Iranian Journal of Medical Ethics and History of Medicine

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Although there is no more propensity for measuring patient's satisfaction as an important qualitative scale of health services, the thing which is slightly seems to be forgotten is the attention towards the concept and expansion of theory framework. The purpose of this study is to remark the meaning of satisfaction and to offer a qualitative definition for that. This research is a qualitative study and content analysis. During the study period  fifteen patients who were hospitalized in Semnan hospitals (2009) were selected. The data were gathered by half-structured interview and analyzed. The results of this study shows four two major themes and four subthemes including feeling of satisfaction and the reception of nurses by patients. Accordingly, satisfaction is a calm sense that the patient feels it after the emotional and logical reception of nurses. The feeling will be sensed by intelligent and sometimes emotional feeling of patient towards the nurse in his/her care unit environment. The results of this study indicate the real and basic meaning of patient's satisfaction from nurses' views. This meaning is even beyond the imagination of experts and managers. These results can be put into work for designing suitable tools to measure the scale of patients' satisfaction of nurses based on their real perception.

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Nurses' ability to communicate with patients is essential for the effectiveness of the nursing process. This factor is more significant in the case of adolescent patients. Appropriate communication between adolescent patients and health care staff is crucial, since it contributes to the patients disclosing important personal information, and helps nurses communicate necessary information, viewpoints or skills through health promotion measures. The present study aimed to draw a comparison between nurses’ and hospitalized adolescents’ understanding of the significance of the nurse-patient relationship and the observance thereof. In this cross-sectional study, 175 nurses and 180 hospitalized adolescents (12-18 years of age) were selected through simple random sampling respectively, all of whom met the criteria necessary to enter the study. The data was collected from children’s hospitals affiliated with the Tehran University of Medical Sciences, and the data collection tools were self-report questionnaires. Data analysis was performed using the SPSS statistical software. Findings of this study showed that there was a significant statistical difference between the understanding of nurses and hospitalized adolescents regarding the importance of the nurse-patient relationship (P=0.019) and its observance (P0.001), and the nurses scored a better understanding than adolescent patients in both cases. This paper also investigated the priorities of each group regarding the significance and observance of the nurse-patient relationship. The results showed that nurses viewed explaining the necessary follow-up care after discharge as the most important part, while adolescent patients believed that proper verbal communication and being listened to patiently were of great significance. Both groups seemed to observe proper verbal and non-verbal communication according to the results of this paper. The findings of this research proved that nurses can be directed to achieve the less observed objectives that are viewed by adolescent patients as significant in order to eliminate the obstacles in proper nurse-patient relationship.

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Nurses have to cope with various forms of tension in the workplace on a daily basis. One of the factors affecting the moral distress experienced by nurses is the ethical climate prevalent in clinical environments. The present study aimed to establish the relationship between moral distress and nurses’ ethical work environment. This was a cross-sectional, correlational study on 210 nurses in select departments of medical/educational centers of the Tehran University of Medical Sciences in 2009. Data collection tools included a demographic questionnaire, Corley’s Moral Distress Scale, and Olson's Ethical Climate Questionnaire. Data analysis was performed using SPSS version 14. Findings confirmed that the nurses under study were tolerating an average amount of moral distress, although they did not perceive the frequency of morally stressful situations to be particularly high. There was no significant relationship between the moral distress of the nurses under study and their evaluation of the ethical climate of their workplace. Of the five factors affecting the ethical climate, there was a meaningful indirect relationship between managers and frequency of moral distress (P ≤ 0.04), and patients and frequency and intensity of moral distress (P = 0.001). The results obtained through this research indicated a need for authorities to pay more attention to medical/educational centers and devise various strategies in order to make work environments more ethical, so that nurses can continue to offer health care services in more relaxed environments and with less stress.

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With the development of professionalism in modern-day nursing, concepts such as accountability and civil responsibility have found a special place in nursing, since responsibility is an intrinsic part of this profession. Accountability typically brings civil responsibility, which means an individual can be held legally responsible for injury they have caused to another person. Due to the autonomy that nurses enjoy in their practice, they have legal responsibilities, which in turn expose them to complaints and lawsuits on grounds of negligence more often than in the past. The objective of this paper was to familiarize nurses with the concept of civil responsibility, and to help them prevent the damages arising from it, as well as to ensure patients’ safety and rights. This was an analytical study that examined the concept of nurses’ civil responsibility based on books and articles on the subject. The study will first explicate the general definition of civil responsibility, and then proceed to explain its application to the nursing profession, and the more common stages of litigation, prosecution and defense. The nursing profession today can benefit from a modern outlook on civil responsibility and nursing errors in order to improve teaching methods in providing better patient care and reduce errors. This can eventually enhance the quality of care, and lead to a decrease in nurses’ civil responsibilities and prevention of a waste of public resources.

