The Relationships Between Ethical Sensitivity, Ethical Decision-Making Ability, and Ethical Conflict Among ICU Nurses: A Structural Equation Model.

Influence of empathy and professional values on ethical decision-making of emergency nurses: A cross sectional study

BackgroundNursing ethical decision-making ability is a core competency of nurses. However, no tool has been developed to measure the ethical decision-making ability of nurses in China. Therefore, we aimed to develop a nursing ethical decision-making ability scale (EDMAS) and assess its validity and reliability.MethodsA literature review, qualitative study, and the Delphi method were employed to identify the most common ethical dilemmas and original scale items. A cross-sectional study was conducted to evaluate the items. The reliability and validity of the scale were evaluated. Exploratory factor analysis (EFA) was employed to investigate the factor structure based on data from group 1 (N = 404). Confirmatory factor analysis (CFA) was employed to assess the construct validity based on the data from group 2 (N = 503). Convergent validity was evaluated using composite reliability (CR) and average variance extracted (AVE). Discriminant validity was assessed by analyzing the maximum shared variance (MSV). We invited 15 experts to evaluate the content validity of the EDMAS. This study was conducted between December 2021 and January 2023.ResultsWe defined 4 nursing ethical dilemmas and 71 original items. We deleted 4 items during the screening process. Additionally, 3 items were deleted from the EFA. The EFA revealed that the EDMAS with 64 items had a four-factor structure (ethical sensitivity, motivation, judgment, and action), accounting for 56.05% of the total variance. The CFA revealed that χ2/df = 1.291, RMSEA = 0.024, CFI = 0.976, TLI = 0.974, NFI = 0.902, and IFI = 0.976. The CR values were between 0.945 and 0.964. The AVE values were between 0.583 and 0.588. The MSV values were between 0.533 and 0.572. The value of I-CVI varied from 0.867 to 1.000, and the S-CVI/Ave was 0.965. The Cronbach’s of the scale was 0.982. The test–retest reliability of the EDMAS was 0.982.ConclusionEDMAS is a reliable and valid tool for evaluating nurses’ ethical decision-making ability and enhancing its ability through ethics training programs.

High ethical sensitivity positively affects the quality of nursing care; nevertheless, Chinese nurses' ethical sensitivity and the factors influencing it have not been described. The purpose of this study was to describe ethical sensitivity and to explore factors influencing it among Chinese-registered nurses, to help nursing administrators improve nurses' ethical sensitivity, build harmony between nurses and patients, and promote the patients' health. This was a descriptive, cross-sectional study. We recruited 500 nurses from several departments in three tertiary hospitals. The Chinese Moral Sensitivity Questionnaire-Revised version and the Jefferson Scale of Empathy-Health Professionals were used to assess the nurses' ethical sensitivity and empathy ability, respectively. Fifteen sociodemographic variables were included in the questionnaires. Informed consent was obtained from the participants regarding participation and data storage and handling. This program has been examined and supported by the research center of medical ethics and professional ethics of Guilin Medical University. The Approval No. was 2016RWYB04. The whole research process is conducted strictly according to ethical requirements. The valid response rate was 84.40% (n = 422). The total score of Chinese Moral Sensitivity Questionnaire-Revised was 35.82 ± 8.17. The subscale scores of moral responsibility and strength and sense of moral burden were 21.50 ± 4.91 and 14.33 ± 3.98, respectively. Significant differences were found among age groups, gender, years of working, category of profession, and quality of family communication regarding nurses' ethical sensitivity (p < 0.05). Regression analysis showed that the main factors influencing nurses' ethical sensitivity were gender, years of working, quality of family communication, career satisfaction, and empathic ability. Our findings suggest that Chinese nurses' ethical sensitivity in tertiary hospitals in Guilin is at a medium level. The director of nursing schools and hospitals in China should pay attention to nurses' ethical sensitivity and should intensify education and training to improve nurses' ethical sensitivity. Further studies should focus on interventions aimed at improving Chinese nurses' ethical sensitivity.

