Health, Spirituality and Medical Ethics

Introduction
Since nurses’ work mainly focuses on patients, ethics in nursing offers a framework to help them ensure the safety of patients and their fellow healthcare providers [1]. Nursing is an ethical profession that includes the values, rights, duties, and responsibilities of nurses in relation to the patient, clients of other professions, and organizations [2]. Gastmans also believes nursing needs to be an ethical practice because professional care and treatment decisions and actions are designed for the comfort and respect of human beings [3]. Sensitivity to ethical issues is one of the criteria for nurses’ professional competence [4].
Lutzen defines moral sensitivity based on individuals’ cognitive ability [5], which helps nurses diagnose patients’ problems at the proper time and make the best decision [6]. Ethical sensitivity requires nurses to recognize patients’ needs by learning and interpreting their verbal and non-verbal behaviors [7]. The development of ethical sensitivity creates an attitude and ethical response in nurses, which enables them to provide effective and ethical care for patients [8]. Moral self-concept has been identified as an important factor influencing moral sensitivity, but there is no sufficient evidence to support it [9].
Moral self-concept refers to how a person feels and thinks about moral issues based on moral values, and awareness of good and evil in human beings [10]. Self-concept is formed and changed in the social process of interaction with others. In other words, moral self-concept develops during one’s adaptation to the moral needs and expectations of others [11]. Moral self-concept does not form spontaneously and easily and requires constant internal and external effort. Ethical education of nurses requires careful planning of the educational system and involvement of students in the category of ethical challenges during their courses. Nursing education provides an opportunity to internalize moral sensitivity and improve moral self-concept [10]. Lee et al. believed that self-concept plays an important role in the development of moral sensitivity and subsequently in moral decision-making [12].
Literature reviews reveal various factors influencing moral sensitivity, such as age, culture, religion, personal experiences, and career attitudes to affect moral sensitivity, income level, work-life quality, professional satisfaction, length of service provided by nurses, ethics education, age groups, and educational background [11, 13, 14]. Borhani et al. studied students’ perceptions of the factors affecting moral sensitivity in a qualitative study and five themes emerged, including individual characteristics, teaching mutual understanding, internal and external control factors, and having immoral experiences [15].
Some studies have explained the effect of educational methods on moral sensitivity. Education can provide a good opportunity to improve moral sensitivity by providing scientific definitions, examples, case studies, and teaching aids [16]. Karimi et al. consider moral self-concept as the product of the interaction of learning and teaching with individual characteristics [17].
The academic nursing training course in Iran lasts four years. Theoretical and practical topics are learned under the supervision of an instructor in the first three years. The fourth year is dedicated to an internship in the clinical environment. The students undertake internships in clinical settings under the indirect supervision of clinical nursing educators [18]. Clinical internship is the main part of education for practical skills. The quality of education in this period is necessary to fulfill future job responsibilities after graduation, and during this period, if the education officials cannot meet the expected abilities, they will fail to fulfill their duties [19, 20]. Nursing students are expected to be empowered by applied ethical knowledge during the clinical training course, to be able to solve ethical issues in the future [21]. A Finnish study showed a significant difference between the moral judgment of first and last-year nursing students; thus, the level of education can affect students’ moral judgment [22]. Some studies have explained the effect of educational methods on moral sensitivity. Education can provide a good opportunity to improve moral sensitivity by providing scientific definitions, examples, case studies, and teaching aids [16]. Weaver and Morse argue that clinical practice and interpersonal relationships in a therapeutic care environment affect moral sensitivity [6].
In Iranian culture, it is believed that the inner instinct of people leads people to moral behavior and sensitivity to moral issues based on their personal characteristics and beliefs, and moral self-concept and moral sensitivity are influenced by culture, customs, and professional conditions in society [23]. Therefore, this study aimed to investigate the sensitivity and moral self-concept in nursing students and the factors affecting it during the internship.

