a problem or situation that involves moral values. It is distinguished from economic, psychological, or social burdens.1 Compared to moral responsibility and strength, the Chinese nurses’ moral burden was relatively low. They were less likely to feel inadequate, sense the patients’ needs, and deal with feelings when a patient was suffering. Compared to previous studies, the Chinese nurses’ scores for the two factors were similar to Western nurses’.1,8,34 Although nurses scored moderately high ethical sensitivity in the survey, we discovered through the interviews that there is a gap in the nurses’ conceptual understanding of ethical sensitivity. Given their high moral responsibility, some nurses made an independent decision for action based on caring needs and professional responsibility, but they did not consider it to be ethical sensitivity. We found that the nurses mainly rely on intuition for making decisions in the day-to-day clinical practice. Although their actions may often align with what is ethically acceptable, they appear to lack awareness of the ethical aspects involved or consciously refer to the ethical frameworks. This finding suggested that the comprehension of ethical sensitivity among the nurses was limited, and the Chinese nurses’ ethical sensitivity still needs to be improved.
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In this study, the degree of ethical sensitivity significantly differed according to age and work experience, consistent with previous research.1,16 Compared with younger and less experienced nurses, older and more experienced nurses had higher ethical sensitivity, possibly because they were more familiar with nursing care.7,8,25 In line with previous studies,16,19 we also found significant difference by clinic wards, which may be a surrogate for beliefs and behaviors. For example, surgical nurses were more prone to act in a materialistic manner, which may impede their ethical sensitivity.19 These findings further confirmed the view that ethical issues are largely contextual26 and linked to the moral climate of the workplace as well as the nurses’ relationship with patients.8 We identified several potential barriers to recognition of ethical issues. First, the lack of knowledge related to ethics reflects the ethics education status quo in China.36 In the nursing baccalaureate curricula, considerable variation exists in the time and space devoted to ethics, only 29% nursing or medical schools designate it as compulsory course, and 51.4% of the instructors for the ethics courses had no formal experience in dealing with ethical issues in practice.37 Consequentially, many nursing students are ignorant about the importance of ethics education. Even after graduation, few nurses and hospitals emphasize ethics in the continuing nursing education.38 Other researchers also identified ethics education as a crucial element to support the staff’s ethical competence.4,39 Based on our findings, we call attention to reforming the nursing ethics curricula, citing the need for students to have adequate theoretical and experiential basis for understanding the ethical dimensions of the profession and of nursing practice. We propose that emphasis should be placed on clinical ethics education, both in the preregistration and post-graduate courses, such as meetings, lectures, or case study programs. It is especially important to strengthen the continuing ethics education system in healthcare workplaces. Of note, it is also necessary to enrich the ethical practice experience of the teachers in order to provide well ethical education. Second, hierarchical organizational climate also reduces the expression of ethical sensitivity among Chinese registered nurses. This reveals strong support to previous findings that hierarchical constraints or a lack of power in the hierarchy interferes with the ethical decision-making processes of nurses. Furthermore, unexamined loyalty to institutions or professional groups can interfere with the nurses’ ability to be an independent moral agent and may promote the belief that nurses are simply cogs in an institutional machine.40 Moral courage is especially important in this environment where there may be pressure to turn a blind eye or overlook poor practice. Thus, how nursing staff develop the courage to learn and to act wisely in response to the conflicting demands in an organization awaits research and solution in the future.41 Third, the conformist working attitude was viewed as another barrier to nurses’ ethical sensitivity. With the conformist working attitude, nurses do not dare innovation. Instead, they follow the crowd, leading the decreased level of awareness in ethical issues surrounding them. In the interviews, the participants reported that many nurses turn a blind eye to the possible ethical conflicts or dimensions for the sake of ‘‘harmony.’’ On the other hand, hospitals attach great importance to uniformity and hierarchy, making the nursing staff risk averse and unwilling to challenge the authority or tradition. In addition, as mentioned above, nursing work directly affects patients’ health and life; therefore, the organization assigns the primary concern for nurses to be the quality of care and safety for the patients, rather than ethical issues or principles. This finding not only confirmed the influence of hierarchical organizational climate on ethical sensitivity but also suggested that the nurse managers should award nurses who have a conformist working attitude. How to help the nurses change their conformist approach needs further study. In line with Hernandez42 and Stichler,43 we also found that the characteristics of a positive work environment include trust, communication, ability to provide excellent care, empowered and collaborative decision-making, professional development opportunities, and so on. In this study, as the most significant facilitator of ethical sensitivity, the positive workplace cultural environment empowers nurses in medical decision-making, communication, and continuing education. The findings resonate with the study by Be´gat et al.,20 who reported strong correlation between the work environment and the nurses’ ethical sensitivity.
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Nurses practice within an organization. The ‘‘ethical climate’’ of a healthcare organization is the implicit and explicit values that shape care delivery.44 Open and honest communication will foster an ethically sensitive environment, encouraging the sharing of thoughts with experts and more experienced nurses. Obtaining support from workplace or coworkers enables nurses to be successful in problem identification and to recognize the ethical consequences of decisions. For example, staff nurses who lack experience may rely on the opinions of senior nurses or coworkers.16 In addition to the positive workplace cultural environment, application of ethical knowledge was also important as a potential facilitator of ethical sensitivity. To provide safe and ethical care, nurses found it helpful to apply ethics knowledge into practice. Most importantly, it provides them the opportunity to reflect on ethics. Practice in ethical reflection was considered to have enhanced the participants’ awareness about ethical issues.4 Therefore, the facilitators found in this study suggested that nurse managers should encourage their staff to apply ethics knowledge in practice, and create a climate and opportunities that enable the nursing staff to discuss and reflect on ethical concerns. In this study, we focused on gaining a better understanding of the comprehension of, the barriers to, and facilitators of ethical sensitivity among Chinese registered nurses using a mixed-methods procedure, which filled the gap in existing literature. The results of this study may help nurses or healthcare organizations reflect on how to cultivate and improve ethical sensitivity of healthcare providers by establishing documented policy or improving the efficacy of interventions. To cultivate or improve nurses’ sensitivity to ethical issues, we propose three strategies based on our results. First, the educational programs in ethics should be established or strengthened, especially in clinical settings, to include patient simulations, case studies, and narrated studies.26 Second, when nurse educators plan courses or give direction on ethical issues for nurses, it is important for them to consider the barriers and facilitators such as age, working experience, working department, and ethics knowledge level. Third, developing a positive workplace cultural environment, rather than the current hierarchical organizational climate, is required to foster open and honest communication about ethics for nurses. Several limitations must be considered when interpreting these results. First, the sample was confined to one region of Mainland China and a relatively small sample size, both of which may limit the generalization of the findings to other Chinese-speaking areas. Second, only nurses practicing in hospitals were recruited in this study. Community and outpatient practitioners were not included, and they may have different experiences and moral views. Our findings need to be validated by larger samples from other nursing fields. It would also be interesting to conduct comparative research on ethical sensitivity among nurses with different cultural backgrounds. Third, the study focused on examining the overall level of ethical sensitivity among Chinese nurses, rather than zooming in on specific issues or problems, such as informed consent. It is recommended that future studies examine the ethical sensitivity in more detail or specific aspects. Finally, although our survey and interviews consistently pointed to workplace cultural environment as a major modulator of ethical sensitivity, these findings need corroboration by better characterization of the workplace with reliable standardized instruments.
