Values and self-perception of behaviour among critical care nurses

Abstract

Background:

Moral distress has various adverse effects on nurses working in critical care. Differences in personal values, and between values and self-perception of behaviour are factors that may cause moral distress.

Research aims:

The aims of this study were (1) to identify ethical values and self-perception of behaviour of critical care nurses in Japan and (2) to determine the items with a large difference between value and behaviour and the items with a large difference in value from others.

Research design:

A nationwide, cross-sectional study was conducted.

Participants and research context:

We developed a self-administered questionnaire with 28 items, which was completed by 1014 critical care nurses in Japan. The difference between value and self-perception of behaviour was calculated from the score of each value item minus the score of each self-perception of behaviour item. The size of the difference in value from the others was judged by the standard deviation of each item.

Ethical considerations:

The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214, M2019-045).

Results:

The items with a large difference between value and behaviour sources were related to the working environment and decision-making support. The items with a large difference in value from others were related to hospital management and disclosure of information to patients.

Discussion:

Improving the working environment for nurses is important for reducing moral distress. Nurses are faced with a variety of choices, including advocating for patients and protecting the fair distribution of medical resources, and each nurse’s priorities might diverge from those of other team members, which can lead to conflict within the team.

Conclusion:

This study revealed items with particularly high risks of moral distress for nurses. The results provide foundational information that can guide the development of strategies to mitigate moral distress.

Keywords

Clinical ethics clinical practice cross-sectional survey intensive care moral distress nursing ethics

Introduction

Moral distress can be defined as ‘knowing the right thing to do but being in a situation in which it is nearly impossible to do it’.^1,2 The effects of moral distress on the medical community have been extensively studied. Moral distress can lead to burnout and high turnover among nurses,³ which can result in higher healthcare costs, lower productivity, lower staff morale and lower quality of care.^4–6 Nurses’ moral distress may also lead to patients’ increased pain, longer hospital stays and inappropriate care.⁷ Therefore, reducing nurses’ moral distress is an urgent global issue. Previous studies on moral distress have focused on critical reflection, reframing and educational interventions.^8–10 However, their findings are not uniform, as the relief of moral distress following intervention varies. Additional studies are needed, and further interventions in moral distress that encompass multiple perspectives (shared decision making, collaboration, nurse–doctor relationships, decision making and the ethical climate of the organisation) should be developed and evaluated.^11,12

Research has shown that conflicts with others, dilemmas, and differences between value and self-perception of behaviour are factors that may cause moral distress.^13–15 Some of the conflicts faced by healthcare professionals working in stressful environments include the use of potentially inappropriate treatments due to uncertainty about the prognosis.^3,16 In addition, there are ethical issues such as differences in opinion on information provision resulting from differences in perception.¹⁷ Recognition of one’s values and how they differ from others’ helps reduce moral distress and ineffective communication, promote understanding,¹⁸ and coordinate responses regarding conflicts and distress.¹⁹ Accordingly, it is necessary to clarify the content of specific nurses’ ethical values that are likely to make a difference depending on the situation and what causes the disagreement between value and self-perception of behaviour.

Healthcare providers, including nurses, working in critical care have more stress because they encounter ethical problems more often than in any other department.²⁰ Nurses are more susceptible to moral distress than physicians,^4,21 and 80% of nurses report moral distress.²² Furthermore, more than 70% of physicians and nurses working in the intensive care unit (ICU) experience conflicts with others, such as colleagues, patients and patients’ families.²³ Previous studies have shown that the moral distress of nurses in critical care is serious.^4,20,21 Although the ethical climate in which clinical nurses work and the values of nurses have been qualitatively clarified, the specific values of each nurse have not been examined.²⁴ In addition, the self-perception of critical care nurses’ behaviour in a unique environment has not been clarified. Clarifying nurses’ values and self-perceptions of their behaviour can lead to a reduction in moral distress. This study focuses on nurses’ professional values and self-perception of behaviour, that is, the degree to which nurses feel that they act in line with their own values.

Research aims

The aims of this study were to determine (1) items with a large difference between value and behaviour and (2) items with a large difference in value from others, to reduce moral distress among critical care nurses in Japan. We believe that finding these can not only increase our understanding of moral integrity – which is one of the important factors related to moral distress⁹ – but also lead to suggestions for reducing moral distress.