Methods
This research is a quasi-experimental study designed for one group to investigate the degree of students’ moral self-concept and ethical sensitivity before and after the internship program and their related factors. A quasi-experimental design is a useful method in situations where true experiments cannot be used for ethical or practical reasons. The minimum required sample size was 34 people in two groups considering the confidence level of 95%, and the test power of 80% [10]. The sample size before the study is equal to half of the estimate of two independent groups plus two [24]. Therefore, 36 samples are enough, and 39 undergraduate nursing students of Islamic Azad University, Shahrekord Branch, entered the study. Inclusion criteria consisted of being in the final year of the Bachelor’s degree, intention to participate in the study, completing the internship period, ending the last year of the Bachelor’s degree program in the clinical setting, and having informed consent to participate in this study. The exclusion criterion was the unwillingness to participate in the study. The first part of the questionnaire was related to the demographic information of nursing students and the second part was Lutzen’s moral sensitivity questionnaire with 25 items, scoring from one (strongly disagree) to five (strongly agree). In total, the scores of the participants varied from a minimum of 28 to a maximum of 196, the reliability of the tool was calculated to be 0.85 using Cronbach’s α by Borhani et al. [10]. In the current study, for reliability calculation, the questionnaire was distributed among 30 nursing students who were not study participants. The Cronbach’s α was obtained at 0.72. Another questionnaire was Chang’s moral self-concept questionnaire consisted of 18 items. It was translated into Persian previously by Borhani et al. and its validity and reliability were measured (Cronbach’s α 0.76) [10]. It is scored from one (completely disagree) to five (completely agree), and the minimum and maximum scores are 18 and 90, respectively. Also, in the present study, for reliability calculation, the questionnaire was distributed among 30 individuals of the study sample who did not participate in the investigation processes of the research. The reliability of the questionnaire was obtained at 0.71 via Cronbach’s α.
Data were analyzed by SPSS software, version 22 using described by number, percentage, Mean±SD and assessed by the paired t-test.
This study was conducted with a quantitative approach and a self-report method. The participants were limited to nursing students of Islamic Azad University, Shahrekord Branch.
Results
A total of 39 nursing students were assessed, of whom 74.4% were female, 25.6% were male, 76.9% were single, 23.1 were married, and all participants were aged 20-24 years. Also, 76.9% did not participate in ethical workshops before the internship.
The Kolmogorov-Smirnov test confirmed normal distribution (P>0.05) of the mean scores of ethical sensitivity and moral self-concept.
The mean score of ethical sensitivity before and after the internship program is shown in Table 1.
The results showed that most participants had a moderate level of ethical sensitivity before the internship (71-112, 61.5%) which improved to a high level (113-155, 56.4%) after the program. The paired t-test results showed a significant difference between the mean score of ethical sensitivity before and after the internship program (P<0.001; Table 1).
The results showed that most participants had a moderate level of self-concept before the internship (37-55, 56.4%), which improved (non-significant) to a high level (56-74, 48.7%) after the program (Table 2).
Table 3 shows a significant relationship between ethical workshop participation and ethical sensitivity and moral self-concept; however, sex and marital status showed no significant relationship with ethical sensitivity and moral self-concept.
Discussion
In this study, nursing students were mostly female (74.4%) and single (76.9%), they reported no workshop participation (76.9%), and all were aged 20-24 years.
Most students had a moderate level of ethical sensitivity before the internship, which improved to a high level. The mean score of ethical sensitivity improved significantly after the internship program (P<0.05); however, the moral self-concept of the students showed no significant difference after the internship program.
The result of this study showed that the ethical sensitivity of nursing students varied significantly from moderate to high levels after the internship program. The same result was also achieved in other studies [25]. In some previous studies, the ethical sensitivity and orientation scores of nursing students were at a moderate level [9, 26]. The different results observed may be due to the lack of a standard for the quality of education in nursing faculties. Nursing educators are required to improve and incorporate ethical teaching strategies that improve ethical sensitivity into the nursing curriculum. Thus, a significant improvement can be achieved in terms of the standard of ethics education in nursing education.
The correlation between moral self-concept and moral sensitivity was positive (r=0.34, P=0.00) [9]. In the study by Tuvesson and Lützén, the moral sensitivity of participants was at a moderate level [27]. Recognizing distressing and ethically problematic situations is highly important in decision-making processes [28]. Fulfilling this highly important task not only requires ethical knowledge but also ethical sensitivity. Individuals who possess ethical sensitivity are capable of solving ethical conflicts. Ethical sensitivity and moral reasoning are the required skills for ethical decision-making in nursing practice, and these skills can be taught and learned [29].
Efforts to improve ethical sensitivity are recommended. These include developing and providing relevant systems and policies, cultivating ethical responsibility, and introducing different departmental education programs that can simultaneously enhance nursing ethical sensitivity and the organization’s ethical climate.
In this study, most students had a moderate level of ethical sensitivity before the internship, which improved to a high level. This difference was not significant for the mean score of moral self-concept before and after the internship period. The reason might be related to taking a longer time to change the moral self-concept.
Jennings et al. believed that the moral self-concept is a complex amalgam of moral constructs and processes [30]. Kim showed that there is a significant relationship between the history of ethical education and moral self-concept with ethical sensitivity [11]. The workplace environment influences nurses’ moral self-concept; Karimi et al. (2019) found that the high mean score of moral self-concept in nurses working in special wards and in the dimensions of moral self-concept, the knowledge showed the highest score and the leadership showed the lowest score [17]. A lower score in leadership indicates the inability of nurses to control the organizational environment on their moral self-concept. Borhani et al. showed that nurses’ concern about ethics can lead to more sensitivity and ethical behavior in decision-making situations. Therefore, improving moral self-concept can enhance ethical sensitivity [10]. Differences in results can be due to differences in the educational system and encountering contextual ethical challenges.
