Investigating the Relationship between Nurses’ Moral Sensitivity and Patients’ Satisfaction with the Quality of Nursing Care

Patient satisfaction is considered as an important indicator of the quality and effectiveness of health system. Moral sensitivity plays an important role in how professional responsibilities and moral decisions are made by nurses. This study aims to investigate the relationship between nurses’ moral sensitivity and patients’ satisfaction with quality of nursing care. This study is descriptive and analytic. First, nurses in internal, surgical and special wards were selected through census method. Then, patients were selected using quota sampling to the ratio of nurses from each section. Data were collected through Demographic Questionnaires, Patient Satisfaction Instrument and Moral Sensitive Questions. Data were analyzed using SPSS 23. There was a significant positive correlation between nurses’ moral sensitivity and patients’ satisfaction with quality of nursing care (P<0.05). The majority of patients (70.5%) had moderate level of satisfaction with quality of nursing care. 93.5% of nurses had high moral sensitivity. There was no statistically significant relationship between nurses’ moral sensitivity and variables of sex, location of work, marital status, type of responsibility and work shift. Relationship between patient satisfaction and type of admission ward was significant (P = 0.03). Increased moral sensitivity in nurses is effective on improving patients’ satisfaction with the quality of nursing care. It is suggested to conduct further research with larger sample size and investigate other factors affecting patient satisfaction in order to ensure the generalizability of research results.


INTRODUCTION
Ethics are set of behavioral characteristics originated from individual's beliefs, values, commitments, inner faith and piety and play role in determination of attitudes and values by him [1].Moral sensitivity is the first component to observe ethics [2] and includes individual's skill and ability to interpret the reactions and feelings of others.This kind of sensitivity is effective on detection of moral conflicts, emotional and intellectual perception of vulnerable situations as well as increasing awareness of ethical consequences resulted from making decisions about others [3][4].The attention paid to moral sensitivity is increasing especially in social fields and occupations [2].Nursing is a social profession [5].Due to the certain circumstances of their profession as well as providing acute and intensive care, nurses are regularly exposed to situations of conflict and tension caused by ethical confusions [6].Lack of attention to ethical issues by nurses may result in ignoring these issues at their stressful workplace.Development of moral sensitivity by creating a fundamental attitude and reaction for nurses help them provide moral and effective care of patients and prevent ethical conflicts and dilemmas [7][8].Moral sensitivity increases the attention, accurate understanding and reviewing needs of patients and their families which in turn plays an important role in the formation of proper clinical reasoning by nurses [4].
Quality in health care systems is complex structure caused by interaction of values, beliefs and attitudes of participants in mentioned system.It is considered an important category to improve quality and make efforts to develop and evaluate it in nursing and health care systems [8].Nurses spend more time with their patients than other employees of the health care system; therefore, they have unique situation in terms of effectiveness and improvement in quality of health care services [9].American Nurses Association has mentioned patient satisfaction as one of the 7 indicators defined to assess the quality of health care organizations' performance [10].Satisfaction is a unique and subjective phenomenon influenced by factors such as quality of health services provided by medical staffs and their ability to communicate mentally with patients, age, sex, level of education, lifestyle, previous experiences, future expectations, patients' individual-social values and their awareness of their own rights [11][12][13][14][15][16].
In today's modern and wide medical world, patients are main shareholders [17].Patient satisfaction increases his constructive participation in care of himself and accelerates the recovery period [10].On the other hand, dissatisfaction with increased anxiety and irritability in patients has led to delayed recovery process and more beds of hospital will be occupied by increasing the length of hospitalization and costs of treatment [18].Different studies have separately investigated quality of care, patient satisfaction and nurses' moral sensitivity.For example, according to results obtained from a research conducted by Buyuk et al., 45% of nurses had ethical problems in their profession [19].In this study, there was no relationship between nurses' job satisfaction and moral sensitivity.Results of research conducted by Freitas et al. show that there is a high correlation between quality of nursing care and patients' satisfaction [20].A study conducted by Izadi et al. showed that there is no connection between nurses' moral sensitivity and caring behavior [3].According to the importance of characteristic of nurses' moral sensitivity, quality of health care and patients' satisfaction and due to limited number of studies conducted in this field which sometimes have led to contradictory results, the present study aims to investigate the relationship between nurses' moral sensitivity and patients' satisfaction with quality of nursing care.

