Moral Sensitivity: some differences between nurses and physicians

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<ul><li><p> Ethics</p><p> online version of this article can be found at:</p><p> DOI: 10.1177/096973300000700607</p><p> 2000 7: 520Nurs EthicsKim Ltzn, Agneta Johansson and Gun Nordstrm</p><p>Moral Sensitivity: some differences between nurses and physicians </p><p>Published by:</p><p></p><p> can be found at:Nursing EthicsAdditional services and information for </p><p> Alerts: </p><p> </p><p> </p><p> </p><p> </p><p> What is This? </p><p>- Nov 1, 2000Version of Record &gt;&gt; </p><p> at University Library Utrecht on June 2, 2014nej.sagepub.comDownloaded from at University Library Utrecht on June 2, 2014nej.sagepub.comDownloaded from </p><p></p></li><li><p>MORAL SENSITIVITY: SOMEDIFFERENCES BETWEEN NURSES</p><p>AND PHYSICIANS</p><p>Kim Ltzn, Agneta Johansson and Gun Nordstrm</p><p>Key words: ethics; health care; moral sensitivity; professionals</p><p>We report the results of an investigation of nurses and physicians sensitivity to ethicaldimensions of clinical practice. The sample consisted of 113 physicians working ingeneral medical settings, 665 psychiatrists, 150 nurses working in general medicalsettings, and 145 nurses working in psychiatry. The instrument used was the MoralSensitivity Questionnaire (MSQ), a self-reporting Likert-type questionnaire consisting of30 assumptions related to moral sensitivity in health care practice. Each of these assump-tions was categorized into a theoretical dimension of moral sensitivity: relational orien-tation, structuring moral meaning, expressing benevolence, modifying autonomy,experiencing moral conflict, and following the rules. Significant differences in responseswere found between health care professionals from general medical settings and thoseworking in psychiatry. The former agreed to a greater extent with the assumptions inthe categories meaning and autonomy and to a lesser degree with the categoriesbenevolence and conflict. Moreover, those from the psychiatric sector agreed to agreater extent to the use of coercion if necessary. Significant differences were also foundfor some of the MSQ categories, between physicians and nurses, and between males andfemales.</p><p>BackgroundThe theoretical approach to ethical problems in health care practice is today a sub-ject of much discussion. There is also a strong divergence of opinion in the liter-ature on differences in ethical reasoning between physicians and nurses. Onepredominant perspective is to associate nursing with the caring, subjective,approach, of which feelings and intuition are the modes of ethical reasoning, andphysicians with the principle thinking and objective approach. Whether nursesare adopting this approach themselves in the process of professional develop-ment1 or whether there is a true distinction between physicians and nurses isalso a subject engaging many scholars. Rickard et al.,1 for example, make a strong</p><p>Nursing Ethics 2000 7 (6) 0969-7330(00)NE375OA 2000 Arnold</p><p>Address for correspondence: Kim Ltzn, Dean, Department of Nursing, Ersta-SkndalUniversity College, Box 4619, 116 91 Stockholm, Sweden.</p><p> at University Library Utrecht on June 2, 2014nej.sagepub.comDownloaded from </p><p></p></li><li><p>Nursing Ethics 2000 7 (6)</p><p>Moral sensitivity: differences between nurses and physicians 521</p><p>case for the position that there are no significant differences between physiciansand nurses. In their study, they explored the extent to which nurses exhibitedpartialist ethical reasoning and physicians impartialist reasoning. A structuredquestionnaire based on four hypothetical moral dilemmas was administered to agroup of randomly selected physicians and nurses. No significant differences werefound, yet both modes of ethical reasoning were evident in nurses as well as inphysicians. </p><p>Both nurses and physicians are expected to make decisions that are consistentwith their professional code of practice. The practical aspect of this mandate per-tains to ethical competency, specifically the ability to understand the ethical natureof individual contexts and to act in a responsible way. However, because nursesand physicians relationship to the patient is different, they may also have dif-ferent ways of viewing their ethical responsibility. It is a fact that physicians arelegally responsible for patient treatment