Objective To discuss the impact of nursing ethics reeducation for the level of ethical cognitive and decision-making ability in practice nursing students. Methods A total of 72 cases of practice nursing students from July 2015 were selected as intervention group and 68 cases of practice nursing students from July 2016 were as control group. The nurses in intervention group participated in two months, a total of 8 times of nursing ethics continuing education courses. The forms of course included flip classroom, case discussion, and scene simulation. The control group accepted routine nursing clinical teaching. The level of ethical cognitive and decision-making ability before and after the intervention were measured in the two groups. Results After the intervention, the scores of ethical cognitive of intervention group were (3.74±0.41) points, higher than the control group (3.20±0.45) points, the difference was significant (t=-7.440, P=0.000); and decision-making ability of intervention group were (283.58±30.38) points, higher than the control group (270.88±29.51) points, the difference was significant (t=-2.507, P=0.013). Conclusions The nursing ethics re-education can improve the cognition of practice nursing students in nursing ethics, at the same time improving the ability of making nursing ethical decisions, helping nursing students making nursing ethical decisions in clinical better. Key words: Students, nursing; Nursing care; Ethics; Education

Ethical conflict is embedded in healthcare and is common in critical care setting. However, there is a paucity of research on the nature of ethical conflict in China. Ethical conflict has cultural and context sensitivity. Therefore, evidence is needed from different backgrounds to help discuss this issue across borders. This study aimed to qualitatively identify the experience of ethical conflict in critical care professionals in China. From December 2021 to February 2022, we performed semi-structured, face-to-face interviews with 21 critical care professionals from five intensive care units in a tertiary general hospital in China. A thematic analysis approach was used to analyse the data. Five themes and 14 sub-themes emerged from the data. Critical care professionals probably felt unable to navigate uncertainty, torn by family issues, outraged by unprofessional behaviours of medical staff, being trapped in a socioeconomic dilemma when having experience of ethical conflict. In addition, they also perceived that they could turn struggle into growth. The experience of ethical conflict in critical care professionals involved a mixture of feelings. This study builds a comprehensive understanding of how ethical conflict affected their perceptions of themselves and their profession and provides implications to develop effective coping strategies. The identification of critical care professionals' experience of ethical conflict would help identify what might trigger the ethical issues and what would be the potential target to optimize in critical practice.

To determine the associated factors of professional identity among intensive care unit (ICU) nurses during the COVID-19 pandemic in China. Multicentre cross-sectional study. This study invited 348 ICU nurses in five hospitals in China from May to July 2020. Online self-report questionnaires were adopted to collect their demographic and occupational characteristics, perceived professional benefits and professional identity. Based on univariate and multiple linear regression analysis, a path analysis was performed to determine the associated factors' effects on professional identity. The mean score of professional identity was 102.38 ± 16.46. Perceived professional benefits, doctor recognition level and family support level were associated with ICU nurses' professional identity. The path analysis revealed that perceived professional benefits and doctor recognition level had direct effects on professional identity. In addition, doctor recognition level and family support level had indirect effects on professional identity through the mediation of perceived professional benefits.

AimTo evaluate the current status and explore influencing factors of junior intensive care unit (ICU) nurses’ recognition and response capabilities to clinical deterioration.DesignThis cross‐sectional study followed the STROBE statement.MethodsFrom November 2024 to January 2025, 260 junior ICU nurses from five tertiary hospitals in China were recruited. Data were collected using a validated 25‐item questionnaire spanning six dimensions to assess their recognition and response abilities. SPSS was used for statistical analyses, including descriptive statistics, Kruskal–Wallis H/Mann–Whitney U tests, and multiple linear regression to examine differences under sociodemographic and occupational factors.ResultsThe total score for recognition and response abilities among 250 junior ICU nurses was 99 (95, 103), with an average item score of 3.96 ± 0.83. Dimension scores ranked from lowest to highest: emergency handling, evaluation, teamwork, disease information analysis, disease information acquisition, and clinical decision‐making. Education level, work experience, and participation in disease observation training were identified as significant influencing factors.ConclusionsJunior ICU nurses in China demonstrate relatively strong overall observation skills but insufficient clinical decision‐making abilities. Nursing managers and educators should integrate these factors into training to enhance young nurses’ capabilities in recognizing and responding to clinical deterioration, which is crucial for improving critical care outcomes.Patient or Public ContributionPatients and the public were not directly involved in the design, implementation, or reporting of this study. However, the results of the study emphasize the importance of improving primary ICU nurses’ clinical decision‐making skills and emergency response skills, which may have an impact on patient care.