Conclusion This mixed-methods study provides an overview of ethical sensitivity among Chinese registered nurses. The Chinese nurses showed moderately high sensitivity to ethical issues encountered in hospitals, but there is still room for improvement. Lack of knowledge related to ethics, lack of working experience as a nurse, hierarchical organizational climate, and the conformist working attitude were found as barriers to recognizing the ethical issues, and positive workplace cultural environment and application of ethical knowledge in practice were considered as the facilitators of ethical sensitivity. These barriers and facilitators offer new and important strategies to support or boost nurses’ sensitivity to ethical issues.
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Acknowledgments The authors would like to thank the nurses who spent time answering the questionnaire. Conflict of interest The authors declare that there is no conflict of interest. Funding This work was funded by a grant from the Fogarty International Center, National Institute of Health (R25 TW007700). References 1. Lu¨tze´n K, Dahlqvist V, Eriksson S, et al. Developing the concept of moral sensitivity in health care practice. Nurs Ethics 2006; 13(2): 187–196. 2. He T, Du Y, Wang L, et al. Perceptions of caring in China: patient and nurse questionnaire survey. Int Nurs Rev 2013; 60(4): 487–493. 3. Schluter J, Winch S, Holzhauser K, et al. Nurses’ moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics 2008; 15(3): 304–321. 4. So¨derhamn U, Kjøstvedt HT and Slettebø A. Evaluation of ethical reflections in community healthcare: a mixed-methods study. Nurs Ethics. Epub ahead of print 8 April 2014. DOI: 10.1177/0969733014524762. 5. Rest JR. Background: theory and research. In: Rest JR and Narvaez D (eds) Moral development in the professions: psychology and applied ethics. Hillsdale, NJ: Erlbaum, 1994, pp. 1–26. 6. Lu¨tze´n K, Nordstro¨m G and Evertzon M. Moral sensitivity in nursing practice. Scand J Caring Sci 1995; 4(9): 131–138. 7. Kim YS, Kang SW and Ahn JA. Moral sensitivity relating to the application of the code of ethics. Nurs Ethics 2013; 20(4): 470–478. 8. Lu¨tze´n K, Blom T, Ewalds-Kvist B, et al. Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nurs Ethics 2010; 17(2): 213–224. 9. Saarni SI, Parmanne P and Halila R. Ethically problematic treatment decisions: a physician survey. Bioethics 2008; 22(2): 121–129. 10. Jiang HL and Cao HA. Discussion on nursing education measures to deal with contemporary nursing ethical problems. Chin J Pract Nurs 2006; 22: 71–72 (in Chinese). 11. Yang QX, Fu XH and Liu HP. A survey of ethical and moral diathesis of nurses in county-level hospitals. Chin Nurs Res 2006; 20: 681–682 (in Chinese). 12. Tang PF, Johansson C, Wadensten B, et al. Chinese nurses’ ethical concerns in a neurological ward. Nurs Ethics 2007; 14(6): 810–824. 13. Pang SMC, Sawada A, Konishi E, et al. A comparative study of Chinese, American and Japanese nurses’ perceptions of ethical role responsibilities. Nurs Ethics 2003; 10(3): 295–311. 14. Gonza´lez-de Paz L, Kostov B, Siso´-Almirall A, et al. A Rasch analysis of nurses’ ethical sensitivity to the norms of the code of conduct. J Clin Nurs 2012; 21(19–20): 2747–2760. 15. McClendon H and Buckner EB. Distressing situations in the intensive care unit: a descriptive study of nurses’ responses. Dimens Crit Care Nurs 2007; 26(5): 199–206. 16. Kim YS, Park JW, You MA, et al. Sensitivity to ethical issues confronted by Korean hospital staff nurses. Nurs Ethics 2005; 12(6): 595–605. 17. Bowman KW and Hui EC. Bioethics for clinicians: Chinese bioethics. CMAJ 2000; 163: 1481–1485. 18. National health and family planning commission of the people’s republic of China. http://www.nhfpc.gov.cn/ (2012, accessed May 2014).
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19. Ersoy N and Go¨z F. The ethical sensitivity of nurses in Turkey. Nurs Ethics 2001; 8(4): 299–312. 20. Be´gat I, Ikeda N, Amemiya T, et al. Comparative study of perceptions of work environment and moral sensitivity among Japanese and Norwegian nurses. Nurs Health Sci 2004; 6(3): 193–200. 21. The Code of Ethics for Nurses. Chinese Nursing Association. http://www.cna-cast.org.cn/en/showInfo.asp? id=289. 22. Lu¨tze´n K, Evertzon M and Nordin C. Moral sensitivity in psychiatric practice. Nurs Ethics 1997; 4(6): 472–482. 23. Herber D, Meslin EM and Dunn EV. Evaluating ethical sensitivity in medical students: using vignettes as an instrument. J Med Ethics 1990; 16(3): 141–145. 24. Sieminska MJ, Szymanska M and Mausch K. Development of sensitivity to the needs and suffering of a sick person in students of medicine and dentistry. Med Health Care Philos 2002; 5(3): 263–271. 25. Kulju K, Suhonen R and Leino-Kilpi H. Ethical problems and moral sensitivity in physiotherapy: a descriptive study. Nurs Ethics 2013; 20(5): 568–577. 26. Comrie RW. An analysis of undergraduate and graduate student nurses’ moral sensitivity. Nurs Ethics 2012; 19(1): 116–127. 27. Akabayashi A, Slingsby BT, Kai I, et al. The development of a brief and objective method for evaluating moral sensitivity and reasoning in medical students. BMC Med Ethics 2004; 5: 1–7. 28. Curry LA, Krumholz HM, O’Cathain A, et al. Mixed methods in biomedical and health services research. Circ Cardiovasc Qual Outcomes 2013; 6(1): 119–123. 29. Speziale HS and Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006. 30. Huang FF, Yang Q, Zhang J, et al. Cross-cultural validation of the Moral Sensitivity Questionnaire-revised version in Mainland China. Nurs Ethics. In Review. 31. Creswell JW, Klassen AC, Plano Clark V, et al. Best practices for mixed methods research in the health sciences. Bethesda, MD: National Institutes of Health, 2011. 32. Green J and Thorogood N. Qualitative methods for health research. London: Sage, 2004. 33. Beauchamp TL and Childress JF. Principles of biomedical ethics. 2nd ed. New York: Oxford University Press, 1989, pp. 51–62. 34. Hanna T and Mona E. Psychosocial work environment, stress factors and individual characteristics among nursing staff in psychiatric in-patient care. Int J Environ Res Public Health 2014; 11(1): 1161–1175. 35. National health and family planning commission of the people’s republic of China. http://www.nhfpc.gov.cn/ mohyzs/s7659/201001/45756.shtml (2010, accessed May 2014). 36. Wu YH, Duan X and Shi Y. Investigation on status of nursing ethic cognition and education among clinical nurses. Chin Nurs Manag 2011; 11(3): 71–73 (in Chinese). 37. Wu YH and Shi Y. Current status and analysis on nursing ethics education in China. Chin Med Eth 2012; 25(4): 447–448 (in Chinese). 38. Meng LM, Liu BL and Xu R. The investigation and analysis of Chinese clinical nurses’ continuing education on nursing ethics. Chin Med Eth 2009; 22(1): 74–75 (in Chinese). 39. Poikkeus T, Numminen O, Suhonen R, et al. A mixed-method systematic review: support for ethical competence of nurses. J Adv Nurs 2014; 70(2): 256–271. 40. Oddi LF, Cassidy VR and Fisher C. Nurses’ sensitivity to the ethical aspects of clinical practice. Nurs Ethics 1995; 2(3): 197–209. 41. Weaver K, Morse J and Mitcham C. Ethical sensitivity in professional practice: concept analysis. J Adv Nurs 2008; 62(5): 607–618. 42. Hernandez S. Promoting a positive work environment. Tar Heel Nurse 2009; 71(3): 16. 43. Stichler JF. Creating a healthy, positive work environment: a leadership imperative. Nurs Womens Health 2009; 13(4): 341–346. 44. Rodney P, Doane GH, Storch J, et al. Toward a safer moral climate. Can Nurse 2006; 102(8): 24–27.