and nurses are responsible for patientcare, which should be consistent with the physicians orders. </p><p>Differences or similarities in how nurses and physicians view ethical issues inhealth care practice may be approached theoretically or empirically. Philosophicalenquiry, for example, typically starts from a commitment to a particular ethicaltheory in the analysis (and solution) of a particular problem. An example of anempirical approach is to describe real examples of difficult ethical problems in anattempt to identify the moral thinking or principles that are behind the decisionsthat are made.2</p><p>Each approach, characterized by the phenomenon of concern and its method-ology, makes a valuable contribution to health care ethics. However, there are lim-its to both of the above described approaches. Specifically, the philosophicalapproach to ethical enquiry may generate conceptual models that may not be truereplicas of the empirical world but, instead, abstract constructions of reality.Similarly, there is also a risk that the descriptive findings of empirical researchwill become uncritically accepted as the norms of practice. </p><p>The phenomenon of concern in the study presented here is the interpersonalaspect of moral decision making, perceived to be a sensitizing factor in how eth-ical issues are identified in health care practice. More specifically, the aim of ourstudy was to describe nurses and physicians moral sensitivity, or attitudes con-cerning patient care. The term attitude is usually defined as a quality of the indi-vidual and is known to be fairly stable over time.3 Thus, a persons attitudetowards something is held to be predictive of decisions that are made, or ofbehaviour in actual situations. In this study, the term attitude is used to mean anassimilation of ideas, feelings and values that influence a persons moral sensi-tivity. We were particularly interested in comparing nurses and physicians in dif-ferent clinical settings, namely, general medical and psychiatric care. </p><p>The theoretical perspective builds on previous research that focuses on moralsensitivity, a personal predisposition guiding ethical decision making. In brief,moral sensitivity exhibited in health care practice is the ability to recognize amoral conflict, show a contextual and intuitive understanding of the patients vul-nerable situation, and have insight into the ethical consequences of decisionsmade on behalf of the person.4 A review of related studies shows that moral sen-sitivity is important as an affective component in the process of ethical decisionmaking. Carpenter,5 for example, explored the process by which nurses make eth-</p><p> at University Library Utrecht on June 2, 2014nej.sagepub.comDownloaded from </p><p></p></li><li><p>Nursing Ethics 2000 7 (6)</p><p>522 K Ltzn, A Johansson and G Nordstrm</p><p>ical decisions in clinical practice. Twenty nurses participated in semistructuredinterviews in which they discussed ethical problems of their choice. Contentanalysis revealed that the process of making a decision begins with an emotionalresponse. Similarly, moral sensitivity can be seen as a type of emotional response,as a necessary component that activates the cognitive process of ethical decisionmaking.</p><p>In a phenomenological study by Smith,6 19 staff nurses were asked to describetheir experiences in making ethical decisions in practice. Two distinct componentsof the ethical decision-making process were identified: deliberation and integra-tion. The findings revealed that nurses need to: (1) recognize the ethical natureof their work; (2) discern which ethical decisions are theirs to make; and (3)acknowledge their authority to make ethical decisions in their practice. </p><p>The findings of other studies based on the concept of moral sensitivity7,8 indi-cate that the type of clinical setting influences how nurses and physicians per-ceive patient care. Another significant finding was that female nurses andphysicians experience moral conflicts in their practice to a greater extent thanmale nurses and physicians. Moreover, these conflicts often involve issues con-cerning patient autonomy. Other ethical issues in nursing practice concern team-work,9 and similarities and differences in the way that nurses and physicians viewethical problems.10</p><p>MethodInstrument</p><p>The Moral Sensitivity Questionnaire (MSQ), constructed from the qualitativeanalysis