A latent profile analysis of nurses’ moral sensitivity

Abstract

Background:

The three-dimensional model of nurses’ moral sensitivity has typically been studied using a variable-centered rather than a person-centered approach, preventing a more complete understanding of how these forms of moral sensitivity are expressed as a whole. Latent profile analysis is a person-centered approach that classifies individuals from a heterogeneous population into homogeneous subgroups, helping identify how different subpopulations of nurses use distinct combinations of different moral sensitivities to affect their service behaviors.

Objective:

Latent profile analysis was used to identify three distinct profiles of nurses’ moral sensitivity. Associations of the profiles with service behaviors were then examined.

Methods:

Five hundred twenty-five nurses from three tertiary hospitals in China were investigated with Moral Sensitivity Questionnaire and Nurses’ Service Behavior Scale. Latent profile analysis was used to analyze the data.

Ethical considerations:

Approval was obtained from the Ethics committee for biomedical research of Medical College, the Hebei University of Engineering.

Results:

A three-profile moral sensitivity model provided the best fit to the data. The resulting profiles were low moral sensitivity, moderate moral sensitivity, and high moral sensitivity. There were significant differences in service behaviors among different profiles of moral sensitivity.

Conclusion:

The results provide a new and expanded view of nurses’ moral sensitivity, which may be used to monitor nurses’ service behaviors comprehensively and to evaluate nursing ethics management strategies.

Keywords

Latent profile analysis moral sensitivity nurses service behaviors

Introduction

Moral sensitivity, defined as awareness of the ethical issues in clinical settings, is the first of four components involved in making an ethical decision and taking an ethical action.^1
–3 Moral sensitivity enables nurses to recognize the ethical nature of every practice action, and then they will be able to make ethically appropriate decision.⁴ Previous studies of nurses’ moral sensitivity, conducted in China,^5,6 Japan,⁷ Korea,⁸ and Sweden,¹ have frequently employed the Moral Sensitivity Questionnaire (MSQ) developed by Lützén and his cooperators, Dahlqvist, Eriksson, and Norberg,³ who identified three dimensions of moral sensitivity: sense of moral burden, moral strength, and moral responsibility. According to Lützén and colleagues’^1,3 concept of moral sensitivity in healthcare practice, moral burden is brought on by a problem or situation that involves moral values, in which nurses “know” what morally should be done but lack the resources or the authority to act accordingly. When nurses are not able to care in the way they feel meets their patients’ needs, they will feel troubled and have a sense of moral burden; moral strength is expressed by having the courage to act and the ability to provide justification for these actions on behalf of the patient, instead of defending oneself; and moral responsibility indicates primarily a moral obligation to work according to rules and regulations, and it is to “know” what constitutes a moral problem from the perspective of the individual patient. Based on this conceptual framework,³ a great deal of theoretical and empirical work completed over the past few decades has substantially increased our understanding of the conditions and factors influencing nurses’ moral sensitivity.

Scholarly interest in moral sensitivity continues to grow, yet most nursing research has adopted a variable-centered approach which focuses on testing the relationships of each facet of moral sensitivity with other variables.⁹ Although such an approach provides valuable information about the direct and unique association of each facet of moral sensitivity with other variables, it ignores the possibility that (a) distinct combinations of moral sensitivity profiles exist in the population and (b) these moral sensitivity profiles may correspond to differences in other variables. This perspective is consistent with taking a person-centered approach to conceptualizing moral sensitivity, which recognizes that distinct moral sensitivity profiles might exist. Investigation of these profiles through the person-centered approach might reveal unique insights into the effects of moral sensitivity profiles on other variables.

According to Gellatly et al.,¹⁰ latent profile analysis (LPA) provides an innovative approach for answering a variety of substantive research questions that is frequently not possible with more traditional methods, such as analysis of variance (ANOVA), regression, cluster analysis, and factor analysis, and it can assist nurse researchers in understanding multifaceted relationships, intricate patterns, and clusters of symptoms that are needed to help guide interventions.¹¹

Background

A person-centered approach—LPA

LPA is used to construct a typology or clustering based on a set of observed variables; that is, to classify observational units into a set of latent classes.^11,12 In related psychology research, the aim of using the latent categorical approach is to simplify the latent classes by investigating their association with external variables and explore the relationships between those variables and other, auxiliary observed variables.¹³

LPA allows for distinct subpopulations to be identified that differ in the quantity (level) and quality (shape) of the profile indicators.¹⁴ According to Marsh et al.¹⁴ and Wang and Hanges,¹⁵ quantitatively distinct profiles vary in the absolute level of the profile indicators. In the current study, this means that one profile could contain nurses who have high levels of sense of moral burden, moral strength, and moral responsibility, whereas another profile could contain nurses who have low levels of sense of moral burden, moral strength, and moral responsibility.

