The association between conscience understanding and clinical performance among nurses working at education hospital of Arak

Background: Patient care with strict professional and ethical standards is an important element in maintaining health-care standards. In this regard, moral behavior of nurses toward patients has an important role in the recovery and return of their health. Conscience acting is suggested to have a positive impact on patients and their relatives. Acting in accordance with the guidance of good values is an incentive to provide good quality care and restricts low-quality performance. In this study, the aim is to determine the clinical relevance between conscience understanding of nurses and their clinical performance. Materials and Methods: In this cross, 194 nurses working in hospitals of Arak Medical Sciences University in 1395 were recruited by random sampling. Demographic and clinical data were collected through questionnaires and were analyzed in terms of descriptive statistics using SPSS 16 software (Chi-square test). Results: The results showed that the perceptions, conscience, and clinical performance based on Chi-square test is not statistically relevant (P ≥ 0.05). However, there was a significant correlation between the areas of health-care interventions and understanding of conscience (P = 0.02) so that 83% (6/50) of the nurses whose caring interventions were at best were also having a higher score on moral conscience. Among the different dimensions of conscience understand, only the moral (ethical) conscience showed a significant relationship with nursing care interventions is (P = 0.03), so that 75 (9.46%) of nurses who scored good in terms of moral (ethical) conscience, also showed a desirable health-care interventions. Conclusion: Nurses, have the main role in improving the quality of health-care services. According to our results, moral conscience considerations have a positive impact on nurses’ approach toward patients in terms of health-care interventions. Hence, the moral approach of nurses toward patients and health-care issues can be very fruitful in fulfillment of health-care organization’s mission to provide a healthy society. Based on these results, more intention is recommended regarding the nursery education and training in terms of moral and ethical practice.

Keywords: Aspects of clinical practice, clinical practice, conscience, sense of conscience

Conscience commonly defined as “the sense or consciousness of the moral goodness or blameworthiness of one’s own conduct, intentions, or character together with the obligation to do right or be good” (Merriam-Webster 2008). A common metaphor for conscience is “the voice of within.” One that heats up when moral conflict arises in which one must decide between good and bad; right and wrong. The voice is somehow assumed not easily fallible and when one has acted contrary to it the person may feel guilty.^[1] The moral act has been regarded as an important factor, especially for physicians, nurses, and health-care professional for the fulfillment of their duties.^[2] Listening to the voice of conscience is considered to invoke the feeling of commitment and making an ethical decision while being more dedicated to the well-being of patients.^[3] It may also increase the self-esteem and self-satisfaction among nurses and health-care professionals.^[4] Conscience behavior cause the nurses to act in agreement with health-care ideals and hardly ignore a convenient service to the patient due to the limitations associated with the work environment and lacking and updated knowledge of the situation. Hence, not only can it prevent the irresponsible behavior toward the patient but may also motivate the nurses to keep themselves professionally and scientifically updated.^[3],[4] Conscience understanding covers five aspects: ethical aspect, caring aspect, management aspect, protective aspect, and retrospective aspect. The ethical aspect reflects the idea which supports the ethics as the base of conscience behavior.^[1] The protective aspect includes the concepts such as protecting oneself or others and also their values without hearting others.^[5] The management conscience includes the concepts such as judgment, supervision, and leadership. This is the aspect that monitors ones behavior. The caring aspect of conscience covers the topics such as commitment to caring and being sensitive to (patient’s) needs and having a sincere behavior toward her/him. In this regard, the health-care professionals would feel the necessity of continuous self-evaluation, continuous learning and establishing a suitable behavior toward the patient and peers based on commitment and responsibility.^[4],[6] The retrospective aspect of conscience includes the concepts such as feeling self-esteemed and self-satisfied or feeling guilty and useless.^[7] However, there are various understanding about these feelings among the nurses and their conscience understanding is highly dependent on ones perception of these aspects.^[4] Having access to a suitable and efficient health cares is the most fundamental need of patients while nurses are the most important clinical crew members which provide service in this regard. To achieve this aim, they need to care about all patients both professionally and sincerely without any unjustified discrimination.^[8] At the first glance, fulfillment of this duty may look independent of moral and conscience considerations. However, medical intervention and ethical issues are entangled in such a way that any health-care decision may not be properly made without considering both topic concurrently.^[9] This approach has also been associated with more efficient use of resources while saving more money and time.^[10] In spite of the undeniable role of ethics in nursing and health-care interventions few studies conducted on this issue in Iran. Hence, we designed the current study to analyze the association between conscience understanding and the medical functioning of nurses.

