Abstract
Objective
This descriptive study was designed to determine the ethical sensitivity and empathy levels of intern nurses.
Method
The sample of this descriptive and cross-sectional study consisted of 100 fourth-year students enrolled in the nursing department of a foundation university. Data were collected using a descriptive information form, the modified moral sensitivity questionnaire for student nurses (MMSQSN), and the basic empathy scale (BES).
Results
It was determined that 68.0% of the intern nurses participating in the research were women, 79.0% chose the profession willingly, 91.0% found the profession suitable, 13.0% experienced ethical problems frequently during their internship, and 62.0% experienced ethical problems from time to time. The MMSQSN and BES scores were 5.29±0.69, and 71.06±13.38, respectively. A statistically significant difference was found between age, perception of a good fit, belief in the suitability of the profession, and experience of ethical problems during the internship and MMSQSN. There was also a statistically significant difference in empathy levels, gender, and experience with ethical problems during the internship and BES.
Conclusion
Intern nurses had significantly high levels of ethical sensitivity and above-average levels of empathy. Ethical sensitivity levels were higher among students who were 23 years old and older, believed that nursing was a good fit for them, and experienced ethical problems during their internship. On the other hand, empathy levels were higher among female intern nurses who experienced ethical problems during their internship. Therefore, to enhance students’ ethical sensitivity and empathy skills, educational methods such as scenario-based learning, psychodrama, and role play are recommended.
Main Points
• Nurses must make complex decisions in their professional practice and take responsibility for them.
• To recognize ethical problems and make the right decisions about their resolution, nurses require a high level of empathy and ethical sensitivity, which can be defined as the ability to distinguish ethical problems.
• It is of great importance for nurses to develop ethical sensitivity and empathy skills throughout their education.
Introduction
In today’s rapidly developing healthcare industry, ethical dilemmas are becoming increasingly prevalent. Nurses, who are dedicated to healing people, must approach these dilemmas with ethical sensitivity, which forms the foundation of the patient-nurse relationship and empathy (1). Ethical sensitivity involves identifying ethical values and problems, as well as recognizing individuals’ roles and responsibilities in conflicting situations (2, 3). Empathy, on the other hand, is the capacity to understand and share the patient’s feelings and thoughts by establishing healthy communication with them and seeing the world from their perspective (4, 5). According to Lilja and Osbecks (6), empathy is essential for ethical sensitivity, and an individual’s ability to understand others’ perspectives is related to ethical sensitivity. Nurses must make complex decisions in their professional practice and take responsibility for these decisions (3). To recognize ethical problems and make appropriate resolutions, nurses require a high level of empathy and ethical sensitivity, which can be defined as the ability to distinguish ethical problems (2, 3). Nurses with high ethical sensitivity and empathy skills are caregivers with a high level of awareness who interpret the verbal and non-verbal behaviors of patients, identify their physical and emotional needs, and include these needs in the caregiving process (5). Nursing care provided by caregivers can increase patient satisfaction, facilitate early discharge, and positively affect patients’ overall health status (7). A low level of ethical sensitivity and empathy, on the other hand, can reduce the quality of patient care, trust in nursing services, and job satisfaction (8). Therefore, it is crucial for nurses to improve their ethical sensitivity and empathy skills through education (9).
Previous studies have reported varying levels of ethical sensitivity among nurses, ranging from low to high (8, 10-12). Additionally, previous studies have shown that nurses possess moderate levels of empathy (7, 13). To improve both ethical sensitivity and empathy skills among nurses, education has been identified as a crucial factor (5, 14, 15). Therefore, it is essential to provide nursing education training that enhances empathic skills and ethical sensitivity. Additionally, the literature has associated the level of ethical sensitivity and empathy with certain socio-demographic factors (5, 16-18). In this context, this study aimed to determine intern nurses’ levels of ethical sensitivity and empathy.
The research questions include the following:
• What are the ethical sensitivity levels of intern nurses?
• What empathy skills do intern nurses possess?
• Is there a significant difference between the socio-demographic characteristics and ethical sensitivity levels of intern nurses?
• Is there a significant difference between the socio-demographic characteristics and basic empathy levels of intern nurses?
Material and Method
Aim and Research Design
This study employed a descriptive design to investigate intern nurses and their levels of ethical sensitivity and empathy.
Population and Sampling
The study population consisted of 110 intern nurses who were enrolled in the 4th grade of the nursing department at a foundation university in The Turkish Republic of Northern Cyprus (TRNC) during the fall semester of the 2023-2024 academic year. No sampling was performed. The sample included 100 students who met the inclusion criteria and voluntarily agreed to participate in the study. The response rate was 91%.