Gabriel et al.¹⁶ regard LPA as a person-centered approach. LPA allows researchers to understand how variables operate between and within people to shape outcomes. LPA is based on the probability model and allows for identification of distinct subpopulations. Use of a person-centered approach enables identification of how different subpopulations of employees characteristically use distinct combinations of different moral sensitivities to affect their work performance.

Moral sensitivity and service behavior

Nurses experience work stressors including nursing shortages and changes in the nurse–patient relationship. Nurses who have been under great work stress for a long time develop moral blindness toward clinical ethical dilemmas.⁶ This is compounded by the fact that it is challenging to solve an ethical problem if the problem’s existence has not yet been recognized.¹⁷ According to Lützén et al.,³ moral sensitivity is defined as an “attention to the ethical values involved in a conflict-laden situation and a self-awareness of one’s own role and responsibility in a situation.” Development of moral sensitivity creates an attitude and ethical response in nurses and enables the provision of ethical care and service for patients,¹⁸ which leads to ethical decision making that favors patients.¹ In this sense, moral sensitivity is the source of nursing ethics, and it is also the prerequisite for nurses’ service behaviors.

Nurses’ service behavior refers to the caring or helpful behavior of nurses directed toward their patients; it is a kind of patient-oriented ethical behavior.¹⁹ According to previous studies,^20,21 there are two kinds of nursing service behaviors: role-prescribed behaviors and extra-role behaviors. Role-prescribed service behaviors involve the extent to which nurses understand the patients’ needs and desires, and can, therefore, provide help or solutions for patients. Extra-role service behaviors involve the extent to which nurses’ non-compulsory and constructive behaviors may enable serving and helping patients.²² Both role-prescribed behaviors and extra-role behaviors are discretionary in nature and are strongly linked to service orientation that involves satisfying clients with job-related issues.²³ In this sense, they are kind of patient-oriented work performance. Moral sensitivity plays an important role in nurses’ recognition and judgment when nurses are faced with ethical issues in everyday service practice. However, previous research has been limited as it has not examined the relationship between nurses’ moral sensitivity profiles and their service behaviors, including role-prescribed behaviors and extra-role behaviors.

Aims of the study

The aim of this study was to investigate whether different moral sensitivity profiles exist among Chinese nurses. LPA was used to classify nurses who showed similar moral sensitivity patterns into a certain profile. Associations of the profiles with service behaviors (both role-prescribed behaviors and extra-role behaviors) were then examined.

Methods

Ethical considerations

Approval was obtained from the Ethics committee for biomedical research of Medical College, the Hebei University of Engineering. Data privacy and confidentiality were maintained and assured by obtaining subjects’ informed consent to participate in the research before data collection, which ensured by not reporting the participant’s identities, and that we only reported the findings in aggregate, and the raw data were destroyed after the completion of data analysis process. Participants were informed that it was not obligatory to take part in the research (to include the completion of the questionnaire) and that they could cease participation from the study at any time and for any reason without adverse effects on their employment, and that the data would be kept in strictest confidence.

Sample and procedure

This study employed random and convenience sampling. During the period of June–July 2017, survey questionnaires were administered to 600 Chinese nurses from three tertiary hospitals (>500 beds each) in Hebei Province. The third author personally distributed the questionnaires to these nurses. Verbal informed consent was obtained from the participants after the researchers explained the purpose, risks, and benefits of the study. Participation was voluntary and no personally identifiable information was collected. As agreed upon by the nurse managers, all of the questionnaires were completed by the nurses during their work hours. Participants were informed that the aim of the survey was only for academic purposes. The questionnaire asked the nurses to self-report information regarding demographics, their own moral sensitivity, and their service behaviors. Completed questionnaires were returned to letterboxes situated in each unit that had been specifically designed for this purpose. The third author collected the filled-out questionnaires at the end of the study.