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Appendix 1 A thematic question guide 1. What are the types of ethical challenges you have encountered at work? How often do you encounter these challenges? Please describe a few recent cases in detail. 2. How do you understand the concept of ‘‘ethical sensitivity’’? Could you provide some examples? 3. How do you evaluate your ability to recognize or become aware of the ethical problems or dimensions? 4. What factors impede your ability to recognize or become aware of ethical problems? Could you provide some examples? 5. What factors facilitate your ability to recognize or become aware of ethical problems? Could you provide some examples?
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Chinese nurses’ perceived barriers and facilitators of ethical sensitivity
Nursing Ethics 1–16 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015574925 nej.sagepub.com
Fei Fei Huang Central South University, China
Qing Yang Yale School of Medicine, USA
Jie Zhang Central South University, China
Kaveh Khoshnood Yale University, USA
Jing Ping Zhang Central South University, China
Abstract Background: An overview of ethical sensitivity among Chinese registered nurses is needed to develop and optimize the education programs and interventions to cultivate and improve ethical sensitivity. Aim: The study was conducted to explore the barriers to and facilitators of ethical sensitivity among Chinese registered nurses working in hospital settings. Research design: A convergent parallel mixed-methods research design was adopted. Participants and research context: In the cross-sectional quantitative study, the Chinese Moral Sensitivity Questionnaire–revised version was used to assess the levels of ethical sensitivity among registered nurses, and the scores were correlated with key demographics, training experiences in ethics, and workplace cultural environments (n ¼ 306). In the qualitative study, semi-structured interviews were used to elicit the nurses’ perceptions of the barriers and facilitators in nurturing ethical sensitivity (n ¼ 15). The data were collected from February to June 2014. Ethical considerations: This study was approved by the Institutional Review Boards of Yale University and Central South University. Results: Despite moderately high overall Chinese Moral Sensitivity Questionnaire–revised version scores, the ethical sensitivity among Chinese nurses lags in practice. Barriers to ethical sensitivity include the lack of knowledge related to ethics, lack of working experience as a nurse, the hierarchical organizational climate, and the conformist working attitude. The positive workplace cultural environments and application of ethical knowledge in practice were considered potential facilitators of ethical sensitivity.
Corresponding authors: Jing Ping Zhang, Xiangya School of Nursing, Central South University, No.172 Tongzipo Road, Changsha, Hunan 410013, China. Kaveh Khoshnood, School of Public Health, Yale University, 60 College Street, New Haven, CT 06520, USA. Emails: [email protected]; [email protected]
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Discussion: The findings of this study were compared with studies from other countries to examine the barriers and facilitators of ethical sensitivity in Chinese nurses. Conclusion: This mixed-methods study showed that even though the Chinese nurses have moderately high sensitivity to the ethical issues encountered in hospitals, there is still room for improvement. The barriers to and facilitators of ethical sensitivity identified here offer new and important strategies to support and enhance the nurses’ sensitivity to ethical issues. Keywords China, ethical sensitivity, mixed-methods design, nursing, registered nurse
Introduction Nursing is an ‘‘ethical laden practice.’’1 The nursing staffs play a pivotal role in healthcare because they spend more time with patients and their families than any other type of healthcare professional.2 Providing nursing care is a physically demanding and intellectually challenging process delivered in contexts that are increasingly complex and fraught with ethical issues and dilemmas.3 In order to make the appropriate decisions, nurses need to have ethical sensitivity,4 defined as the ability to recognize the presence of an ethical problem or an ethical dimension in a situation when no ethical conflict is apparent.5,6 Ethical sensitivity helps determine relative importance of different ethical issues for any given situation, promote contextual and intuitive understanding of the patient’s vulnerability, and derive insight into the ethical consequences of any decision made on behalf of the patient.5,6 For healthcare professionals, ethical sensitivity is theoretically a positive attribute, because the recognition of ethically problematic issues is a prerequisite for making the appropriate decisions and engaging in ethical behaviors.7 Heightened ethical sensitivity among nurses encourages better clinical decision-making, more apt application of the codes of conduct, and less stress.7,8 Ethical behavior can have a positive impact on healthcare quality.9 On the other hand, inadequate ethical sensitivity can predispose nurses to experience ethical conflicts and jeopardize patient care.3,10–13 Ethical conflicts are a source of psychological distress and burnout, and may even lead to nurses leaving the profession.14,15 Ethical sensitivity is influenced by many factors, such as religiosity, education, and life experience, resulting in individual differences.16 Moreover, cultural values play an important role in shaping the ethical experience among healthcare professionals.17 For example, Chinese nurses are more inclined to understand ethical responsibilities in terms of virtue (a sense of responsibility to make judgments based on how to provide the best possible care for patients), while American nurses tend to rely on ethical principles (justice, beneficence, respect for person, etc.).11 China had 2.49 million registered nurses as of 2012.18 With the increased awareness of the importance of ethical sensitivity in nursing practices globally,1,7,19,20 it is imperative to examine the ethical sensitivity among healthcare providers, particularly nurses, in Mainland China. The leadership in nursing education in China has also increased emphasis on ethical sensitivity,21 which can be cultivated through training and education.22 Understanding the existing levels of ethical sensitivity among healthcare providers is the key to informing changes to education. To the best of our knowledge, no such empirical study has been carried out. Consequently, there is limited insight into how to provide and improve ethical training programs for nurses in China. Ethical sensitivity is a dynamic process of interpretation and decision-making based on the unique context of the situation.19,20 Understanding this complex process requires an in-depth qualitative approach.23,24 Mixed-methods studies can effectively and comprehensively provide insight into ethical sensitivity. While quantitative analysis offers relatively objective measurement, qualitative interviews explore the contextual depth and details of ethical problems, which can be used to triangulate the quantitative data to provide additional insight and validate or repudiate the quantitative data.17
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Ethical sensitivity has been examined in Western and other Asian countries (e.g. Japan, Korea, and Europe) among nurses,7,8,13,16,19,22 physicians,15 physiotherapists,25 and health professional students.23,26,27 We found only one mixed-methods study exploring the ethical sensitivity of undergraduate and graduate nursing students, which was conducted in the United States.26 Most previous studies were cross-sectional and used structured (e.g. Moral Sensitivity Questionnaire) or unstructured (e.g. clinical scenarios) questionnaires. Additionally, many studies emphasized the low level of ethical sensitivity among health professionals and the necessity to strengthen ethical sensitivity to meet the needs of patients.24 Therefore, an overview of ethical sensitivity among Chinese registered nurses is needed to develop and optimize the education programs or interventions to cultivate and improve ethical sensitivity.