Data Collection Tools
Descriptive information forms, the modified moral sensitivity questionnaire for student nurses (MMSQSN), and the basic empathy scale (BES) were used for data collection.
Descriptive Information Form
The form was developed by the researchers in line with the relevant literature and included six questions: Age, gender, willingness to become a nurse, suitability for nursing, completion of ethics courses, and experience with ethical dilemmas during internship (5, 13).
Modified Moral Sensitivity Questionnaire for Student Nurses (MMSQSN)
The MMSQSN was originally developed by Lützén et al. (19) to measure the moral sensitivity of student nurses, modified by Comrie and adapted into Turkish by Yilmaz Sahin et al. (20). The instrument consists of a 7-point Likert scale with 30 items and six subdimension. Total scores ranged from 30 to 210, with higher scores indicating higher ethical sensitivity. The scale score averages were evaluated as very important (7-5.9), important (5.8-5), neutral (4.9-3.1), and unimportant (less than 3.1). The Cronbach’s alpha of the Turkish version of MMSQSN was 0.73 (20).
Basic Empathy Scale (BES)
The BES was developed by Jolliffe and Farrington to measure empathy levels based on four basic emotions: Fear, sadness, anger, and happiness (21). It was adapted into Turkish by Topçu et al. (22). The 20-item scale had two dimensions: Cognitive and affective empathy. Items were scored on a five-point Likert scale, ranging from 20 to 100, with higher scores indicating higher levels of empathy. The Cronbach’s alpha coefficients of the cognitive and affective empathy dimensions in the Turkish version of the BES were 0.76 and 0.80, respectively (22).
Data Collection Process
Data were collected in the classroom after obtaining permission from the course instructor and determining the appropriate time for data collection. Students were informed of the study purpose and were asked to complete the informed consent form and data collection instruments. The instruments took approximately 10 minutes to complete.
Ethical Considerations
We obtained institutional and ethical approval for the study from the Eastern Mediterranean University Ethics Committee (ETK00-2023-0172/28.09.2023) and the department of nursing, respectively. Additionally, written informed consent was obtained from all participants in accordance with the principles of the Helsinki Declaration.
Statistical Analysis
SPSS (Statistical Package for the Social Sciences) version 26.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. Socio-demographic characteristics and scores obtained from the MMSQSN and BES were presented as descriptive statistics. Non-parametric tests, specifically Mann-Whitney U and Kruskal-Wallis H tests, were used to compare socio-demographic characteristics with scores obtained from the MMSQSN and BES because the data did not meet normal distribution as indicated by the Kolmogorov-Smirnov and Shapiro-Wilk tests. The Cronbach’s alpha values of MMSQSN and BES were 0.83 and 0.85, respectively. Statistical significance was set at p<0.05.
Results
Table 1 presents the socio-demographic characteristics of the participants. Accordingly, 51.0% were 23 years of age or older, 68.0% were female, 79.0% deliberately chose to become a nurse, 91.0% felt nursing was a good fit for them, 100.0% took an ethics course, 13.0% experienced ethical problems frequently, 62.0% experienced them occasionally, and 25.0% never experienced ethical problems.
Table 2 presents the scores obtained by MMSQSN and BES. The mean scores obtained from the MMSQSN and its subdimension of interpersonal orientation, experiencing the ethical dilemma, beneficence, creating ethical meaning, modified autonomy, and getting expert opinion were 5.29±0.69, 6.09±0.81, 4.09±1.74, 5.38±1.02, 5.38±0.63, 5.38±1.14, and 5.44±1.00, respectively. The mean scores of the BES and its affective and cognitive subscales were 71.06±13.38, 37.77±7.46 and 33.29±7.52, respectively.
There was a statistically significant difference between the age of the participants and the score obtained from the modified autonomy subdimension of the MMSQSN (p<0.05). Participants aged 23 years and older had higher scores on the modified autonomy subdimension than those aged 22 years and younger. There was also a statistically significant difference between the belief that nursing was a good fit and the scores obtained from the interpersonal orientation subdimension of the MMSQSN (p<0.05). Finally, the participants who often experienced ethical problems during internship received significantly higher scores from the MMSQSN and its subdimension of interpersonal orientation, experiencing the ethical dilemma, beneficence, and modified autonomy, while their scores obtained from the subdimension of creating ethical meaning were significantly lower than those of the other participants (Table 3).