Measures

Moral sensitivity

Moral sensitivity was measured using Lützén et al.’s nine-item scale.³ Permission from Lützén et al.,³ the authors of the original scale, was obtained for translating and adapting the MSQ into Chinese. As presented in online Appendix, MSQ assesses three types of moral sensitivity in healthcare practice—sense of moral burden (four items), moral strength (three items), and moral responsibility (two items).³ Respondents rated their agreement with the statements on a 5-point scale (1 = total disagreement, 5 = total agreement); higher scores indicate higher moral sensitivity. A sample item from the sense of moral burden subscale is “My ability to sense the patient’s needs means that I do more than I have the strength for.” A sample item from the moral strength subscale is “I have a very good ability to sense when a patient is not receiving good care.” A sample item from the moral responsibility subscale is “It helps me to know what is good or bad for the patient when I can follow rules and regulations.” Reliability analysis of the data using Cronbach’s alpha indicated adequate reliability (α = 0.798).²⁴

A confirmatory factor analysis (CFA) using maximum likelihood estimation indicated that the three-factor model provided acceptable fit (χ² = 120.129, df = 21; root mean square error of approximation (RMSEA) = 0.095; goodness of fit index (GFI) = 0.951; comparative fit index (CFI) = 0.921) and that each moral sensitivity item loaded significantly on its specified factor.

Service behavior

Nurses’ service behaviors were measured using the eight-item Nurses’ Service Behavior Scale (NSBS) developed by Chen.²⁰ Permission from Chen was obtained for adapting the NSBS. As presented in online Appendix, the NSBS consists of two dimensions: role-prescribed behaviors (five items) and extra-role behaviors (three items). The eight items are rated on a 5-point scale ranging from strongly disagree (1) to strongly agree (5). In the current study, Cronbach’s alphas for role-prescribed behaviors, extra-role behaviors, and overall service behaviors were 0.875, 0.851, and 0.849, respectively. The CFA results showed that the model fit well with χ²/df = 3.99, RMSEA = 0.076, GFI = 0.973, and CFI = 0.980.

Data analysis

LPA^25,26 was used to extract latent profiles of nurses on the basis of their moral sensitivity levels. The LPA was conducted with Mplus 8.2.²⁷ Consistent with Nylund et al.,²⁸ we used the following fit indices to select the optimal number of profiles: the Bayesian information criterion (BIC), the Akaike information criterion (AIC), the Vuong–Lo–Mendell–Rubin likelihood ratio test (VLMR), the Lo–Mendell–Rubin adjusted likelihood ratio test (LMR-A), the bootstrapped likelihood ratio test (BLRT), and the entropy test. Lower BIC and AIC indicate better fit. A significant p value on the VLMR, LMR-A, and BLRT indicates that a solution with k number of profiles is better than the k – 1 solution. Entropy designates the degree of certainty in the classification of participants into profiles, with a value near 1 indicating a high degree of certainty. Values of entropy above 0.80 are considered acceptable.²⁹

Results

Participants

Five hundred twenty-five completed survey forms were returned, corresponding to 87.5% of the total number of nurses. The overall sample was overwhelmingly female (96.2%), young (94.3% under age 40), and had received collegiate education (40.5% had a bachelor’s degree or above) as shown in Table 1.

Table 1.

Demographic characteristics.

Demographics	Classification	Frequency	Percent	Cumulative percent
Gender	Female	505	96.2	96.2
Gender	Male	20	3.8	100.0
Working years as a nurse	≤5	286	54.5	54.5
	6 –10	134	25.5	80.0
	11–15	61	11.6	91.6
	16 –20	17	3.2	94.9
	>20	27	5.1	100.0
Age	≤20	13	2.5	2.5
	21–30	368	70.1	72.6
	31– 40	114	21.7	94.3
	>40	30	5.7	100.0
Education level	Certificate (technical school)	13	2.5	2.5
	Junior college	299	57.0	59.4
	Bachelor’s degree	212	40.4	99.8
	Master’s degree or above	1	0.2	100.0
Professional title	Primary nurse	235	44.8	44.8
	Senior nurse	222	42.3	87.0
	Supervisor nurse	56	10.7	97.7
	Co-chief nurse	12	2.3	100.0
Employment type	Formal	93	17.7	17.7
	Contracted	409	77.9	95.6
	Temporary	23	4.4	100.0
Position	General nurse	493	93.9	93.9
	Deputy head nurse	20	3.8	97.7
	Head nurse	12	2.3	100.0

Formal nurses are regular employees who are paid by the country, whereas contract nurses sign job contracts with the individual hospitals which pay their salaries; temporary staffs are usually the college interns, who get no salaries.