The purpose of the study The main aim of this study was to explore the levels of ethical sensitivity among Chinese registered nurses working in the hospital setting, to examine the association between ethical sensitivity and demographic, cultural, and professional factors, and to identify the barriers and facilitators in the development of ethical sensitivity.
Methods Design A convergent parallel mixed-methods research design was adopted,28 and the quantitative and qualitative components of the study were conducted concurrently from February to June 2014. In the crosssectional quantitative study, self-administered questionnaires were used to assess the level of ethical sensitivity of the registered nurses and collect information on key demographics, ethics training experiences, and characteristics of the workplace cultural environment. In the qualitative study, semi-structured interviews were used to elicit the nurses’ perceptions of the barriers and facilitators in nurturing ethical sensitivity.
Participants and setting Participants were recruited from three tertiary hospitals (500þ beds each) and one secondary hospital (300– 500 beds) in Changsha, Hunan Province, by cluster random sampling. A total of 90 full-time registered nurses from each hospital were randomly selected from the staff directory using computer-generated random numbers. The nurses had worked at the study hospital for at least 12 months. Nurses who completed the survey were invited to voluntarily and freely share their thoughts on ethical sensitivity. We intentionally selected nurses of different backgrounds (age, gender, ward, working experience, ethics training experience, etc.) for the semi-structured individual in-depth interviews. A total of 15 eligible nurses participated in the interview. This sample size met the criteria for theoretical saturation after coding.29
Data collection Questionnaires. The Chinese Moral Sensitivity Questionnaire–revised version (MSQ-R-CV),30 together with a background questionnaire, was distributed to 360 nurses and individually collected by the researchers. MSQ-R-CV is a self-administered questionnaire incorporating a 6-point Likert-scale (1 ¼ ‘‘I totally disagree’’ and 6 ¼ ‘‘I totally agree’’). The MSQ-R-CV consists of nine items representing the two main factors
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of ethical sensitivity—sense of moral burden (four items) and moral responsibility and strength (five items). The ratings of the items are added to generate the total score, which ranges from 9 to 54. A higher total score indicates increased ethical sensitivity. The reliability and validity of MSQ-R-CV were confirmed previously.31 The Cronbach’s alpha was 0.82. The Spearman–Brown coefficient was 0.75. Item-total correlation values ranged from 0.52 to 0.72. Exploratory factor analysis showed that the two-factor model explained 56.4% of the overall variance. Confirmatory factor analysis yielded w2/df ¼ 1.22, comparative fit index (CFI) ¼ 0.99, root mean square error of approximation (RMSEA) ¼ 0.03, and Tucker–Lewis Index (TLI) ¼ 0.99. This is consistent with adequate reliability and validity. The additional personal and professional background information collected included age, gender, marital status, level of education, religion, position, professional title, experience working as a nurse (years), institution, ward, ethics training, and workplace culture. Semi-structured interview. The individual interviews were conducted in private at a mutually convenient time for each participant. All interviews were conducted by the first author. A thematic question guide (Appendix 1) covered the following topics: the participant’s understanding of the concept of ‘‘ethical sensitivity’’, his/her ability to recognize or become aware of ethical problems or dimensions, and factors impeding/facilitating the recognition of ethical problems. An average interview lasted 40 min. The responses were transcribed verbatim and translated from Chinese into English and discrepancy checked by two authors (F.F.H. and Q.Y.).
Ethical considerations This study was approved by the Institutional Review Boards (IRB) of Yale University and Central South University. Verbal informed consent was obtained from the survey participants after explaining the purpose, risks, and benefits of the study. Participation was voluntary and anonymous. No personally identifiable information was collected. The participants in the semi-structured interviews gave written consent before the start of the interview. All participants were assured confidentiality and informed about the right to withdraw at any time.
Data analysis The quantitative data were analyzed with SPSS 16.0 (IBM, Chicago, IL). Descriptive analysis was provided for the MSQ-R-CV scores and background characteristics. Continuous variables were assessed for homogeneity of variance and normality. The scores of different groups were compared with student’s t-test and one-way analysis of variance (one-way ANOVA). Multiple linear regression was performed to assess the association between background characteristics and ethical sensitivity scores. The dependent variable was ethical sensitivity. Independent variables were the demographic, cultural, and professional factors shown to have significance in the t-test or one-way ANOVA. All variables were entered in a stepwise fashion. Statistical significance was established at p < 0.05. The qualitative data were entered into ATLAS.ti for thematic content analysis.32 To increase the validity and reliability of the qualitative data, two authors (F.F.H. and J.Z.) independently read the interview transcripts line by line, and performed inductive coding based on categories in the question guide. Both authors discussed and compared the preliminary coding and re-examined the original transcripts as discrepancies arose, until a consensus was achieved. Then, the similar codes were summarized to generate the final themes. To increase the validity and interpretability of the overall study, a ‘‘pure mixed interpretative’’ approach was used.31 Equal weight was placed on both qualitative and quantitative findings, and the main points of interface between the results from the two methods were further interpreted. Finally, both the
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quantitative and qualitative data were used in the interpretation of the results, and three categories were devised based on the research aim: ‘‘Comprehension of ethical sensitivity,’’ ‘‘Barriers to ethical sensitivity,’’ and ‘‘Facilitators of ethical sensitivity.’’