This study was conducted through a 6-month period from March to August 2015. Six hundred nurses from five major teaching hospitals of Arak, Iran, were selected randomly and enrolled into the study. The inclusion criteria included having the official and academic nursery approvals, and the exclusion criteria was considered as unwillingness to fill out the questionnaires or filling them inappropriately, and uncompleted to gather data. We used three demographic questionnaires and a modified version of conscience understanding designed by Jalali et al.^[11] The original version of this questionnaire is designed in five sections: ethical conscience (7 questions), protective conscience (5 questions), manager conscience (4 questions), caring conscience (3 questions), and retrospective conscience (5 questions). We also added two sections of Meretoja questionnaire on clinical proficiency to the Jalali questionnaire so to prepare the final version of our questionnaire.^[12] These two sections included questions on interventional caring skills (10 questions) and profession issues (19 questions). The reliability of Jalali and Mertojarito questionnaires were confirmed with Cronbach’s alpha and Guttman split-half tests. This study was conducted under the terms of Arak Medical University ethical committee with all the enrolled population and other engaged peoples were fully informed of these terms. Data were analyzed using the statistical software software SPSS of 20 version (IBM SPSS software predictive analytics, united states industry, US) (arithmetical mean, standard deviation), using Chi-square test. The significant level was set at P < 0.05.

Our results showed that out of 193 participants most of them were women (153) with BSc education and <7 years of working skills [Table 1], [Table 2] and [Table 3]. Based on our results, there was no significant association between the conscience understanding and clinical functioning of nurses [Table 4], (P ≥ 0.005). However, we found a significant association between conscience understanding and caring interventions of nurses (P = 0.02). Eighty-three of the nurses (50.6%) who had the highest caring scores were also doing best on conscience understanding [Table 5]. Among the different aspects of conscience understanding, only the ethical conscience was significantly associated with caring interventions (P = 0.03). This result is based on the fact that 75 nurses (46.9%) who had highest scores on ethical conscience also had the highest scores on caring interventions [Table 6].

Consideration of conscience in the fulfillment of nursing duties has been suggested to increase the caregiving standards and guarantee the safety and good quality of patients’ life. In this regard, the nurse is expected to act sincerely and fairly toward the patient, regarding the available resources.^[7],[13] In this study, we tried to uncover the plausible association between conscience understanding and the medical functioning of nurses working at Arak teaching hospitals, Iran. Our data showed that only the ethical aspect of conscience understanding is significantly associated with clinical intervention and improved the caring intervention of nurses. Although clinical interventions may look a professional behavior and independent of moral and conscience considerations but looking more closely shows that these issues are highly intertwined and have undeniable mutual effects toward each other.^[10],[14] Some researchers like Marriner have even claimed that in clinical nursing, the clinical intervention is composed of three main behaviors; ethical behavior, clinical judgment, and caring interventions.^[15] Dahlqvist et al. have also suggested that ethical commitment is an indispensable part of nursery cares and even has a higher priority than caring intervention. Deey proposed that such approach decrease the low quality of nursery services and motivate the nurses in doing their best toward patients and their companions.^[12] The study of Jensen and colleagues also showed that the conscience considerations can highly affect the nurses in fulfillment of their duties and has a undeniable role in their professional functioning.^[16],[17] In spite of all these notions, nurses sometimes fail to act on these moral considerations. The condition and cultural attitudes of working atmosphere is believed to highly affect the nurses’ behavior. If the majority of healthcare staff are ignorant of acting based on conscience understanding, this can force the newbies to neglect ethical considerations that has been taught during the nursery school.^[5] In a study conducted by Jalali et al., it was shown that institutional and environmental conditions can highly affect the nurses in terms of moral acting and conscience-based behaviors.^[11] On the other hand, they also showed that the amount of stress that a nurse undergoes as the result of human resources shortage, mismanagements, and lack of proper facilities is highly associated with nurses’ misbehavior regarding the moral and ethical considerations.^[11] The very high load of duties and long working hours have also been determined as the key factors which affect nurses attitude toward conscience behavior by Dehghani et al.^[9] In this study, we showed that the ethical aspect of conscience is associated with better caring intervention of nurses. However, these results need further confirmation by studies which include larger populations and various cultural background. It is also suggested that the working conditions be considered in interpretation of results in such studies.

The well-trained human resources are the basic prerequisite for any society to succeed and prosper. Nurses with a high ethical conscience can have many benefits in the workplace. For example Given the fact that humans have an internal moral capacity, nurses, by combining their profession and ethics, see their profession as a mission and mission. In this study, we tried to uncover the plausible association between conscience understanding and the medical functioning of nurses working at Arak teaching hospitals, Iran. Our data showed that only the ethical aspect of conscience understanding is significantly associated with clinical intervention and improved the caring intervention of nurses. In this regard, the conscience attitude of nurses may improve the efficacy of health-care sector both in terms of patient care and management of resources. Regarding the fact that Iranian cultural background is very incentive on acting based on moral and ethical considerations, we hope that our results can further promote these considerations in professional nursery behaviors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_533_17

[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]