Descriptive statistics

Table 2 shows the descriptive statistics results. Moral sensitivity was positively related with service behaviors, role-prescribed behaviors, and extra-role behaviors (r = 0.492***, 0.417***, and 0.203***, respectively). The three dimensions of moral sensitivity, sense of moral burden, moral strength, and moral responsibility, were positively related with each other.

Table 2.

Descriptive statistics (N = 525).

	M	SD	1	2	3	4	5	6	7	8	9	10	11	12	13
1. Gender	0.038	0.192	1
2. WY	1.791	1.101	−0.080	1
3. Age	2.307	0.614	−0.083	0.840***	1
4. Edu	2.383	0.539	−0.068	0.267***	0.325***	1
5. Pr	1.704	0.748	−0.041	0.671***	0.671***	0.480***	1
6. Emp	1.867	0.451	0.037	−0.652***	−0.651***	−0.245***	−0.558***	1
7. Po	1.084	0.350	−0.19	0.501***	0.475***	0.204***	0.488***	−0.412***	1
8. MS	3.966	0.434	0.138**	0.078	−0.006	−0.02	0.002	0.008	0.051	1
9. SB	4.150	0.502	0.070	0.174***	0.121**	0.016	0.110*	−0.094*	0.043	0.492***	1
10. BU	3.890	0.498	0.124**	0.048	−0.013	−0.042	−0.016	0.030	0.037	0.894***	0.412***	1
11. ST	3.948	0.517	0.136**	0.060	−0.029	−0.042	−0.027	0.003	0.063	0.830**	0.439***	0.581***	1
12. RE	4.145	0.559	0.073	0.105*	0.043	0.063	0.075	−0.029	0.026	0.748***	0.377***	0.535***	0.475***	1
13. RSB	4.357	0.504	0.013	0.198***	0.167***	0.086*	0.174***	−0.153***	0.042	0.452***	0.854***	0.344***	0.396***	0.417***	1
14. ESB	3.800	0.760	0.109*	0.087*	0.029	−0.066	0.002	0.004	0.030	0.367***	0.817***	0.346***	0.336***	0.203***	0.399***

M: mean; SD: standard deviation; WY: working years as a nurse; Edu: education level; Pr: professional title; Emp: employment type; Po: position; MS: moral sensitivity; SB: service behavior; BU: sense of moral burden; ST: moral strength; RE: moral responsibility; RSB: role-prescribed service behavior; ESB: extra-role service behavior.

*p < 0.05, **p < 0.01, ***p < 0.001 (2-tailed).

LPA

An LPA was conducted with Mplus 8.2²⁷ to identify the potential profiles of nurses’ moral sensitivity and their different effects on nurses’ service behaviors. According to the guidelines of Nylund et al.,²⁸ we started to specify two latent profiles, and then increased the number of latent profiles until we realized the optimal number of profiles. The indices for the LPA and profile structure are shown in Table 3. The p-values for LMR and BLRT were not significant for profiles 3, 4, 5, and 6. The entropy test value for a three-profile model was the highest among all of the results, and the values for AIC, BIC, and SSA-BIC (Sample-size adjusted BIC) exhibited the greatest decline from the two-profile model to the three-profile model. Therefore, the three-profile model was considered to be the optimal solution.

Table 3.

Results of latent profile analysis.

Number of profiles	LL	FP	AIC	BIC	SSA-BIC	LMRp value	Entropy
2	–1057.381	10	2134.763	2177.396	2145.654	0.0000	0.799
3	–983.876	14	1995.752	2055.439	2011.000	0.0055	0.887
4	–970.682	18	1977.364	2054.105	1996.969	0.1427	0.770
5	–956.967	22	1957.934	2051.729	1981.896	0.2322	0.781
6	–943.461	26	1938.923	2049.771	1967.241	0.4439	0.809

LL: Log likelihood; FP: Free parameters; AIC: Akaike information criterion; BIC: Bayesian information criterion; SSA-BIC: Sample-size adjusted BIC; LMR: Lo–Mendell–Rubin; BLRT: Bootstrapped likelihood ratio test.