Results A total of 306 (response rate 85%) registered nurses completed the questionnaires. Their demographic, cultural, and professional characteristics were summarized in Tables 1 and 2. The overall sample was overwhelmingly female (96.4%), young (82.4% under age 36), and had received collegiate education (72.7% had a Bachelor’s degree or above). Of the 15 nurses who were interviewed individually, 80% were female. Their age ranged from 24 to 53 years and their work experience ranged from 2 to 30 years. One-third was unit managers. Slightly less than half (45%) reported having had ethics education.
Comprehension of ethical sensitivity The overall score of ethical sensitivity among Chinese registered nurses was 40.22 + 7.08 (range ¼ 20–54) based on the MSQ-R-CV (Table 3). The factor score for ‘‘moral responsibility and strength’’ was higher (23.85 + 4.40) than for ‘‘sense of moral burden’’ (16.37 + 3.75). However, in the interviews, 15% of nurses could not verbalize their understanding of the concept of ethical sensitivity. Among those who attempted to express their understanding, only 10% gave the correct definition. In addition, many nurses voiced that they do not consciously think about ethical issues in their day to day work. Well, I don’t know what ethical sensitivity is. I have never heard of this term. I’ve been working as a nurse for several years now. For the day to day work, I’m just trying to do my best to fulfill the patient care responsibilities. I might have encountered ethical issues, but even then I never consciously acknowledged them. Therefore, I don’t know what type of problems would count as ethical problems. When I make decisions in my work, I never thought about whether something involves ethics, I just make intuitive judgments. (32 years old, internal medicine)
Barriers to ethical sensitivity What are some of the underlying causes for the failure to recognize the presence of an ethical problem or ethical dimension for Chinese nurses? The following major barriers emerged from our study, in no particular order: the lack of knowledge related to ethics, lack of working experience as a nurse, hierarchical organizational climate, and the conformist working attitude. Lack of knowledge related to ethics. In the survey, nurses who have had education in nursing ethics, no matter in what form (formal ethics education, seminar, or self-study), showed higher ethical sensitivity (t ¼ 3.115, p ¼ 0.002) (Table 4). Consistently in the interviews, participants reported that insufficient exposure to ethics education programs and inadequate knowledge about ethics contributed to poor ethical sensitivity in clinical practice. The majority (85%) of nurses knew of the four basic ethical principles by name (respect for autonomy, nonmaleficence, beneficence, and justice),33 but they could not explain the meanings and connotations or how to use these principles in the daily practice. The lack of ethical knowledge may contribute to confusion about the ethical aspects of the situations encountered in practice:
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Table 1. Nurses’ demographics data.
Characteristics Age (years) 25 26–35 36 Missing Experience working as a nurse (years) 1–5 6–10 11–20 21 Missing Gender Female Male Marital status Single Married Divorce Widowed Level of education Certificate (technical school) Diploma (associate’s degree) Bachelor’s degree Master’s degree or above Missing Religion Buddhist Christian No religious faith Declined to answer Missing Institutiona Tertiary (level 3) hospital Secondary (level 2) hospital Ward Surgery Internal medicine Obstetrics and Gynecology Pediatrics Operating room ICU Emergency Assistb Position General nurse Unit manager
Survey (n ¼ 306)
Interview (n ¼ 15)
N (%)
N (%)
107 (35%) 145 (47.4%) 47 (15.4%) 7 (2.3%)
2 (13.3%) 8 (53.4%) 5 (33.3%)
133 (43.5%) 80 (26.1%) 61 (20.9%) 22 (7.2%) 7 (2.3%)
3 (20%) 6 (40%) 4 (26.7%) 2 (13.3%)
295 (96.4%) 11 (3.6%)
12 (80%) 3 (20%)
127 (41.5%) 173 (56.5%) 5 (1.6%) 1 (0.3%) 3 (1%) 80 (26.2%) 217 (71.1%) 5 (1.6%) 1 (0.3%)
1 (6.7%) 4 (26.7%) 9 (59.9%) 1 (6.7%)
21 (7.1%) 2 (0.7%) 260 (88.4%) 11 (3.7%) 12 (3.9%) 224 (73.2%) 82 (26.8%) 56 (18.3%) 72 (23.5%) 6 (2%) 10 (3.3%) 33 (10.8%) 61 (19.9%) 55 (18%) 13 (4.2%)
2 (13.3%) 2 (13.3%) 2 (13.3%) 2 (13.3%) 2 (13.3%) 2 (13.3%) 1 (6.7%) 2 (13.3%)
284 (92.8%) 22 (7.2%)
10 (66.7%) 5 (33.3%) (continued)
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Table 1. (continued)
Characteristics Professional title Primary nurse Junior nurse Senior nurse
Survey (n ¼ 306)
Interview (n ¼ 15)
N (%)
N (%)
96 (31.4%) 194 (63.4%) 16 (5.2%)
ICU: intensive care unit. a Tertiary hospital (500þ beds) and Secondary hospital (300–500 beds). b Includes the Nuclear medicine department and Outpatient chemotherapy infusion center.
Table 2. Nurses’ ethics training and workplace culture data (n ¼ 306). Characteristics
N (%)
Ethics training Received ethics education Yes No Missing Setting of ethics educationa Nursing education at school Continuing education in the workplace Seminars outside of workplace Self-study Application of ethical knowledge in practice Yes No Workplace culture Have support system to promote continuing education Yes No Have well-developed continuing education system Yes No Facilitate academic discussion and exchange of views Yes No Accept and encourage nurses’ participation in medical decision-making Yes No Nurses have opportunity to exchange views with other medical professionals Yes No Nurses with ethics training can share experience with others Yes No a
Multiple choice.
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161 (53.1%) 142 (46.9%) 3 (1%) 84.8% 29.1% 40% 8.5% 140 (87.2%) 21 (12.8%)
293 (95.6%) 12 (4.4%) 246 (80.5%) 60 (19.5%) 285 (93%) 21 (7%) 245 (80.1%) 61 (19.9%) 248 (81%) 58 (19%) 191 (62.4%) 115 (37.6%)
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Table 3. Chinese nurses’ responses on MSQ-R-CV. Rank order
Factor
Itema
Mean + SD
1 2 3 4 5 6 7 8 9
Moral responsibility and strength Moral responsibility and strength Moral responsibility and strength Moral responsibility and strength Sense of moral burden Moral responsibility and strength Sense of moral burden Sense of moral burden Sense of moral burden
#1. Feel responsibility #9. Rules and regulations #2. Ability to sense #5. Sense not good care #7. Balance between good and harm #3. Ability to talk #8. Feel inadequate #4. Sense need #6. Suffering
5.15 + 1.13 4.93 + 1.21 4.89 + 1.15 4.47 + 1.14 4.45 + 1.17 4.41 + 1.16 4.24 + 1.31 4.07 + 1.24 3.61 + 1.50
MSQ-R-CV: Chinese Moral Sensitivity Questionnaire–revised version; SD: standard deviation. a Item title abbreviations adapted from Lu¨tze´n et al.1
I didn’t learn much about ethics in school. I am not exposed to much ethics know-how at work, either. Because of the lack of knowledge, I am not aware of the ethical aspects of clinical practice or the roles I play. (24 years old, pediatrics)
Lack of working experience as a nurse. We compared the ethical sensitivity scores of nurses from different demographic and professional backgrounds. Those who are older than 36 years of age or have worked for more than 21 years displayed higher level of ethical sensitivity than their younger and less experienced colleagues (F ¼ 3.963 and F ¼ 3.328, respectively, p ¼ 0.02). Seniority and experience was also mentioned in the interviews. For example, one interviewee (26 years old, surgery) said, After graduation, I have worked in the thoracic department for two years. Compared with the senior nurses with rich clinical experiences, I feel that my sensitivity to ethical issues is relatively low. In my daily work, if I encounter ethical conflicts or problems, I frequently consult with the more experienced nurses.