METHODS OF THE RESEARCH
This study is descriptive and analytic conducted on all patients and nurses working in internal, surgical, dialysis, ICU and CCU wards in hospitals affiliated to Shushtar University of Medical Sciences in 2016.The number of nurses working in mentioned wards was 82 through census method which was reduced to 77 because of the unwillingness of 5 nurses to participate in the study.Based on similar studies [4,12,21] and according to formula , d = 0.07, P = 0.2, α = 0.05, number of patients participating in the study was 134; finally, it was considered 150 after estimating the number collapsed.Patients were selected using quota sampling based on the number of beds available in that section.
Inclusion criteria for nurses included having clinical work experience in one of the sections for at least 3 months, having bachelor's or master's degree, spending at least a full working shift in section considered, being satisfied with participating in the study and completing questionnaire.Inclusion criteria for patients included patients aged between 15 and 65, being aware and desiring to complete the questionnaire, having the ability to communicate verbally with the researcher, being hospitalized for at least 24 hours and being on the verge of discharge from hospital, knowing the nurse providing health care and lack of membership in medical staff.Data were collected using nurses' demographic data (sex, location of work, marital status, type of responsibility, working shift) and patients' demographic information (sex, level of education, number of hospitalization, kind of hospitalization ward), Patient Satisfaction Instrument and Moral sensitive Questionnaire.
Patient Satisfaction Instrument was rendered into Persian in 2008, including 25 questions and three dimensions of technical-professional care (7 items), reliability (11 items) and patient training (7 items).Based on five-point Likert Scale, each item is graded from strongly agree (5 points), agree (4 points), I'm not sure (3 points), disagree (2 points) to strongly disagree (1 point).This instrument has both positive and negative items and points of negative items are calculated inversely.The minimum and maximum score of patient satisfaction is respectively 25 and 125.To calculate the mean score of patient satisfaction, points of all items were added and then the result is divided into 25.Score less than 58 indicates dissatisfaction; scores between 58 and 92 indicate moderate satisfaction and scores higher than 92 show full satisfaction.This questionnaire has been used in different studies [11][12].
Moral sensitivity questionnaire was developed by Lutzen in 1994, including 30 questions which measures moral sensitivity.This part contains 6 subscales, including level of professional knowledge, integrity and benevolence, experience of ethical problems and conflicts, the knowledge of how to communicate with patients, the use of moral concepts in ethical decisions and respect the patient's autonomy.This questionnaire is scored on five-point Likert Scale.As 5 points is allocated to completely agree, 4 points to agree, 3 points to no idea, 2 points to disagree and 1 point to completely disagree and score 0-4 is considered for each item.The maximum and minimum score is respectively 120 and zero.Accordingly, when the total score of each sample is 0-50, it will show low moral sensitivity, score 51-75 indicates moderate sensitivity and score 76-120 shows high sensitivity.These are standard questionnaires that have been frequently used in different research [4,7,11,12,19].Moreover, to determine the validity of the instrument, face and content validity was used in this study.Therefore, the questionnaire was examined and evaluated by 10 faculty members of Shushtar University of Medical Sciences in terms of content, clarity and simplicity of any statements in it and then the questionnaires were used after considering and applying comments.To determine the reliability, internal consistency (Cronbach's alpha) was used.For this purpose, the questionnaires were given to 20 patients and 10 nurses.Cronbach's alpha coefficient was respectively 0.81 and 0.79 for patients' satisfaction and nurses' moral sensitivity questionnaires.After obtaining official permits, the researcher attended at research environment and described research purposes for qualified nurses and patients.After assuring participants of confidentiality of information and receiving informed written consent, questionnaires were completed and collected.To evaluate the statistical indicators, descriptive statistics (mean, standard deviation, etc.), independent t-test, one-way analysis of variance (ANOVA) Scheffe test were used.Kolmogorov-Smirnov test was used to investigate the data normality.Data were analyzed using SPSS 23.

RESULTS
Patients' demographic information is shown in Table 1.Based on the findings, 93.5% of nurses had high moral sensitivity.Also, the majority of patients (70.5%) were moderately satisfied with the quality of nursing care.The results indicated that significance level of t-test for nurses' moral sensitivity was less than acceptable value 0.05 and average level of nurses' moral sensitivity is significantly more than assumed mean of the community.Also, significance level of t-test for patients' satisfaction with the quality of nursing care is less than acceptable value 0.05; hence, it can be said that the average level of patients' satisfaction with the quality of nursing care (63.73) is significantly less than assumed mean of the community (Table 2).There was a significant positive correlation between nurses' moral sensitivity and patients' satisfaction with the quality of nursing care (P<0.05)(Table 3).The results of independent t-test showed that there is no statistically significant difference between moral sensitivity and demographic variables (sex, work place, marital status, type of responsibility, working shift) (Table 4).
The results of one-way analysis of variance (ANOVA) indicated that the relationship between patients' satisfaction with the quality of nursing care and variables such as level of education (p=0.23) and number of hospitalization days (p=0.44) is not significant.Results of independent t-test showed that there is no significant difference between male and female patients' satisfaction with the quality of nursing care (p=0.29).One-way analysis of variance (ANOVA) indicated that there was a significant difference between patients' satisfaction with the quality of nursing care and various parts of hospitalization (p=0.03).According to the results of Scheffe followup test, the highest and lowest levels of satisfaction were respectively related to the CCU ward with the mean of 68.35 and dialysis unit with the mean of 59.36.