Figure 1 and Table 4 present the latent profile structure of moral sensitivity. Profile 1 was the group with low moral strength (M = 2.698, SD = 0.228), and relatively high sense of moral burden (M = 3.132, SD = 0.123) and moral responsibility (M = 3.145, SD = 0.223). The participants who possessed this profile comprised 3.7% of the sample. All the dimensions are at a lower level. We named this profile “low moral sensitivity.” Profile 2 was the group with high sense of moral burden (M = 4.496, SD = 0.039), moral strength (M = 4.525, SD = 0.053), and moral responsibility (M = 4.669, SD = 0.041). We named this profile “high moral sensitivity,” and it comprised 24.3% of the sample. Profile 3 was the group with a moderate level of sense of moral burden (M = 3.724, SD = 0.022) and moral strength (M = 3.817, SD = 0.020), and a high level of moral responsibility (M = 4.019, SD = 0.029). We named this profile “moderate moral sensitivity.” This group comprised 72.0% of the sample.

Figure 1.

Latent profile analysis result.

Table 4.

Means and standard deviations for the three-profile model (N = 525).

Profile	% of sample	Sense of moral burden		Moral strength		Moral responsibility
Profile	% of sample	M	SD	M	SD	M	SD
1	3.7	3.132	0.123	2.698	0.228	3.145	0.223
2	24.3	4.496	0.039	4.525	0.053	4.669	0.041
3	72.0	3.724	0.022	3.817	0.020	4.019	0.029

M: mean; SD: standard deviation.

Comparing service behaviors of moral sensitivity profiles

To examine the outcomes of the three profiles, we compared the differences between nurses’ service behaviors and the related dimensions of each profile on the NSBS.³⁰ Table 5 presents the comparison of NSBS outcome means among the three profiles. Profile 2 exhibited the highest service behaviors, including role-prescribed behaviors and extra-role behaviors, compared to both Profile 1 and Profile 3, implying that the higher the moral sensitivity, the higher the service behaviors. In addition, Profile 3 showed significantly higher NSBS scores for in-service behaviors and role-prescribed behaviors compared to Profile 1, but these two profiles showed no significant difference in extra-role behaviors. This indicates that classification into Profile 3 is more likely to positively impact nurses’ role-prescribed behaviors rather than extra-role behaviors.

Table 5.

Comparisons of outcomes in each profile.

Variable	Profile 1: low moral sensitivity (a)	Profile 2: high moral sensitivity (b)	Profile 3: moderately moral sensitivity (c)	χ²
Service behaviors	3.808_b,c	4.590_a,c	4.020_a,b	196.755***
Role-prescribed behaviors	3.856_b,c	4.770_a,c	4.238_a,b	222.548***
Extra-role behaviors	3.821_b	4.346_a,c	3.623_b	114.604***

The values for all the variables are means. Analysis samples are 525. Subscript letters represent the mean value of this profile was significantly different from the mean value of the profile labeled by the subscript letter. For example, the value 3.808_b,c under Profile 1 indicates that service behavior in Profile 1 (a) was significantly different from service behavior in Profile 2 (b) and Profile 3 (c).

***p < 0.001.

Discussion

Interpreting the findings

The purpose of this article was to identify latent profiles of nurses’ moral sensitivity and then to examine how these different profiles were associated with nurses’ service behaviors. This approach resulted in division of the data collected from 525 nurses into three distinct profiles. The three-cluster model proved to be the best solution based on the model accuracy indices and with regard to reflections on the findings. The three profiles include a low, moderate, and high moral sensitivity. The number of classifications was similar to results from Mohammadi et al.³¹ and Dalla Nora et al.,³² but differed from previous studies by Huang et al.⁶ and Kulju et al.,³³ in which nurses’ moral sensitivity was only divided into two types (“high” and “low”). With reference to the definition of moral sensitivity,³ this study corroborates the existence of a moderate moral sensitivity level between the low and the high in our population.