The necessity of training and preparing nurses to have a higher professional self-concept and self-esteem is felt. Also, nurses’ self-concept is affected by the public image of the nursing profession; thus, social support plays a role in creating this moral self-concept in students.
The moralistic nature of the nursing profession is both due to the content of this major and the student’s motivations. In other words, it can be safely assumed that nurses are mainly driven by strong moral motivations, and even if they are not aware of it at the beginning, this recognition is acquired in the process of professional socialization. In addition, incidents involving ethical considerations are numerous, and it is only expected that nurses have higher levels of ethical self-concept.
Regarding the factors related to moral sensitivity, there are conflicting results. The results of the current study showed a significant difference between the ethical sensitivity of students and the history of participating in the ethics workshop. Torabizadeh et al. found a significant relationship between the preceptorship program and the moral self-concept of nursing students [31], which is consistent with the findings of Snowden et al. and Ekramifar et al. [32, 33].
It is suggested to hold workshops and seminars to improve the ethical sensitivity of nursing students. The results of Soltani et al. are consistent with those of the present study who showed the effectiveness of the nursing ethics workshops. Nurses can make appropriate decisions in clinical environments by knowing the strategies to deal with ethical challenges [34]. However, discussing moral dilemmas with other nurses can be challenging. Therefore, the nursing profession needs a kind of culture building in the field of nurses’ self-reflection about ethical problems in clinical environments.
The results of the current study showed no significant difference between the ethical sensitivity of students and their gender, which is supported by some studies [34-36]. In the study by Lützén and Nordin, women’s ethical sensitivity was more than men’s, but men had fewer arguments and moral problems in daily activities [5]. Possibly the difference in the results is related to the setting.
The results of the current study showed no significant difference between the ethical sensitivity of students and their age. Some studies reported the same results [10, 35, 37]. On the contrary, Tuvesson & Lützén reported a significant relationship between the mean score of moral sensitivity and age [27]. Kim et al. showed that nurses aged 25 to 30 years had a higher level of ethical sensitivity compared to those aged <25 and >30 years [38]. It is possible that despite the increasing age of nurses, the ability to recognize ethical problems decreases and leads to a decrease in sensitivity to ethical issues. This difference with the result of the current study may be due to the variety of age distribution among nurses versus nursing students because of less experience in confrontation with ethical challenges.
Alnajjar et al. also showed the effect of age, academic year, and clinical work experience on ethical sensitivity [26]. Öztürk et al. in addition to the cases mentioned by Alnajjar et al., considered marital status, family structure, and gender as effective factors [13]. Ertuğ et al. found a history of moral education, age, and level of education related to ethical sensitivity [14].
Conclusion
This study showed that the ethical sensitivity of nursing students varied significantly after the internship program. The importance of the moral self-concept on the ethical sensitivity of nursing students should be recognized and clarified for practical application. Ethical sensitivity training of students should be conducted and an effective method of participating in ethics workshops concisely should be noticed. For nursing students with high levels of ethical sensitivity, more attention should be paid to providing external support, such as regarding ethical problem-solving feedback. These results reflect the need for ongoing efforts to develop methods for nursing students’ ethics education programs. Furthermore, moral self-concept development needs long-term multidimensional efforts.
Today, due to scientific advances, nurses face different ethical issues that were not the case before. Therefore, moral sensitivity and improving moral self-concept involve nurses in effectively solving these challenges.
Limitations
The sample size was small and limited to the nursing students of Islamic Azad University Shahrekord Branch, which may limit the generalizability of the results. Thus, there is a need for a larger and more diverse sample of nursing students. Also, the survey was based on self-report, which was likely to be biased. In addition, this research was a quasi-experimental study; future studies could use different study methods, such as tracking individuals over time through clinical training programs, to further study measuring changes in moral sensitivity and moral self-concept before and after interventions.
Ethical Considerations
Compliance with ethical guidelines
The study was approved by the Ethics Committee of Islamic Azad University, Falavarjan Branch (Code: IR.IAU.FALA.REC.1398.035). Essential permissions were obtained to conduct the research from the Research Vice-Chancellor of Islamic Azad University, Falavarjan Branch. The participants were assured that the information would remain confidential the findings would be published anonymously and the participants could receive the results if they want.
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.
Authors' contributions
Supervision and statistical analysis: Simin Tahmasbi; Data collection and writing: All authors.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors acknowledge the cooperation and contribution of nursing students who participated in this study.