DISCUSSION
This study aimed to determine the relationship between nurses' moral sensitivity and patients' satisfaction with the quality of nursing care provided in Shushtar hospitals.The research results indicated that there is a significant positive correlation between nurses' moral sensitivity and patients' satisfaction with the quality of nursing care.Although a research which investigates the relationship between nurses' moral sensitivity and patients' satisfaction with the quality of nursing care was not found, several studies have been conducted which investigate the relationship between nurses' moral sensitivity and different aspects of their job performance; the findings of such studies are consistent with the results obtained from the present research.For example, the results of research conducted by Jo & Kim showed that moral sensitivity is effective on nurses' performance in the field of providing end of life care [20][21][22][23].Also, findings of research carried out by Mohammadi et al. showed that there is a positive correlation between increasing nurses' moral sensitivity and improving the quality of their working life [21].The results of research by Mohammadi et al. showed that nurses with higher level of moral sensitivity were more skilled at delivering unpleasant news to patients and their families [24].The findings of this study indicated a significant positive correlation between nurses' moral sensitivity and patients' satisfaction with the quality of nursing care.In explaining such finding, it can be said that moral sensitivity may increase the ability to communicate effectively and professionally, empathy, accountability and improve the quality of nurses' working life [18,21,[24][25][26] and increase patients' satisfaction through improving nursing care behaviors [27].
The results of this study indicate that the majority of nurses had high moral sensitivity.This finding is inconsistent with results of research conducted in this field in which nurses' moral sensitivity was estimated at an average level [3,19,[28][29][30][31].The reason of the difference between findings may be due to the low number of nurses participating in this study compared to other studies.Also, according to findings, there was no statistically significant relationship between level of nurses' moral sensitivity and variables, including sex, organizational position, employment status, work place, marital status and type of working shift.These findings are consistent with most of the results obtained from similar research [3,[28][29][30][31].In explaining this finding, it can be said that cultural environment and religious educational background probably play more important and effective role in the formation of intellectual-moral aspects and individual's moral sensitivity than other demographic variables [3,7,21,32,33].
According to the findings of this study, patients' satisfaction with the quality of nursing care was at moderate level.This result is consistent with the findings of some similar studies in terms of patient satisfaction [34][35]; however, in the research conducted by Mo'taqed et al., level of patients' satisfaction was higher than average [36].The results obtained from research carried out by Khezri et al. indicated that 84.4% of patients were dissatisfied with nursing services [12].Researchers believe that this difference in patients' satisfaction can be influenced by various factors such as culture, expectations, previous experience, personal and social values, lifestyle and patients' awareness of their own rights [10,37].In this study, there was no relationship between sex, number of hospitalization, level of education and patients' satisfaction with the quality of nursing care; this finding is consistent with findings of similar research [10,12,34,38].In the present study, the relationship between kind of admission ward and patients' satisfaction was significant; in the way that the highest satisfaction with the quality of nursing services related to CCU ward.This result is consistent with the results of some studies conducted [36].
Researchers believe that categories such as spending more time for direct care of patients, less workload and use of experienced nurses in this ward can be considered as possible reasons for higher level of patients' satisfaction with nursing care provided in CCU [11].Based on the findings of this research, it can be concluded that promotion of various aspects of moral development, including moral sensitivity can improve nurses' performance by affecting their thought and behavior and as a result increase patients' satisfaction.The small sample size and lack of investigating other factors affecting patients' satisfaction are limitations of this study.Hence, it is suggested to conduct further research with larger sample size and investigate other factors affecting patient satisfaction in order to ensure the generalizability of research results and discuss more about the effect of moral sensitivity on patients' satisfaction.

CONCLUSION
The research results showed that promotion of nurses' moral sensitivity is effective on increasing patients' satisfaction with nursing care.According to the importance of patients' satisfaction with nursing care which is considered as an important indicator in determining the quality and effectiveness of health care system and due to the influential role of various aspects of ethics, including moral sensitivity in nurses' performance, attention and efforts to promote nurses' moral sensitivity as the largest group of health team seem essential.Therefore, to enhance the quality of services provided in health care system, administrative and educational managers can take advantage of systematic in-service programs to increase nurses' moral sensitivity in addition to training professional morality to nursing students.The findings of this study can provide an opportunity for further research and various interventions designed to improve the quality of nursing services by offering basic information.

Table 1 .
Frequency and percentage of patients participating in the study divided by sex, number of hospitalization and level of education

Table 2 .
One-sample t-test results to compare the current situation of nurses' moral sensitivity and patients' satisfaction level with the quality of nursing care with assumed mean of the community

Table 3 .
Correlation coefficient between nurses' moral sensitivity and patients' satisfaction with the quality of nursing care

Table 4 .
Comparison of male and female nurses participating in the study, special and public wards, different positions, morning shift and working shift, married and single using independent t-test