The setting of clinical practice may also play a role in building ethical sensitivity. For example, as shown in Table 4, the average ethical sensitivity score of nurses working in the surgical and gynecological ward was lower than that of nurses working in other departments (p < 0.05). In my opinion, the types of ethical issues encountered, the ability to recognize them, and the approaches to find solutions may depend on specialty. Nurses in internal medicine and surgery have different value systems and work routines. For example, for whatever reason, the surgical nurses tend to withhold prognostic information from the patients more than internal medicine nurses . . . (41 years old, surgery)
Hierarchical organizational climate. It was highlighted in the interviews that the hierarchical organizational climate lower or limit the nurses’ sensitivity to ethical concerns. Nurses often have great responsibilities but little power in making decisions. One interviewee (35 years old, intensive care unit (ICU)) said, When I notice my colleagues behave in ways not meeting the ethical standards, I usually pretend I did not see them and try not to draw attention. Reporting such behaviors would negatively impact my relationship with my colleagues. More importantly, others may view my action as an act of disloyalty to my department or the hospital. I don’t want to take such risks by questioning the action of those in authority.
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Table 4. Total MSQ-R-CV scores and associated background characteristics. Variables
Mean + SD
Demographics Age (years) 25 39.55 + 8.01 26–35 39.94 + 5.83 36 42.81 + 5.98 Experience working as a nurse (years) 1–5 39.26 + 6.43 6–10 40.31 + 7.53 11–20 40.68 + 8.06 21 44.23 + 4.59 Ward Surgery 37.07 + 7.88 Internal medicine 40.56 + 7.24 Obstetrics and Gynecology 36.00 + 4.43 Pediatrics 41.60 + 6.90 Operating room 40.94 + 5.35 ICU 41.69 + 7.28 Emergency 40.04 + 6.14 Assista 44.85 + 5.57 Ethics training Received ethics education Yes 40.56 + 6.31 No 39.92 + 7.92 Application of ethical knowledge in practice Yes 41.22 + 5.83 No 37.11 + 6.40 Workplace culture Accept and encourage nurses’ participation in medical decision-making Yes 40.89 + 5.83 No 37.11 + 6.40 Nurses have opportunity to exchange views with other medical professionals Yes 41.00 + 7.03 No 37.67 + 6.24 Have well-developed continuing education system Yes 40.86 + 7.13 No 38.55 + 6.15 Nurses with ethics training can share experience with others Yes 41.32 + 6.90 No 38.88 + 6.97
t/F
p
3.963
0.02
3.328
0.02
3.36
0.002
3.115
0.002
2.840
0.005
2.288
0.023
3.286
0.001
2.271
0.024
2.938
0.004
MSQ-R-CV: Chinese Moral Sensitivity Questionnaire–revised version; SD: standard deviation; ICU: intensive care unit.
As such, normalization of bad ethical behavior has deleterious effects on workplace culture and professional behaviors. The conformist working attitude. Although not explicitly examined in the survey, an emerging theme when we asked about barriers to developing ethical sensitivity was the conformist working attitude. The majority of nurses interviewed reported that they try to conform to the convention and avoid controversy and believed
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this attitude may hinder their ethical sensitivity. In clinical practice, the nurses were unwilling to challenge the common practice or tradition. One interviewee (40 years old, gynecology) said, . . . Take informed consent for example, conventionally, I prefer to hide the truth from the patient. Especially in the cases of malignant tumors, in order to protect the patient, I would only share the truth with his family. Of course, I understand that doing so violates the ethical principles of informed consent and honesty. But this is what the majority of nursing staff does, so I won’t be blamed for it. I think that right now most nurses like to follow the crowd in their daily practice. They see what others are doing, and they do the same thing. They won’t break the convention, especially in the realm of ethics. (43 years old, pediatrics)
Facilitators of ethical sensitivity A positive workplace culture was considered the most significant facilitator of ethical sensitivity among Chinese registered nurses. The application of ethical knowledge in practice was also an important facilitator. Positive workplace culture. As shown in Table 4, the positive workplace culture emerged as the most important enabler for nurses’ awareness about ethical issues. The positive qualities we identified include accept and encourage nurses’ participation in medical decision-making, well-developed continuing education system, opportunity to exchange views with other medical professionals, and opportunity for nurses with ethics training to share their experiences with others (p < 0.05). Similar results emerged in the interviews. Nurses paid attention to sharing thoughts and obtaining support from coworkers or organization when they faced with overwhelming ethical situations. In particular, open and honest communication was considered helpful for increasing the nurses’ sensitivity to ethical dimensions: It is helpful to communicate with others, such as my colleagues or the experts. For example, our hospital regularly holds interdisciplinary team discussions, which is great for sharing experiences. In the meetings, we not only hear from the expert ethics scholars, but we also exchange opinions with our colleagues on ethical issues. (45 years old, emergency medicine)
In addition to communication, a well-developed continuing education system was also reported as important for cultivating the nurses’ ethical sensitivity: I often feel confused and at loss when faced with ethical issues involving the interests of the patient. I think the majority of the nurses in clinical practice needs continuing education, but there are very few educational programs on ethics. If the hospital can organize some ethics forums or seminars, I will definitely attend, because it would be really helpful and useful to me. (34 years old, assist ward)
Application of ethical knowledge in practice. Our survey revealed that registered nurses who use ethical knowledge in practice scored higher on MSQ-R-CV than nurses who do not (t ¼ 2.840, p ¼ 0.005). In the interviews, many nurses also considered the application of knowledge as an important enabler for recognizing ethical problems. One interviewee said, Well, I think ethics knowledge can be very helpful in practice. Applying ethics knowledge, I am more aware of my own lack of ethical sensitivity, I want to learn more about ethics, and I have a better opportunity to reflect on ethical issues . . . (50 years old, assist ward)
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Table 5. Independent predictors for the level of ethical sensitivity in Chinese nurses (n ¼ 306). Predictors Nurses have opportunity to exchange views with other medical professionals Nurses with ethics training can share experience with others Experience working as a nurse (years) Application of ethical knowledge in practice
Standardized beta
t
p
0.152 0.150 0.118 0.114
2.736 2.673 2.114 2.052
0.007 0.008 0.035 0.041
Adjusted R2 ¼ 0.56.