Introduction: Caring behavior is a unique behavior that can promote patients’ well-being, the performance of healthcare workers, and the general effectiveness of healthcare institutions. The mechanism and possible predictors of caring behavior are under-researched in health and organizational behavior literature. Based on the aforementioned, this study examined the predictive effect of ethical sensitivity (dimensions included) on caring behavior, and gender differences in caring behavior and ethical sensitivity among public healthcare workers in Delta State, Nigeria. Methods: A cross-sectional research design and a quantitative approach for data collection were adopted. Simple random sampling was adopted for selecting the participating hospitals while the convenience sampling technique was utilized for selecting the healthcare workers. Two instruments with good psychometric properties were used for the data collection. The simple linear regression and independent sample t-test were used for testing the hypotheses via the IBM-SPSS v.25. Results: The participants comprised 150 healthcare workers from public-owned hospitals consisting of 73(48.7%) males and 77(51.3%) females with a mean age of 40.60 years and a standard deviation of 9.30. The results of the study indicated that ethical sensitivity positively and significantly predicted caring behavior. Also, two dimensions of ethical sensitivity, moral strength, and moral responsibility positively and significantly predicted caring behavior while a sense of moral burden did not. Finally, there was no significant gender difference in caring behavior and ethical sensitivity. Conclusion: This study highlights the role of ethical sensitivity, moral strength, and moral responsibility in predicting higher levels of caring behavior among healthcare workers. Thus, it was recommended that hospital administrators, health policymakers, and practitioners seeking to boost the caring behavior of healthcare workers should focus on enhancing factors such as sensitivity to ethical standards. Also, administrators of medical education can nurture intending healthcare workers (medical students) on the importance of ethics in the medical profession.

With the deepening of globalization, ethical decision-making issues in international business activities have become increasingly complex, creating an urgent need to cultivate business professionals with cross-cultural ethical competencies. This study aims to validate the effectiveness of pedagogical intervention in social norm perception on international business ethical decision-making within virtual simulation contexts. Adopting a 2×2×3 mixed experimental design, 312 undergraduate and graduate students from business schools in South China were recruited as participants, randomly assigned to either a virtual simulation teaching group or a traditional case-based teaching group, and stratified by cultural background (Eastern vs. Western). Through an 8-week teaching intervention, participants' international business ethical decision-making abilities and social norm perception levels were measured at three time points: baseline, post-test, and delayed test. The results revealed that: (1) Virtual simulation teaching intervention significantly enhanced students' ethical decision-making abilities, with the experimental group showing an improvement of 1.46 points and an effect size of 2.04, significantly outperforming the control group's improvement of 0.60 points; (2) Social norm perception played a significant mediating role between teaching intervention and ethical decision-making ability, with a mediation effect of 1.04, accounting for 71.2% of the total effect, where descriptive norm perception demonstrated the strongest mediating effect; (3) Virtual simulation teaching showed the most significant effects in the dimensions of moral sensitivity identification and ethical conflict analysis, with effect sizes reaching 2.58 and 2.30, respectively; (4) Cultural background significantly moderated the teaching effectiveness, with students from Eastern cultural backgrounds benefiting significantly more (d=2.75) than those from Western cultural backgrounds (d=1.57); (5) The teaching effects demonstrated good sustainability, with delayed testing showing that the virtual simulation group maintained high performance levels. This study confirms the effectiveness of virtual simulation technology in business ethics education, providing theoretical foundations and practical guidance for constructing personalized teaching models based on social norm perception, and holds significant importance for promoting the digital transformation and quality enhancement of international business ethics education.