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Quality of nursing care services directly influences individuals' health status. Compiling codes of ethics according to the religion and culture of each population could be an appropriate approach in improving quality of health care services especially nursing care. Hence, the most important priority in our national health system is developing ethical guidelines.
For this purpose a task force has been established in collaboration with nurses, physicians, lawyers and clergymen who were expert in the field of medical ethics. The code of ethics for Iranian nurses was drafted in 2010. The draft that included 12 values and 71 regulations of professional ethics were finally approved in the second session of the Ethics Supreme Council of the Ministry of Health and Medical Education on 6 March, 2010.
The values consist of concepts such as maintaining human dignity, adherence to professional obligations, accountability and responsibility, patient privacy, promotion of scientific and practical competence and respect to individual's autonomy.
Also, 71 regulations of professional ethics divided to five sections including "Nurse and Community" consisting of 9 items, "Nurse and Professional Commitments" with 14 items, "Nurse and Clinical Services" with 23 items, "The Nurse and Other Healthcare Providers in Medical Team" with 15 items, and also "Nurse, Education and Research" including 10 items.

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In spite of increasing advances in technology, medical equipments, costs, geriatric population, consideration to ethical and legal issues has increased in nursing profession. This study aimed to explore ethical codes and consideration of ethical issues and severity of ethical distress experienced by nurses at intensive care units. A cross-sectional survey using questionnaire was conducted by a census of nurses in intensive care units in educational and treatment centers of Hamadan. Nurses value most the ethical codes related to responsibility (95.1%), accountability (95.1%), patient support (77.3%), secret keeping (83.4%), and honesty (78.5%). They studied patient rights statement 2.47 times with standard deviation of 2.86. Only 50.3 percent of nurses had education about professional ethics. Nurses had mean of mark in severity of ethical distress 99.34 ±46.61. Severity of ethical distress was moderate in nurses. There was not significant relationship between demographic data and severity of ethical distress. There are more needs to assess for effects and effective factors on ethical distress in intensive care units nurses.

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Nurses play an important role in end-of-life care for dying patients. Based on the essence of the work environment, nurses are confronted with dying patients and their requests for euthanasia more than other care givers. However, little is known about their attitudes towards euthanasia. Hence, aim of present study was to determine nurses' attitudes toward euthanasia. In this descriptive-analytical study, 91 nurses who employed in intensive care units situated in educational and medical hospitals affiliated to Guilan University of Medical Sciences participated. Nurses attitudes evaluated by using Euthanasia Attitude Scale. Data analyzed by descriptive and inferential statistics (T-test, ANOVA and generalized linear models) by SPSS software version 16. Majority of nurses (83.5%) had negative attitude toward euthanasia. Univariate analysis showed no significant statistical relationship between demographic factors and nurses' attitude toward euthanasia, whilst age (P < 0.029) and employment status (P < 0.004) were related to nurses' attitude toward euthanasia in regression analysis.     
Findings of the present study showed that majority of nurse's believe in care of dying patients for health maintenance and life continuance even in the end stage of life. They don't accept euthanasia at any condition. Perhaps, more accurate studies need to assess other confounding factors such as nurses' knowledge, practice and role.

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Errors occur commonly in hospitals and nurses are potential observers of these misconducts and they can prevent them by reporting. This research studies the types of errors, misconducts, and inappropriate situations in the nursing field, compares these errors in private and public hospitals and finally studies individuals' reactions to these errors (whistle-blowing and not whistle-blowing). Two hundred and forty five subjects were chosen out of 2260 nurses in Isfahan hospitals. In this study, a list of errors, misconducts and whistle-blowing criteria by McDonald instrument was used. Results showed that there is significant difference between error models in private and public hospitals, also between strategies used by whistle-blowers and non whistle-blowers when they observed errors, misconduct and inappropriate situations.  Sixty-two percent of nurses revealed errors after observing them. Identifying the types of errors can help health decision makers to decrease them and will raise awareness of this issue. In addition, by decreasing the impediments of whistle-blowing, errors and organizational misconducts will be decreased.