Finally, Table 5 highlights the four factors that could predict the level of ethical sensitivity among Chinese registered nurses: (a) nurses have the opportunity to exchange views with other medical professionals, (b) nurses with ethics training can share experiences with others, (c) longer working experience as a nurse, and (d) application of ethical knowledge in practice. These factors accounted for 56% of the total variance (adjusted R2 ¼ 0.56) in ethical sensitivity scores. These four predictors further confirmed the barriers to and facilitators of ethical sensitivity mentioned above.
Discussion To our knowledge, this is the first mixed-methods study to provide an overview of ethical sensitivity among Chinese registered nurses. The findings, both from the survey and the interviews, revealed that although the Chinese nurses’ ethical sensitivity levels were moderately high, they remain in need of improvement. Moreover, the barriers to and facilitators of ethical sensitivity reported here offer new and important strategies to support and enhance nurses’ sensitivity to ethical issues. In our sample, the average score of participants on MSQ-R-CV was 40.22 + 7.08, similar to Western healthcare providers’ ethical sensitivity (mean ¼ 40),1,8 and higher than psychiatric nurses34 and physiotherapists.25 The moderately high ethical sensitivity of Chinese nurses particularly reflect on the dimension of ‘‘moral responsibility and strength.’’ Driven by virtue, after the policy of ‘‘High Quality Nursing Care’’35 was adapted, more Chinese nurses have become aware of the importance to be morally responsible, which includes acknowledging moral problems from the perspective of the patient, having the courage to take actions, and justifying their actions on behalf of the patients instead of themselves. As the ‘‘positive’’ dimension of ethical sensitivity, moral responsibility and strength plays an important role in nurses’ recognition and judgment when faced with ethical issues in everyday practice. In contrast, moral burden is considered the ‘‘negative’’ dimension, which is brought on by a problem or situation that involves moral values. It is distinguished from economic, psychological, or social burdens.1 Compared to moral responsibility and strength, the Chinese nurses’ moral burden was relatively low. They were less likely to feel inadequate, sense the patients’ needs, and deal with feelings when a patient was suffering. Compared to previous studies, the Chinese nurses’ scores for the two factors were similar to Western nurses’.1,8,34 Although nurses scored moderately high ethical sensitivity in the survey, we discovered through the interviews that there is a gap in the nurses’ conceptual understanding of ethical sensitivity. Given their high moral responsibility, some nurses made an independent decision for action based on caring needs and professional responsibility, but they did not consider it to be ethical sensitivity. We found that the nurses mainly rely on intuition for making decisions in the day-to-day clinical practice. Although their actions may often align with what is ethically acceptable, they appear to lack awareness of the ethical aspects involved or consciously refer to the ethical frameworks. This finding suggested that the comprehension of ethical sensitivity among the nurses was limited, and the Chinese nurses’ ethical sensitivity still needs to be improved.
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In this study, the degree of ethical sensitivity significantly differed according to age and work experience, consistent with previous research.1,16 Compared with younger and less experienced nurses, older and more experienced nurses had higher ethical sensitivity, possibly because they were more familiar with nursing care.7,8,25 In line with previous studies,16,19 we also found significant difference by clinic wards, which may be a surrogate for beliefs and behaviors. For example, surgical nurses were more prone to act in a materialistic manner, which may impede their ethical sensitivity.19 These findings further confirmed the view that ethical issues are largely contextual26 and linked to the moral climate of the workplace as well as the nurses’ relationship with patients.8 We identified several potential barriers to recognition of ethical issues. First, the lack of knowledge related to ethics reflects the ethics education status quo in China.36 In the nursing baccalaureate curricula, considerable variation exists in the time and space devoted to ethics, only 29% nursing or medical schools designate it as compulsory course, and 51.4% of the instructors for the ethics courses had no formal experience in dealing with ethical issues in practice.37 Consequentially, many nursing students are ignorant about the importance of ethics education. Even after graduation, few nurses and hospitals emphasize ethics in the continuing nursing education.38 Other researchers also identified ethics education as a crucial element to support the staff’s ethical competence.4,39 Based on our findings, we call attention to reforming the nursing ethics curricula, citing the need for students to have adequate theoretical and experiential basis for understanding the ethical dimensions of the profession and of nursing practice. We propose that emphasis should be placed on clinical ethics education, both in the preregistration and post-graduate courses, such as meetings, lectures, or case study programs. It is especially important to strengthen the continuing ethics education system in healthcare workplaces. Of note, it is also necessary to enrich the ethical practice experience of the teachers in order to provide well ethical education. Second, hierarchical organizational climate also reduces the expression of ethical sensitivity among Chinese registered nurses. This reveals strong support to previous findings that hierarchical constraints or a lack of power in the hierarchy interferes with the ethical decision-making processes of nurses. Furthermore, unexamined loyalty to institutions or professional groups can interfere with the nurses’ ability to be an independent moral agent and may promote the belief that nurses are simply cogs in an institutional machine.40 Moral courage is especially important in this environment where there may be pressure to turn a blind eye or overlook poor practice. Thus, how nursing staff develop the courage to learn and to act wisely in response to the conflicting demands in an organization awaits research and solution in the future.41 Third, the conformist working attitude was viewed as another barrier to nurses’ ethical sensitivity. With the conformist working attitude, nurses do not dare innovation. Instead, they follow the crowd, leading the decreased level of awareness in ethical issues surrounding them. In the interviews, the participants reported that many nurses turn a blind eye to the possible ethical conflicts or dimensions for the sake of ‘‘harmony.’’ On the other hand, hospitals attach great importance to uniformity and hierarchy, making the nursing staff risk averse and unwilling to challenge the authority or tradition. In addition, as mentioned above, nursing work directly affects patients’ health and life; therefore, the organization assigns the primary concern for nurses to be the quality of care and safety for the patients, rather than ethical issues or principles. This finding not only confirmed the influence of hierarchical organizational climate on ethical sensitivity but also suggested that the nurse managers should award nurses who have a conformist working attitude. How to help the nurses change their conformist approach needs further study. In line with Hernandez42 and Stichler,43 we also found that the characteristics of a positive work environment include trust, communication, ability to provide excellent care, empowered and collaborative decision-making, professional development opportunities, and so on. In this study, as the most significant facilitator of ethical sensitivity, the positive workplace cultural environment empowers nurses in medical decision-making, communication, and continuing education. The findings resonate with the study by Be´gat et al.,20 who reported strong correlation between the work environment and the nurses’ ethical sensitivity.
