The present study investigated ethical awareness and moral sensitivity in nurses of Hamadan University of Medical Sciences, Iran. The results showed that ethical awareness and moral sensitivity were significantly different based on some variables such as marital status, gender, work shift and type of employment.
We found that the mean score of nurses' ethical awareness in this study was moderate. The results of other studies conducted in Iranian universities of medical sciences also indicated that the majority of nurses had a moderate level of ethical awareness (9, 15, 19, and 38). Similarly, Sadeghi et al, (2018) reported that the level of ethical awareness in emergency nurses worked in hospitals of Alborz province was moderate (39). Also, Mohammadi et al, (2017) reported that the knowledge of nursing staff and students of Hamadan University of Medical Sciences about the principles of ethics in nursing profession was moderate (1). In the study of Paudel Subedi et al (2018), the majority of nurses had moderate knowledge about the ethical aspects of the nursing profession (40).
The results of this study showed that ethical awareness was higher in women than men, consistent with some other studies (44 − 42). However, in the study of Shafiei et al (2012), there was no significant relationship between the level of ethics awareness in nurses and gender (19). It seems that male nurses have less opportunity to learn or implement ethics guides in the nursing profession due to their main responsibility in providing family livelihood in the culture of Iranian society, by working in more shifts and different hospitals.
In the present study, although the mean score of ethical awareness in married people was higher than singles, but this difference was not statistically significant, consistent with the study of Shafiei et al (19). Contrary to our results, in other studies, married nurses had significantly higher scores on compliance with professional ethics codes and ethical awareness (38, 43).
Another result of this study showed that there was no significant difference in the level of ethical awareness according to different levels of work shifts. Conversely, in the study of Mohjal-Aghdam et al (2013), there was a statistically significant relationship between ethical knowledge and work shifts in nurses of Tabriz hospitals (13). Also, Sedghi-Sabet et al (2017) showed that knowledge of the ethical aspects of the nursing profession was significantly higher level of awareness in people working in morning fixed shifts (38).
Based on the findings, the level of ethical awareness was not different based on the employment types consistent with the study by Shafiei et al (2012) (19). Contrary to our findings, a number of studies have shown that formal employees had a higher level of awareness (38, 44). Also, in the study of Mohammadi et al (2017), there was a significant relationship between ethics and \employment status. Ethical awareness was higher in people with contractual and formal employment status (1).
In this study, we found that the overall mean score of moral sensitivity was moderate and the majority of nurses had a moderate level of moral sensitivity, which is consistent with other studies conducted in Iran (20, 22, 34, 45–48). Nora et al (2017) in Brazil also reported the moderate level of moral sensitivity among nurses in primary health care centers as moderate (24). Contrary to our results, some other studies conducted in Iran reported nurses' moral sensitivity above average or desirable (32, 46, 49). The result of these differences indicates that various factors may affect the moral sensitivity of nurses, including culture, workplace conditions, unfavorable economic conditions, unpleasant experiences of nurses from previous encounters with patients, nurses' education and literacy, receiving ethics training during college education, the volume of nursing care, and the number of patients under care.
According to the findings of this study, the level of moral sensitivity in the married group was higher than singles and widows. Some studies also have shown that the mean score of nurses' moral sensitivity based on marital status is significantly different (47, 51). In contrast, other studies have not reported a significant association between marital status and moral sensitivity (4, 18, 20, 22, 34, 45). It seems that the effect of marital status on moral sensitivity is defined and adjusted through more influential variables that need to be further studied.
The results of this study showed that the mean score of moral sensitivity of nurses in the fixed morning shift was higher than other work shifts. However, other Iranian studies did not find a statistically significant relationship in this regard (4, 18, 22, 29). This difference in moral sensitivity may be due to the more communication of nurses in morning shift with hospital managers, the possibility of more participation in hospital committees, attending in educational courses, as well as a higher percentage of nurses with more work experience in the morning shifts.
This study showed that the mean scores of moral sensitivity in contract and corporate nurses were higher than other types of employment. Sadrollahi et al (2015) also showed that with the stabilization of employment status, the moral sensitivity of nurses has decreased (34). However, other similar studies have shown that moral sensitivity has no significant relationship with the type of employment of nurses (18, 22, 29). Contract and corporate nurses seem to be more sensitive in their work and care in the hope of definitive employment, but formal nurses are less sensitive to occupational and ethical issues due to job security and burnout due to more years of work.
The results of the present study showed that there was no significant association between ethics awareness and moral sensitivity in nurses. Contrary to our findings, Sadeghi et al (2018) mentioned a significant relationship between the awareness and moral sensitivity of emergency nurses in central Iran, in which moral awareness and sensitivity were predictors of moral performance (39). Hassanpour et al (2011) also showed that nursing ethics education had a positive effect on nurses' moral sensitivity (18).
This study had some limitations that need to be considered in interpreting and generalizing the findings. This study was performed only in the group of nurses and other groups of medical care were not examined. The effect of nurses' cultural background and religious beliefs on the level of ethical sensitivity related to their profession was not controlled. Also, the information obtained in this study was based on nurses' self-reporting and no other methods were used to validate the data; therefore, it is suggested that in future studies, standard objective tools be used to properly evaluate performing professional ethics in nurses.