Nurses with low moral sensitivity (Profile 1) represented less than 4% of the total sample, and they reflected just above-average scores on all three components, but lower scores than those nurses in other profiles. Gastmans³⁴ characterized nursing as an “ethically laden practice” because of the decisions and choices involved in providing comfort and preserving the human dignity of persons who are in need of professional care and treatment. Therefore, nurses with low moral sensitivity who represented less than 4% of the population were probably not unexpected in nurse profession. In addition, nurses belonging to Profile 1 had low moral strength and a relatively high sense of moral burden and moral responsibility. These findings are not consistent with prior study results indicating that compared to moral responsibility and strength, Chinese nurses’ sensitivity to moral burden was relatively low.⁶ The reasons for this result may be that the samples in the two studies came from different types of healthcare organizations, and the situation has been shown to have potential effects on moral sensitivity.^6,35

Nurses with high moral sensitivity (Profile 2) represented nearly 25% of the total sample. Nurses in this group had high sense of moral burden, moral strength, and moral responsibility, and they exhibited the highest service behaviors, role-prescribed behaviors, and extra-role behaviors compared to both low moral sensitivity and moderately moral sensitivity nurses. Nurses characterized as having high moral sensitivity who acknowledge moral problems from the perspective of the patient have the courage to take actions, and justify their actions on behalf of patients instead of themselves. In their nursing practice, they not only understood the patient’s needs and provided help and solutions for patients, but they also provided nursing care that goes beyond existing role expectations and formal job descriptions. In order for nurses to identify ethical problems and make the best decisions, they must have advanced levels of moral sensitivity.³⁶ Regarding service behaviors, our profile-based findings mirror the results of studies using other approaches (i.e. variable-centered approach, which dominated empirical nursing care research¹³) that have found that nurses with higher levels of moral sensitivity tend to enhance their service behaviors.²¹

The group situated between the low and high moral sensitivity nurses (Profile 3) represented the largest group (72% of the total sample). They demonstrated a moderate level of sense of moral burden and moral strength, and a relatively high level of moral responsibility. Huang et al.⁵ found that more Chinese nurses have become aware of the importance of being morally responsible since adoption of the “High Quality Nursing Care” policy in China. It is evident in our study that nurses’ moral sensitivity played an important role in producing moral behavior. In addition, members of the Profile 3 group indicated that they engaged in more frequent in-service behaviors and role-prescribed behaviors compared to nurses with low moral sensitivity, but these two profiles showed no significant differences with extra-role behaviors. The reasons for this result may be that the nurses in both Profile 2 and Profile 3 had high scores on the component of moral responsibility, which represents a moral obligation to work according to rules and regulations; therefore, these nurses strictly followed the rules and did not provide service behaviors which extended beyond formal role requirements.

Implications for nursing research and practice

In this research, we report on the use of a person-centered approach for the identification of the structure of moral sensitivity profiles in nursing practice. We believe these results offer important contributions beyond the findings of past literature, which has largely approached the study of moral sensitivity using variable-centric paradigms under the separation perspective. Given the complex nature of nursing research, LPA presents an advantage over traditional approaches by allowing a nuanced understanding of variability among individuals beyond patterns of simple high-versus-low behavior.¹¹ In this sense, this article responds to the call for the use of novel methodologies in nursing research to enable translation of research findings into practice.³⁷ In addition, our research answers the call for more studies examining moral sensitivity in more detail,⁶ as we identified that the three factors of nurses’ moral sensitivity (sense of moral burden, moral strength, and moral responsibility) may co-occur, and there are three distinct combinations of moral sensitivity profiles that exist in nurses. The unique classification of moral sensitivity resulting from this method has clear intervention implications for nursing research, for example, to investigate for whom and in what way interventions are beneficial to raise nurses’ moral sensitivity and service behaviors. Especially for the nurses with low moral sensitivity, nursing managers and researches should focus on the factors to increase their moral strength, such as professional and institutional processes that influence the work environment.³⁸ And then, they can raise these nurses’ courage to act and ability to argue in support of those actions.

The results of this study suggest that Chinese nurses represent a heterogeneous population with respect to their moral sensitivity. These results provide a readily available set of concepts that healthcare managers may use to guide efforts to increase the moral sensitivity levels of a specific group of nurses and ultimately, improve their service behaviors. Hospital administrators and nurse managers should specifically help nurses with moderate moral sensitivity to develop the courage to act wisely in response to the conflicting demands in their organization and to assist these nurses in dealing with moral problems in a justifiable manner. By doing so, nurse managers in healthcare workplaces may improve nursing staffs’ moral strength and increase their feeling of a sense of moral burden. In addition, in a study by Palazoğlu and Koç,³⁶ when compared to nurses with high moral sensitivity, nurses with low moral sensitivity exhibited lower levels of burnout. The nursing profession requires attentiveness toward all healthcare needs of patients as well as being sensitive toward these needs. In this context, it would be beneficial to provide clinical nursing supervision which focuses on ethical problems and ethical decision making and which would reduce stress and burnout and result in high-quality nursing service behaviors among nurses.³⁶