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Moral distress is one of ICU nurses' major problems that can happen due to various reasons and may have several consequences. Considering that certain variables can be related to moral distress and turnover intention in nurses, this study was done to determine the correlation between ICU nurses' demographic characteristics and their moral distress and turnover. In this correlational study, 159 ICU nurses were selected from medical universities of Iran. Data collection instruments included a demographic questionnaire, ICU nurses' moral distress scale, and Hinshaw and Atwood's turnover scale. Data analysis was done by using SPSS 17_. The findings showed high level of moral distress and turnover in ICU nurses. The results revealed a positive statistical correlation among ICU nurses' age, their work experience, the ratio of nurses to ICU beds and their moral distress. However, there was no correlation among sex, marital status, educational degree, work shift and moral distress. Similarly, moral distress and intent to turnover did not have a statistical correlation.The results showed that increasing recruitment of young nurses and nursing staff, and diminishing ICU nurses' moral distress and turnover intention are essential.

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Moral distress is considered as an important issue in nursing. Nurses participation in ethical decision making and taking deliberate action are facing them with many ethical challenges in their work environment. Confronting those challenges can lead to moral distress. This descriptive study was conducted to determine moral distress and its contributing factors from the perspective of oncology nurses in Tehran teaching hospitals in 2011. Data collection was done through a demographic questionnaire, the Moral Distress Scale – revised (MDS-R) and a questionnaire on moral distress related factors administered to all oncology nurses with inclusion criteria. Findings showed that nurses reported a high level of moral distress overall. The highest level of moral distress was associated with giving inadequate information to patients about informed consent and carrying out a physicians’ order for unnecessary tests and treatments. A significant correlation was found between oncology nurses’ age, their work experience and employment status with moral distress. Institutional factors such as managers’ support, nurses’ autonomy and having determined duties had the greatest effect on moral distress from oncology nurses’ view. Oncology nurses commonly encounter situations that are associated with high levels of moral distress, and therefore strategies need to be developed in order to mitigate moral distress.

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Moral distress is one of the common issues in nursing that has been receiving a lot of attention in research related to this profession. Moral distress is a phenomenon that can impact nurses, patients and health systems greatly. One significant impact of moral distress on nurses is its role on their desire to continue to work in their profession, and the present cross-sectional, descriptive and analytical study was conducted in order to determine this impact. Study samples were nurses in Birjand teaching hospitals who were selected through polls and according to entrance criteria. A 22-item questionnaire was developed by combining demographic information, Corley’s moral distress scale and the nurses’ desire to stay in the profession. The questionnaire was translated from English by the researcher and its validity and reliability were assessed. The results indicated that there is no significant relationship between moral distress and the desire to stay in the nursing profession (P>0/05). Moreover, levels of moral distress in the nurses in this study were moderate 2.25±0.6 (mean±SD) Given the level of moral distress in nurses and its possible consequences, strategies and solutions should be devised to familiarize nurses with moral distress and its underlying factors in order to reduce the undesirable outcomes of this phenomenon more effectively.

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Nurses and administrators can identify and implement mechanisms to manage, change, and improve the ethical climate in their workplace through an understanding and awareness of this concept as well as how it is perceived by everyone involved.This study aimed to compare the nurses’ perception of the actual and ideal organizational ethical climate in hospitals of Ahwaz Juondishapour University of Medical Sciences. This was a cross-sectional descriptive study conducted on 558 nurses working at 9 medical centers of Ahwaz Jondishapour University of Medical Sciences selected by systematic sampling. Data instrument consisted of 2 parts: 1) demographic characteristics, and 2) actual & ideal climate questionnaire based on the Farsi version of Olson’s ethical climate questionnaire, used to assess nurses’ perception of the hospital ethical climate in 5 categories (managers, colleagues, physicians, patients, and hospitals). Descriptive and inferential statistical tests, independent T-test and One-Way ANOVA were used to analyze the data.Results demonstrated a positive hospital ethical climate (mean = 3.66), while the nurses’ perception of the ideal ethical climate was positive as well. A significant difference was found between the mean scores of the nurses’ perceptions of actual & ideal ethical climates (P<0.05). Results demonstrated a significant relationship between nurses’ work experience & organizational level, and their perceptions of the hospital ethical climate.A positive ethical climate exists in hospitals, although it is far from the ideal ethical climate, and therefore managers must maintain the actual ethical climate and at the same time implement strategies to improve their hospitals’ ethical climate.