Research design

A nationwide, cross-sectional study was conducted.

Development of questionnaire

A self-administered questionnaire was used to obtain information about critical care nurses’ values and self-perception of behaviour in ethical practice and their demographic characteristics. The items for values were determined in the following three phases. First, we extracted 82 items regarding nursing ethics, morals and dilemmas by reviewing 12 (4 in English, 8 in Japanese) articles.^25–36 Second, we conducted semi-structured interviews with eight nurses working in the ICU with an average experience as a nurse of 9.8 years (range: 4–15 years). Among the eight participants, one nurse was a certified nursing specialist in critical care and three nurses had Master of Science in nursing. The average time of the interview survey was 45.8 min (range: 25–91 min). Participants were asked about ethical problems and distress they felt in their daily clinical practice and what they valued in such cases. We extracted 60 items related to values based on the interviews, resulting in 142 provisional items. Finally, six doctoral students in nursing and three faculty members in nursing discussed item overlap and adequacy. As a result, the items were grouped into 28 categories, and for each category, we developed one representative question. The 28 questions of the ‘values of ethical practice for nurses working in critical care’ were determined.

Participants rated degree of value and self-perception of behaviour for the 28 items. For value, we asked about the degree to which the nurse put value on each item. For the self-perception of behaviour, nurses were asked to rate the degree to which they think they do it in usual clinical situations for each item. Items were rated on a 4-point Likert-type scale, with 4 = ‘I think so very much’, 3 = ‘I think so’, 2 = ‘I don’t think so’ and 1 = ‘I don’t think so at all’. The difference between value and self-perception of behaviour was calculated from the score of each value item minus the score of each self-perception of behaviour item. The higher the difference, the greater the difference between value and self-perception of behaviour. We also defined that the self-perception of behaviour was better than the value, and the difference was set to 0.

Pilot study

To confirm the survey’s feasibility, we conducted a pilot test. Fourteen nurses working in the critical care unit of a university hospital in an urban area in Japan answered the questionnaire with the 28 question items. We collected questions and opinions about the items on the questionnaire, confirmed the tendency of answers and modified the expressions of the items based on the feedback. There was no extreme response distribution or feedback about confusing expressions. Through the pilot study, the content validity and face validity of the questionnaire were confirmed.

Participants and research context

Registered nurses working in critical care units in Japan were invited as participants. Participants from the pilot survey were excluded.

Data collection procedure

In Japan, there are 934 hospitals with critical care units, and 300 were randomly selected from a hospital database developed by the Ministry of Health, Labour, and Welfare in Japan.³⁷ Subsequently, we sent letters asking for participants to the nursing director of each selected hospital. Next, cover letters and questionnaires were sent by post to the nursing directors who gave consent, and they were distributed to nurses working in intensive care areas in the hospitals. The cover letter explained that the survey was confidential and anonymous. All participants were given a questionnaire with a check box for consent to research, a cover letter and a return envelope. We asked that the questionnaires be completed and returned individually within 2–3 weeks. The data collection period was from August 2019 to December 2019.

The justification of the sample size is as follows: When the response rate is 50% and the sampling error is maximised, the required number of samples is 400 for an error of ±5%. The recovery rate was estimated to be approximately 20% based on previous studies.³⁶ For multivariate analyses, the sample sizes needed to be increased to account for the additional variables in the analyses. Thus, the sample size was increased to 500, and we distributed the questionnaire to 2500 nurses.

Data analysis

We collected participant characteristics, and calculated the distribution of answers for each item of ‘the degree of value in ethical practice’ and ‘the degree to which they could practically do [something] in their clinical situation’ and descriptive statistics of the difference. The mean value and standard deviation (SD) of each item were calculated. Statistical Package for Social Sciences (SPSS), version 25, was used for all analyses.

Ethical considerations

This study was conducted with the approval of the Ethics Review Committee of the Tokyo Medical and Dental University of Medicine (approval nos. M2018-214, M2019-045). Participation in the study was voluntary, and the information given to the participants specified that there were no disadvantages of not participating in the study. We obtained written consent from the interviewees. Participants in the questionnaire survey were given an enclosed document explaining the study, and participants put a check mark to confirm their intention to participate in the research.