Limitations

There were a few limitations in this study that may have affected its outcomes. One potential limitation is that all of the variables were measured via self-report with survey methodology leading to possible response bias from each respondent.³⁹ Second, this research was conducted at three tertiary hospitals in China. Our findings may be generalizable only to this type of hospital setting. Third, respondents from all of the three profiles reported relatively high moral sensitivity, which may indicate a social desirability bias often encountered in ethics research.⁴⁰

Conclusion

The results of this study suggest that there are three profiles of nurses in regard to moral sensitivity: low moral sensitivity, moderate moral sensitivity, and high moral sensitivity. In addition, our study has shown that nurses with low moral sensitivity, moderate moral sensitivity, and high moral sensitivity have significant differences in their service behaviors, including both role-prescribed behaviors and extra-role behaviors. As such, this study provides compelling evidence that focusing on the specific dimensions of moral sensitivity, and the patterns in which they actually occur in organizations, is useful for understanding the different ways in which nurses go the extra mile at work. Therefore, different interventions for different profiles of nurses are beneficial to raise all the nurses’ moral sensitivity and service behaviors. These results provide a new and expanded view of nurses’ moral sensitivity, which can be used to monitor their service behaviors comprehensively and evaluate nursing ethics management strategies.

Supplemental material

Supplemental Material, Appendix_1 - A latent profile analysis of nurses’ moral sensitivity

Supplemental Material, Appendix_1 for A latent profile analysis of nurses’ moral sensitivity by Na Zhang, Jingjing Li, Zhen Xu and Zhenxing Gong in Nursing Ethics

Footnotes

Acknowledgements

We are grateful to the hospitals and their employees who participated in this study. We thank LetPub () for its linguistic assistance during the preparation of this manuscript.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the National Natural Science Foundation of China Project (71901031, 71801120 and 71801017) and the Social Science Program of the Beijing Municipal Education Commission Project (SM201911232006).

ORCID iD

Na Zhang

Supplemental material

Supplemental material for this article is available online.

References

Lützén

Blom

Ewalds-Kvist

, et al. Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nurs Ethics 2010; 17(2): 213–224.

Rest

. Moral development: Advances in theory and research. New York: Praeger, 1986.

Lützén

Dahlqvist

Eriksson

, et al. Developing the concept of moral sensitivity in health care practice. Nurs Ethics 2006; 13(2): 187–196.

Ersoy

Goz

. The ethical sensitivity of nurses in Turkey. Nurs Ethics 2001; 8(4): 299–312.

Huang

Yang

Zhang

, et al. Cross-cultural validation of the Moral Sensitivity Questionnaire–Revised Chinese version. Nurs Ethics 2016; 23(7): 784–793.

Huang

Yang

Zhang

, et al. Chinese nurses’perceived barriers and facilitators of ethical sensitivity. Nurs Ethics 2016; 23(5): 507–522.

Bégat

Ikeda

Amemiya

, et al. Comparative study of perceptions of work environment and moral sensitivity among Japanese and Norwegian nurses. Nurs Health Sci 2004; 6(3): 193–200.

Han

Kim

, et al. Validation of a Korean version of the Moral Sensitivity Questionnaire. Nurs Ethics 2010; 17(1): 99–105.

Milliken

. Refining moral agency: insights from moral psychology and moral philosophy. Nurs Philos 2018; 19(1): e12185.

10.

Gellatly

Cowden

Cummings

. Staff nurse commitment, work relationships, and turnover intentions. Nurs Res 2014; 63(3): 170–181.

11.

Schmiege

Meek

Bryan

, et al. Latent variable mixture modeling: a flexible statistical approach for identifying and classifying heterogeneity. Nurs Res 2012; 61(3): 204–212.

12.

Lin

Liang

, et al. Using a patient-centered approach to identify symptom clusters among adolescents with cancer. Cancer Nurs 2019; 42: 198–207.

13.

Mäkikangas

Kinnunen

. The person-oriented approach to burnout: a systematic review. Burnout Research 2016; 3(1): 11–23.

14.