There was a statistically significant difference between gender and BES scores (p<0.05). Female participants obtained significantly higher scores on the BES and its affective and cognitive empathy subscales. There was also a statistically significant difference between experiencing an ethical problem during the internship and the scores for the BES and its cognitive empathy subscale (p<0.05). Participants who had never experienced ethical problems during their internship obtained significantly higher scores on the BES and its cognitive empathy subscale (Table 4).
Discussion
This study determined the ethical sensitivity and empathy levels of intern nurses. The results revealed that the participants had high levels of ethical sensitivity but only moderate empathy. The study found a significant difference in the MMSQSN scores with age, perception of professional suitability, and experiencing ethical problems during internship. Similarly, the BES scores showed a positive significant difference in gender and ethical problems experienced during internship.
Ethical sensitivity develops through education and can be maintained by maintaining professional competence and exhibiting behaviors in accordance with the ethical codes of the profession (23). The study found that intern nurses had a significantly higher level of ethical sensitivity. This is consistent with the findings of Yanti and Krisnawati (24) and Hançerlioğlu et al. (25) who also reported a high level of ethical sensitivity among nursing students (24, 25). On the other hand, Hakbilen et al. (26), Şahiner et al. (27), Akça et al. (28), Borhani et al. (14) and Kızılırmak and Calpbinici (29) reported moderate levels of ethical sensitivity among nursing students (3). The variation in the level of ethical sensitivity in these studies and ours can be attributed to differences in the characteristics of nursing students as well as their family and cultural backgrounds. Therefore, nursing curricula should incorporate ethical principles, professional codes, and values to enhance students’ ethical sensitivity. This will enable them to make informed decisions when faced with ethical dilemmas or problems in their professional lives.
Various factors, such as age, gender, willingness to become a nurse, and taking ethics courses during nursing education, can affect the level of ethical sensitivity among nurses (5, 30). Parallel to the literature, we found a positive significant difference between age, perceived suitability for the profession, ethical problems experienced during internship, and MMSQSN scores. Specifically, intern nurses aged 23 years and older obtained higher scores in the modified autonomy subdimension of the MMSQSN. Participants who believed that nursing was a good fit for them obtained higher scores in the interpersonal orientation subdimension. Additionally, students who experienced ethical problems during their internship obtained higher scores from the MMSQSN and its interpersonal orientation, experiencing ethical dilemma, beneficence, and modified autonomy subdimension, but their scores in the creating ethical meaning subdimension were significantly lower. Therefore, intern nurses who willingly become nurses and believe that nursing is a good fit for them are more likely to adopt professional ethical values and become aware of ethical problems they encounter.
The participants’ mean scores on the BES and its affective and cognitive empathy subscales were 71.06±13.38, 37.77±7.46, and 33.29±7.52, respectively, indicating above-average empathy skill levels. Previous studies by Guven Ozdemir and Sendir (13), Arifoğlu and Sala Razı (31) and Turan et al. (32), and reported moderate levels of empathy among nursing students. Although Çakan and Çiftçi (33) found that nursing students had above-average levels of empathy, Üstündağ et al. (34) also reported high levels of empathy as well. Differences in empathy levels among the participating intern nurses may be explained with reference to their socio-economic characteristics and courses they took. The study also found a statistically significant difference in gender, experiencing ethical problems during the internship, and BES scores. Female nursing students scored higher on the BES and its affective and cognitive empathy subscales. Additionally, participants who experienced ethical problems during their internships scored higher on the BES and its cognitive empathy subscale. Previous research has also found that female nursing students tend to have higher levels of empathy (13, 35, 36). This may be due to the larger number of female nurses in the profession and the physiological and psychological differences. On the other hand, higher levels of empathy among nursing students who experienced ethical problems during internships may be explained by a higher level of awareness among these students.
Study Limitations
This study’s findings are limited to senior students at a single university, and because of the limited sample size, cannot be generalized to other populations. Further studies with larger populations are required.
Conclusion
The study found that intern nurses had a significantly high level of ethical sensitivity and an above-average level of empathy. Ethical sensitivity levels were higher among students who were 23 years old and older, believed that nursing was a good fit for them, and experienced ethical problems during their internship. On the other hand, empathy levels were higher among female intern nurses who experienced ethical problems during their internship. Based on these findings, ethical sensitivity and empathic skills should be emphasized in all nursing courses. Educational methods such as scenario-based learning, psychodrama, and role play are recommended to enhance students’ ethical sensitivity and empathy.