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One of the most important issues in nursing ethics is moral distress, which is a severe psychological problem among nurses. The purpose of this study was to determine the nurses’ moral distress in the hospitals of the northwest of Iran.This was a cross-sectional study in which 418 nurses were selected by randomized multistep sampling method in the northwest of Iran in 2012. Data collection was done using the moral distress standard scale with high reliability and validity. In order to analyze data, descriptive (mean, standard deviation, frequency and percent) and inferential statistics (independent t-test and one way ANOVA) were used.The mean score of nurses’ moral distress was 148.49 ± 32.93, and 222 nurses (53%) suffered from severe moral distress. Of the three provinces under study, Zanjan (152.46 ± 35.88) and intensive care units (152.72 ± 33.36) had the highest moral distress scores. Among the respondents’ demographic characteristics, province (P < 0.01), education (P < 0.05), type of shift (P < 0.05) and job status (P < 0.05) were significantly related to the level of moral distress experienced by the nurses.Due to the high level of moral distress in the nursing profession, dealing with it requires a lot of attention. Studies on casual and predictive factors in different wards and teaching coping strategies to nurses appear to be necessary in order to address this issue.

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Moral distress is an important issue in the field of medical ethics that can have serious effects on nurses, patients and health organizations. One of the most common effects of this phenomenon is professional stress in nurses. Stressful situations in nurses’ job environment lead to burnout and dissatisfaction, and adversely affect the quality of care.This was a cross-sectional study aimed to determine the relationship between moral distress and professional stress in 220 nurses of educational hospitals in the city of Birjand. Data were collected using a 51-item questionnaire based on Corley’s Moral Distress Scale and Wolfgang’s Health Professions Stress Inventory. Reliability and validity of the questionnaire were assessed by the researchers, and its reliability was calculated using Cronbach’s alpha (93%).The results indicated a positive relationship between moral distress and professional stress (P<0/05, r = 0/8). Intensity and frequency of moral distress and professional stress were reported average.Moral distress and professional stress were reported at a frequency and severity of moderate size. Findings of this study can provide guidelines for educating nurses on this phenomenon and the conditions leading to it. They may also be used to develop management strategies and establish organizations to prevent and minimize the consequences of these phenomena in nurses.

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Considering and preserving patients’ human dignity is one of the most essential moral obligations in the medical and nursing professions. Indeed, respecting patients’ human dignity is the essence of nursing care which is frequently emphasized by national and international nursing standards.This study was conducted based on the qualitative approach, using an interpretive phenomenological method, which aimed to explore the meaning of patients’ dignity preservation based on nurses’ lived experiences. Using purposeful sampling method, a sample of 12 participants was chosen and the data were collected through 16 individual, in-depth and semi-structured interviews. The transcribed interviews were analyzed based on the hermeneutic approach using the analysis method proposed by Diekelmann, Allen and Tanner (1989). The mentioned interviews continued until no new meanings emerged and until the researchers were satisfied with the depth of their understanding. Through fusion of the horizons of the participants’ lived experiences and the researchers’ pre-understandings, the extracted meanings of patients’ dignity preservation emerged as: “respecting the equal human essence”, “providing professional patient-centered care” and “respecting the rights of patients’ companions”.The findings revealed that it is essential to respect the patients’ and also their companions’ rights and recognize the humanness and individuality of each patient for preserving and promoting patients’ dignity and providing more dignified care at the bedside.

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Despite the efforts of health care practitioners, medical errors are inevitable. Disclosure of errors is patients’ demand and right. The aim of this study was to determine the nursing staff’s attitudes about disclosure of medical errors to patients and its relationship with disclosure of actual and hypothetical errors. In this descriptive cross-sectional study, 180 of the nursing staff employed in the educational hospitals of the city of Khorramabad were selected by non-probability quota and available sampling. Data collection tools were a valid and reliable questionnaire including some questions about the nursing staff’s attitude toward disclosing medical errors to patients, recording and reporting actual errors, and scenarios to investigate the tendency of nurses for reporting hypothetical errors. The data was analyzed SPSS software. The findings indicate that the mean score of the nursing staff’s attitude about disclosing medical errors to patients was 80.50 14.4. The mean score of the nursing staff’s attitudes toward recording minor actual errors (P < 0.02) and their tendency to disclose hypothetical errors causing minor injuries (P < 0.001), moderate injuries (P < 0.001) and major injuries (P < 0.003) were meaningfully more than those who did not tend to disclose errors. There was no significant difference between attitudes of nurses with a history of disclosing actual errors that lead to major harms to patients (P = 0.64) and those who did not report such medical errors to patients. Attitude of the nursing staff toward disclosing medical errors to patients was at a moderate level, which practically increases the probability of concealing errors.