Marsh

Lüdtke

Trautwein

, et al. Classical latent profile analysis of academic self-concept dimensions: synergy of person- and variable-centered approaches to theoretical models of self-concept. Struct Equ Modeling 2009; 16(2): 191–225.

15.

Wang

Hanges

. Latent class procedures: applications to organizational research. Organ Res Methods 2011; 14(1): 24–31.

16.

Gabriel

Daniels

Diefendorff

, et al. Emotional labor actors: a latent profile analysis of emotional labor strategies. J Appl Psychol 2015; 100(3): 863–879.

17.

Treviño

Brown

. Managing to be ethical: debunking five business ethics myths. Acad Manage Exec 2004; 18(2): 69–81.

18.

Esmaelzadeh

Abbaszadeh

Borhani

, et al. Ethical sensitivity in nursing ethical leadership: a content analysis of Iranian nurses experiences. Open Nurs J 2017; 11: 1–13.

19.

Laine

Davidoff

. Patient-centered medicine: a professional evolution. JAMA 1996; 275(2): 152–156.

20.

Chen

. A study of the relationships between orientation training, service behavior, and job performance of the newly hired nurses in Veteran hospitals. Master’s Dissertation, National Chi Nan University, Puli Township, Taiwan, 2010.

21.

Zhang

Gong

, et al. Effects of ethical leadership on nurses’ service behaviors. Nurs Ethics 2019; 26(6): 1861–1872.

22.

Zhang

Gong

, et al. Ethical climate and service behaviours in nurses: the moderating role of employment type. J Adv Nurs 2019; 75: 1868–1876.

23.

Malhotra

Ackfeldt

. Internal communication and prosocial service behaviors of front-line employees: investigating mediating mechanisms. J Bus Res 2016; 69(10): 4132–4139.

24.

Nunnally

. Psychometric theory. Am Educ Res J 1978; 5(3): 83.

25.

Lazarsfeld

Henry

. Latent structure analysis. Am Sociol Rev 1968; 34(2): 327–359.

26.

Muthén

. How to use a monte carlo study to decide on sample size and determine power. Struct Equ Modeling 2002; 9(4): 599–620.

27.

Muthén

. Mplus user’s guide. 7th ed. Los Angeles, CA: Muthén & Muthén, 1998–2012.

28.

Nylund

Asparouhov

Muthén

. Deciding on the number of classes in latent class analysis and growth mixture modeling: a Monte Carlo simulation study. Struct Equ Modeling 2007; 14(4): 535–569.

29.

Muthén

. Integrating person-centered and variable-centered analyses: growth mixture modeling with latent trajectory classes. Alcohol Clin Exp Res 2010; 24(6): 882–891.

30.

Asparouhov

Muthén

. Auxiliary variables in mixture modeling: three-step approaches using Mplus. Struct Equ Modeling 2014; 21(3): 329–341.

31.

Mohammadi

Borhani

Roshanzadeh

. Moral sensitivity and moral distress in critical care unit nurses. Med Ethics J 2017; 10(38): 19–28.

32.

Dalla Nora

Zoboli

Vieira

. Validation of a Brazilian version of the Moral Sensitivity Questionnaire. Nurs Ethics 2017; 26(3): 823–832.

33.

Kulju

Suhonen

Leino-Kilpi

. Ethical problems and moral sensitivity in physiotherapy. Nurs Ethics 2013; 20(5): 568–577.

34.

Gastmans

. A fundamental ethical approach to nursing: some proposals for ethics education. Nurs Ethics 2002; 9(5): 494–507.

35.

Zhang

. Chinese insurance agents in “bad barrels”: a multilevel analysis of the relationship between ethical leadership, ethical climate and business ethical sensitivity. SpringerPlus 2016; 5(1): 2078.

36.

Palazoğlu

Koç

. Ethical sensitivity, burnout, and job satisfaction in emergency nurses. Nurs Ethics 2017; 26(3): 809–822.

37.

Milliken

. Nurse ethical sensitivity: an integrative review. Nurs Ethics 2018; 25(3): 278–303.

38.

Lindh

Severinsson

Berg

. Nurses’ moral strength: a hermeneutic inquiry in nursing practice. J Adv Nurs 2009; 65(9): 1882–1890.

39.

Polit

Beck

. Nursing research: Principles and methods. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2004.

40.

Randall

Fernandes

. The social desirability response bias in ethics research. J Bus Ethics 1991; 10(11): 805–817.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.01 MB