This study evaluated the potential impact of service-learning on ethics education by comparing student scores in Ethical Decision-Making Abilities (ED-MA) before and after a service-learning experience. An important next question for the field is whether a project-based ethics-education model can be developed and used to predict resulting impacts on ethical decision making. The findings of this study suggest that service-learning has a positive impact on Ethical Decision-Making Abilities (ED-MA). However, statistically significant higher mean differences in ED-MA were reported only when students participated in particularly intense and engaged service experiences. The study included a pre- and posttest of more than 800 students involved in service-learning experiences at 21 universities. The study has implications for the understanding of and application of best-practice models in ethics education and service-learning when using James Rest’s construct explaining ED-MA.

Clinical decision-making by intensive care unit nurses is vital for ensuring patient safety. It is hypothesized that professional autonomy and interprofessional collaboration are determinants that influence the quality of decision-making; however, empirical evidence supporting this hypothesis within Iranian intensive care unit settings remains limited. To examine the correlations between perceived autonomy, nurse-physician collaboration, and clinical decision-making ability among intensive care unit nurses. This study employed a cross-sectional design, with 400 intensive care unit nurses from two university hospitals in Tehran completing validated Persian versions of the P-AITCS-II, the Dempster/DPBS, and the Lauri & Salanterä instruments to measure interprofessional collaboration, professional autonomy, and clinical decision-making, respectively. We followed STROBE reporting recommendations. Descriptive statistics characterized the sample and scale scores. Bivariate associations were assessed using correlation and group-comparison tests, and multiple linear regression was employed to estimate the independent associations of autonomy and collaboration with decision-making after adjusting for relevant covariates. Ethical approval and informed consent were obtained. The study sample comprised 400 participants, with a mean age of 33.19 years (SD = 5.67). In bivariate analyses, higher perceived autonomy and greater interprofessional collaboration were positively associated with better clinical decision-making (p < 0.05). In multivariable linear regression models that included covariates, perceived autonomy and interprofessional collaboration remained independent predictors of decision-making ability (p < 0.05). The entire model explained approximately 14.2% of the variance in decision-making, suggesting that additional determinants may influence nurses' decision-making processes. The total mean score of the participants was classified at an intuitive-analytic decision-making level, indicating a combined reliance on experience-based intuition and structured analytic processes. Among the intensive care unit nurses within this sample, higher perceived professional autonomy and enhanced interprofessional collaboration were independently correlated with improved self-reported clinical decision-making capabilities. Given the cross-sectional nature of the study, causality cannot be established. Longitudinal research employing objective performance metrics is necessary to examine causal relationships and to guide organizational strategies that foster both autonomy and collaborative practice.

Background: Limited information on risk factors for ethically difficult clinical situations exists. Identifying common factors in these situations could encourage a more proactive, system-wide approach to ethical issues, which could mitigate patient and family suffering, providers’ moral stress, and costly ethical conflicts. Methods: Quantitative and qualitative data analyses were performed on physician responses to an online survey that queried physician perceptions about ethically complex situations in a large academic medical center and community hospital. Results: Representing 30 specialties, 114 physicians responded. The most frequently encountered situation was working with patients who lacked capacity for decision making. End-of-life treatment decisions and family adamancy were ranked as the most intense situations. Interactional risk factors such as different moral perspectives and poor communication were most prominent (53.9%); patient and family risk factors were also described (33%). Physicians identified early and frequent communication with seriously ill patients and their families as the primary protection against ethical conflict. Ethics skill-building, good teamwork, and creating an ethics-minded culture were also featured as important preventive measures. Pressure from others to take morally uncomfortable action was most often cited as a source of moral stress. The pressure of limited time to address ethical issues was also frequently mentioned. These pressures could progress to ethical conflicts, which often compounded moral stress. A majority of physicians reported willingness to work with nurses on ethically difficult situations. Conclusions: Physicians are very aware of ethical complexities in their clinical practice and take their moral responsibilities very seriously. Communicating effectively with patients, families, and other health care team members and advocating for adequate resources, including ethics resources, are important avenues to mitigate ethical conflicts.