of moral sensitivity in psychiatric nursing practice,4,11 was used in thecollection of data. The MSQ is a self-administered questionnaire, designed as aseven-point scale that consists of 30 assumptions. An example of such an assump-tion is: I believe that good care involves respecting the patients self-choice. Theanchors of each assumption are I totally disagree and I totally agree. A scoreof 17 for each item indicates the extent of agreement or disagreement with theassumption. Twenty-nine assumptions are categorized according to the followingsix theoretical dimensions of moral sensitivity4,11:</p><p> Relational orientation is reflected in the health care professionals concern forhow actions will affect the relationship with the patient (category: relation).</p><p> Structuring moral meaning refers to making sense of a patients limited auton-omy by finding that actions are meaningful, that is, they neither harm northreaten the patients integrity (category: meaning).</p><p> Expressing benevolence refers to actions that are motivated by doing that whichis believed to be good or in the best interest of the patient (category: benev-olence).</p><p> Autonomy is reflected in views that the principle of patient autonomy, mean-ing self-choice, must be respected (category: autonomy).</p><p> Experiencing moral conflict (category: conflict). Following the rules refers to actions that are instructed by routines and ward</p><p>policies (category: rules).</p><p> at University Library Utrecht on June 2, 2014nej.sagepub.comDownloaded from </p><p></p></li><li><p>Nursing Ethics 2000 7 (6)</p><p>Moral sensitivity: differences between nurses and physicians 523</p><p>Assumption no. 30: It is sometimes justified to tell a patient that an injectionmay have to be given by force if he or she refuses the prescribed oral medica-tion, explores the attitude to the threat of coercion and is analysed as a singleitem.</p><p>Respondents</p><p>The total sample in this study consisted of 1073 health care professionals whocompleted and returned the MSQ by post. The respondents comprised thefollowing professional groups:</p><p>Group A: physicians in general care settings (n = 113);Group B: psychiatrists (n = 665);Group C: nurses in general care settings (n = 150);Group D: nurses working in psychiatry (n = 145).</p><p>In group A, 240 questionnaires were distributed to physicians at a largeteaching hospital in Sweden. Of these, 113 were returned completed (47%). Theage range was 2865 years (mean 46.8). A detailed description of the procedurefor the selection of groups B, C and D, as well as demographic data, has previ-ously been published.7,8 For the gender distribution in all groups, see Table 1.</p><p>The responses to the questionnaire in Group A were treated as new data andcompared with data collected in previous studies.7,8 The statistical method usedwas the t-test, which determines differences between two independent groups.The criterion for statistical significance was p &lt; 0.05.</p><p>The Ethics Committee of Huddinge University Hospital approved the study.</p><p>FindingsDifferences between groups</p><p>Significant differences in responses among the four groups AD were foundfor the MSQ categories meaning, benevolence, autonomy and conflict(Figure 1 and Table 2). No differences were found for the categories relation andrules. </p><p>Table 1 Gender distribution within groups AD</p><p>Group Male Female Missinga Total(n=462) (n=577) (n=34) (n=1073)</p><p>A) Physicians, medical care 69 37 7 113B) Psychiatrists 365 288 12 665C) Nurses, general care 8 131 11 150D) Nurses, psychiatric care 20 121 4 145</p><p>a Gender not indicated.</p><p> at University Library Utrecht on June 2, 2014nej.sagepub.comDownloaded from </p><p></p></li><li><p>524 K Ltzn, A Johansson and G Nordstrm</p><p>Nursing Ethics 2000 7 (6)</p><p>MEANING BENEVOLENCE</p><p>General nurse Psychiatric nurse</p><p>General physician Psychiatrist General physician Psychiatrist</p><p>General nurse Psychiatric nursep &lt; 0.001</p><p>p &lt; 0.001 p &lt; 0.001</p><p>ns ns ns ns</p><p>p &lt; 0.001</p><p>p &lt; 0.001 p &lt; 0.001p &lt; 0.01p &lt; 0.001</p><p>AUTONOMY CONFLICT</p><p>General nurse Psychiatric nurse</p><p>General physician Psychiatrist General physician Psychiatrist</p><p>General nurse Psychiatric nursens</p><p>p &lt; 0.001 ns</p><p>ns ns ns</p><p>p</p></li></ul>


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