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Due to the development of societies and nursing sciences, complexity of the ethical situations that nurses encounter is increasing. Moral sensitivity is the first component of ethical behavior, but most of the nurses encounter many barriers in acquiring it. This study was an attempt to determine barriers to ethical sensitivity in nurses’ viewpoints in educational hospitals of Sabzevar in 2012.This descriptive cross-sectional study was conducted on a random sample of nurses working in hospitals affiliated to Sabzevar University of Medical Sciences, Iran (n = 125). Data were gathered through a questionnaire developed by the researchers containing 30 items in four categories of ethical sensitivity barriers including “managerial”, “environmental”, ”patient related” and “nurse related”. Validity and reliability of the questionnaire were assessed = α) 0.85), and data were analyzed by SPSS version 16.The most important barriers were “insufficient number of staff” (83.2%) in the management area, “inappropriate and intensive working shifts” (78.4%) in the nurse related category, “lack of awareness of nurses’ duties among patients” (84.8%), in the patient related category and “overcrowded wards” (76.8%) in the environmental area. The results of this study emphasize the importance of moral sensitivity barriers in all four areas of management barriers, environmental barriers, and barriers to nurses and patients, and could be of special interest to managers and health planners.

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Moral distress is one of the ethical challenges that nurses face due to the nature of their career. Nurses' frequent confrontation with this phenomenon can have different outcomes such as frustration and boredom in providing patient care. This will lead directly to a decline in care quality and can hamper the accomplishment of health goals. Therefore, the present study examined the relationship between moral distress and compassion fatigue in nurses.This cross-sectional study was conducted on 260 nurses of intensive care units in Kerman who were selected through convenience sampling method. In this study, Corley’s moral distress scale and Figley’s Compassion Fatigue Scale were used for data collection. The collected data were analyzed using the SPSS software and descriptive and analytical statistics.The results of this study indicate that there is a significantly positive relationship between moral distress and compassion fatigue (P<0.05). From a total range of 0 to 5, the average score of moral distress was 3.5±0.8 in terms of intensity, and 3.9±0.55 in terms of frequency. The mean of compassion fatigue score was 3.5±0.68 from a range of 0 to 5.Moral distress and its association with compassion fatigue suggest that conditions contributing to moral distress can have an important role in the quality of care. It is clear that strategies should be adopted to prevent the occurrence of these conditions. Informing nurses about moral distress and its consequences as well as periodic consultations will play an important part in the identification and management of moral distress and its consequences.

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Considering the advances in today's world, the increased complexity of diseases and longer life expectancy, nurses experience a great deal of moral distress. One factor that is likely to contribute to the development of moral distress is the ethical climate prevailing in hospitals. This study aimed to assess the relationship between nurses' perceptions of moral distress and the ethical climate in Shahid Sadoughi University of Medical Sciences in Yazd. This correlational descriptive study used the Moral Distress Scale (MDS) and Hospital Ethical Climate Survey (HECS) to examine 370 nurses working in a number of hospitals including Shahid Sadooghi, Shahid Rahnemun, Shahid Afshar and Savaneh Sukhteghi. Data analysis was performed using SPSS18 and descriptive and analytical statistics. Findings showed that the intensity of perceived moral distress among nurses was 3.41±1.28, and their perceptions of the ethical climate were 3.22±0.78. There was a significant negative relationship between nurses’ perception of moral distress and the ethical climate (P=0.00). The findings of this study suggest that development of plans to improve the ethical climate prevailing in hospitals might decreases nurses’ perceived moral distress.

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In the nursing profession, moral distress is a challenge thatc an have different consequences. The nurses’ moral courage to make the right decision can play an important role in the prevention of moral distress, and thus promote moral comfort. The present study examined the relationship between moral distress and moral courage in nurses. In this study, 313 nurses from hospitals in southern Khorasan Province were selected through quota sampling, and Corley’s Moral Distress Scale and the Professional Moral Courage Scale by Sekerka, et al. were used for data collection. The collected data were analyzed by descriptive and analytical statistics. The findings showed a significant relationship between the intensity of moral distress and moral courage (P = 0.03, r = - 0.44). From a range of 0 - 5, the mean of moral distress was 3.7 ± 0.5 in terms of intensity, and 3.55 ± 0.86 in terms of frequency. The mean score of moral courage was calculated at 3.33 ± 0.46 from a range of 1 - 5.The significant correlation between moral distress and moral courage strongly suggests that high levels of moral courage in nurses can play an important role in controlling moral distress. Determining the factors that create moral courage and developing strategies and circumstances such as promoting an appropriate moral climate could play a major role in encouraging moral behavior and controlling moral distress.