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Nurses practice within an organization. The ‘‘ethical climate’’ of a healthcare organization is the implicit and explicit values that shape care delivery.44 Open and honest communication will foster an ethically sensitive environment, encouraging the sharing of thoughts with experts and more experienced nurses. Obtaining support from workplace or coworkers enables nurses to be successful in problem identification and to recognize the ethical consequences of decisions. For example, staff nurses who lack experience may rely on the opinions of senior nurses or coworkers.16 In addition to the positive workplace cultural environment, application of ethical knowledge was also important as a potential facilitator of ethical sensitivity. To provide safe and ethical care, nurses found it helpful to apply ethics knowledge into practice. Most importantly, it provides them the opportunity to reflect on ethics. Practice in ethical reflection was considered to have enhanced the participants’ awareness about ethical issues.4 Therefore, the facilitators found in this study suggested that nurse managers should encourage their staff to apply ethics knowledge in practice, and create a climate and opportunities that enable the nursing staff to discuss and reflect on ethical concerns. In this study, we focused on gaining a better understanding of the comprehension of, the barriers to, and facilitators of ethical sensitivity among Chinese registered nurses using a mixed-methods procedure, which filled the gap in existing literature. The results of this study may help nurses or healthcare organizations reflect on how to cultivate and improve ethical sensitivity of healthcare providers by establishing documented policy or improving the efficacy of interventions. To cultivate or improve nurses’ sensitivity to ethical issues, we propose three strategies based on our results. First, the educational programs in ethics should be established or strengthened, especially in clinical settings, to include patient simulations, case studies, and narrated studies.26 Second, when nurse educators plan courses or give direction on ethical issues for nurses, it is important for them to consider the barriers and facilitators such as age, working experience, working department, and ethics knowledge level. Third, developing a positive workplace cultural environment, rather than the current hierarchical organizational climate, is required to foster open and honest communication about ethics for nurses. Several limitations must be considered when interpreting these results. First, the sample was confined to one region of Mainland China and a relatively small sample size, both of which may limit the generalization of the findings to other Chinese-speaking areas. Second, only nurses practicing in hospitals were recruited in this study. Community and outpatient practitioners were not included, and they may have different experiences and moral views. Our findings need to be validated by larger samples from other nursing fields. It would also be interesting to conduct comparative research on ethical sensitivity among nurses with different cultural backgrounds. Third, the study focused on examining the overall level of ethical sensitivity among Chinese nurses, rather than zooming in on specific issues or problems, such as informed consent. It is recommended that future studies examine the ethical sensitivity in more detail or specific aspects. Finally, although our survey and interviews consistently pointed to workplace cultural environment as a major modulator of ethical sensitivity, these findings need corroboration by better characterization of the workplace with reliable standardized instruments.
Conclusion This mixed-methods study provides an overview of ethical sensitivity among Chinese registered nurses. The Chinese nurses showed moderately high sensitivity to ethical issues encountered in hospitals, but there is still room for improvement. Lack of knowledge related to ethics, lack of working experience as a nurse, hierarchical organizational climate, and the conformist working attitude were found as barriers to recognizing the ethical issues, and positive workplace cultural environment and application of ethical knowledge in practice were considered as the facilitators of ethical sensitivity. These barriers and facilitators offer new and important strategies to support or boost nurses’ sensitivity to ethical issues.
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Acknowledgments The authors would like to thank the nurses who spent time answering the questionnaire. Conflict of interest The authors declare that there is no conflict of interest. Funding This work was funded by a grant from the Fogarty International Center, National Institute of Health (R25 TW007700). References 1. Lu¨tze´n K, Dahlqvist V, Eriksson S, et al. Developing the concept of moral sensitivity in health care practice. Nurs Ethics 2006; 13(2): 187–196. 2. He T, Du Y, Wang L, et al. Perceptions of caring in China: patient and nurse questionnaire survey. Int Nurs Rev 2013; 60(4): 487–493. 3. Schluter J, Winch S, Holzhauser K, et al. Nurses’ moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics 2008; 15(3): 304–321. 4. So¨derhamn U, Kjøstvedt HT and Slettebø A. Evaluation of ethical reflections in community healthcare: a mixed-methods study. Nurs Ethics. Epub ahead of print 8 April 2014. DOI: 10.1177/0969733014524762. 5. Rest JR. Background: theory and research. In: Rest JR and Narvaez D (eds) Moral development in the professions: psychology and applied ethics. Hillsdale, NJ: Erlbaum, 1994, pp. 1–26. 6. Lu¨tze´n K, Nordstro¨m G and Evertzon M. Moral sensitivity in nursing practice. Scand J Caring Sci 1995; 4(9): 131–138. 7. Kim YS, Kang SW and Ahn JA. Moral sensitivity relating to the application of the code of ethics. Nurs Ethics 2013; 20(4): 470–478. 8. Lu¨tze´n K, Blom T, Ewalds-Kvist B, et al. Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nurs Ethics 2010; 17(2): 213–224. 9. Saarni SI, Parmanne P and Halila R. Ethically problematic treatment decisions: a physician survey. Bioethics 2008; 22(2): 121–129. 10. Jiang HL and Cao HA. Discussion on nursing education measures to deal with contemporary nursing ethical problems. Chin J Pract Nurs 2006; 22: 71–72 (in Chinese). 11. Yang QX, Fu XH and Liu HP. A survey of ethical and moral diathesis of nurses in county-level hospitals. Chin Nurs Res 2006; 20: 681–682 (in Chinese). 12. Tang PF, Johansson C, Wadensten B, et al. Chinese nurses’ ethical concerns in a neurological ward. Nurs Ethics 2007; 14(6): 810–824. 13. Pang SMC, Sawada A, Konishi E, et al. A comparative study of Chinese, American and Japanese nurses’ perceptions of ethical role responsibilities. Nurs Ethics 2003; 10(3): 295–311. 14. Gonza´lez-de Paz L, Kostov B, Siso´-Almirall A, et al. A Rasch analysis of nurses’ ethical sensitivity to the norms of the code of conduct. J Clin Nurs 2012; 21(19–20): 2747–2760. 15. McClendon H and Buckner EB. Distressing situations in the intensive care unit: a descriptive study of nurses’ responses. Dimens Crit Care Nurs 2007; 26(5): 199–206. 16. Kim YS, Park JW, You MA, et al. Sensitivity to ethical issues confronted by Korean hospital staff nurses. Nurs Ethics 2005; 12(6): 595–605. 17. Bowman KW and Hui EC. Bioethics for clinicians: Chinese bioethics. CMAJ 2000; 163: 1481–1485. 18. National health and family planning commission of the people’s republic of China. http://www.nhfpc.gov.cn/ (2012, accessed May 2014).
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Appendix 1 A thematic question guide 1. What are the types of ethical challenges you have encountered at work? How often do you encounter these challenges? Please describe a few recent cases in detail. 2. How do you understand the concept of ‘‘ethical sensitivity’’? Could you provide some examples? 3. How do you evaluate your ability to recognize or become aware of the ethical problems or dimensions? 4. What factors impede your ability to recognize or become aware of ethical problems? Could you provide some examples? 5. What factors facilitate your ability to recognize or become aware of ethical problems? Could you provide some examples?
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