BackgroundWorking as an ambulance nurse involves facing ethically problematicsituations with multi-dimensional suffering, requiring the ability to createa trustful relationship. This entails a need to be clinically trained inorder to identify ethical conflicts.AimTo describe ethical conflicts in patient relationships as experienced byambulance nursing students during clinical studies.Research designAn exploratory and interpretative design was used to inductively analysetextual data from examinations in clinical placement courses.ParticipantsThe 69 participants attended a 1-year educational programme for ambulancenurses at a Swedish university.Ethical considerationsThe research was conducted in accordance with the Declaration of Helsinki.Participants gave voluntary informed consent for this study.FindingsThe students encountered ethical conflicts in patient relationships when theyhad inadequate access to the patient’s narrative. Doubts regarding patientautonomy were due to uncertainty regarding the patient’s decision-makingability, which forced students to handle patient autonomy. Conflictingassessments of the patient’s best interest added to the conflicts and alsomeant a disruption in patient focus. The absence of trustful relationshipsreinforced the ethical conflicts, together with an inadequacy in meetingdifferent needs, which limited the possibility of providing proper care.DiscussionContextual circumstances add complexity to ethical conflicts regardingpatient autonomy, dependency and the patient’s best interest. Students feltthey were fluctuating between paternalism and letting the patient choose,and were challenged by considerations regarding the patient’s communicationand decision-making ability, the views of third parties, and the need forprioritisation.ConclusionThe essence of the patient relationship is a struggle to preserve autonomywhile focusing on the patient’s best interest. Hence, there is a need foreducation and training that promotes ethical knowledge and ethicalreflection focusing on the core nursing and caring values of trust andautonomy, particularly in situations that affect the patient’sdecision-making ability.

Purpose– There is reason to believe that an ethically minded approach to hiring and the development of an ethical context should be associated with incremental decreases in employees’ perceptions of ethical conflict. It is also likely that the selection of ethical employees, and the reduced ethical conflict that follows, are positively related to employees’ positive work attitudes. The purpose of this paper is to test these relationships.Design/methodology/approach– Using a self-report questionnaire, information was collected from 187 employees working for a medium-sized financial services organization with offices located primarily in the Midwestern USA.Findings– Results of structural equation modeling indicated that employees’ perceptions of ethics-related selection were negatively related to perceived ethical conflict, and that reduced ethical conflict and enhanced ethics-related selection were associated with an increased positive work attitude, which was comprised of job satisfaction, an intention to stay, and organizational commitment.Research limitations/implications– The results cannot prove causal association between the constructs, and the use of one focal firm limits generalizability.Practical implications– Organizational leaders and HR professionals should develop ethics-based hiring practices to reduce ethical conflict and strengthen a company's ethical context.Originality/value– This investigation is relevant because strong relationships among ethics-related hiring, ethical conflict, and positive work attitudes would suggest that companies must use ethical selection criteria and maintain an ethical culture/climate that meets or exceeds employees’ expectations about ethics. Furthermore, this study adds to the relatively few published works exploring the relationship between ethical conflict and work attitudes.

With the continuous advancement of global medical technology and the increasing demand for humanized medical services, the cultivation of medical students' comprehensive quality has become a core goal of medical education. The purpose of this study is to explore the core role and practical value of medical humanities education in the cultivation of medical students' comprehensive quality, and to provide theoretical support and practical reference for the reform of global medical education. This study adopted a mixed research method combining systematic literature review and cross-sectional survey. First, a comprehensive search was conducted in databases such as PubMed, Web of Science, and CNKI to sort out and analyze domestic and foreign literatures on medical humanities education and medical students' comprehensive quality cultivation in the past 10 years; then, a questionnaire survey was carried out among 500 medical students from 10 medical colleges and universities in different countries to investigate their cognitive level of medical humanities, the current situation of receiving humanities education, and the impact of humanities education on their professional literacy, communication ability and ethical judgment. The results showed that medical humanities education has a significant positive correlation with the improvement of medical students' comprehensive quality, which can effectively enhance their empathy ability, sense of professional responsibility, ethical decision-making ability and doctor-patient communication skills; however, there are problems such as inadequate integration of humanities education into professional training, single teaching mode and uneven teaching quality in medical education in many countries. The conclusion points out that medical humanities education is an indispensable part of medical students' comprehensive quality cultivation, and it is necessary to construct a diversified and integrated medical humanities education system integrating curriculum setting, practical teaching and cultural edification to promote the all-round development of medical students and meet the needs of modern medical practice.