Results

Characteristics of participants

Out of the 300 hospitals, 94 were accepted in the study (acceptance rate: 31.3%). Of the 2375 questionnaires distributed, 1014 (response rate: 42.7%) were returned. Of these, questionnaires in which participants had chosen the same answer for more than 90% of the 28 items, and questionnaires with missing data (for the 28 items, not demographic data) were excluded. And the number of valid responses was 917 (valid response rate: 38.6%). The characteristics of the participants are given in Table 1.

Table 1.

Characteristics of participants (N = 917).

	n	% or mean ± SD [range]
Years of nursing experience (n = 909)		11.9 ± 7.8 [0–38.0]
Years of experiences in intensive care facility (n = 908)		5.6 ± 4.3 [0–22.0]
Sex (n = 912)
Female	761	83.4
Male	151	16.6
Position (n = 914)
Staff nurse	769	84.1
Chief nurse	124	13.6
Head nurse	21	2.3
Educational background (n = 908)
Vocational college	609	67.1
University	251	27.6
Graduate school	14	1.5
Other	35	3.8
Certification (n = 839)
RN	794	94.6
CN	41	4.9
CNS	4	0.5
Intention to leave job (n = 876)
No	767	87.6
Yes	109	12.4

SD: standard deviation; RN: registered nurse; CN: certified nurse; CNS: certified nursing specialist.

Values and the self-perception of behaviour in ethical practice

The results of values and self-perception of behaviour in the ethical practice of critical care nursing are shown in Table 2. The item with the highest mean value in ethical practice was ‘Protect patient privacy’ (3.74 ± 0.44). This item had the smallest standard deviation, and the range was from 3 to 4. Only one item had a mean value score of less than 3: ‘Keep hospital management and evaluation in mind’ (mean ± SD: 2.88 ± 0.76).

Table 2.

Values and self-perception of behaviour in ethical practice of critical care nursing (N = 917).

Items of ethical practice	Value		Self-perception of behaviour		Difference of value and behaviour		Rank of difference of value and behaviour
Items of ethical practice	Mean	SD	Mean	SD	Mean	SD	Rank of difference of value and behaviour
Protect patient privacy	3.74	0.44	3.1	0.7	0.65	0.68	13
Opinions should be shared among medical professionals	3.73	0.45	3.03	0.71	0.7	0.72	9
Protect the dignity of the patient	3.7	0.46	2.94	0.68	0.77	0.67	6
Medical professionals should help each other	3.7	0.46	3.08	0.73	0.63	0.73	14
Prioritising the relief of patients’ pain	3.7	0.46	3.09	0.63	0.62	0.64	15
Emphasise the safety of medical staff	3.68	0.47	3.1	0.7	0.58	0.71	17
The highest priority is to respect patients’ wishes	3.62	0.5	2.71	0.63	0.91	0.67	4
Focus on working hours and QOL of medical staff	3.65	0.5	2.56	0.85	1.1	0.96	1
Nurses should always practice personalised care for patients	3.58	0.51	2.83	0.62	0.75	0.66	8
Provide patient information to family members	3.6	0.51	3.13	0.61	0.47	0.58	23
Patient consent should be obtained for treatment/care to be performed	3.61	0.51	3.04	0.69	0.58	0.65	18
Nurses should continue to learn and update their knowledge and skills	3.64	0.51	2.77	0.65	0.88	0.7	5
Obtain consent from family members	3.56	0.54	3.17	0.65	0.42	0.58	27
Family members should be considered and cared about	3.58	0.54	3.06	0.71	0.53	0.62	22
Strive to confirm intentions even for patients who have difficulty expressing their intentions	3.52	0.55	2.75	0.72	0.77	0.7	7
Evidence-based medicine/treatment should be provided	3.46	0.56	3.03	0.65	0.46	0.65	25
Anything that can cause harm to the patient should be reported	3.51	0.58	2.98	0.7	0.54	0.64	21
Prioritise patient care over other tasks	3.42	0.59	2.77	0.67	0.66	0.7	12
Patient care and treatment should be distributed fairly	3.33	0.62	2.8	0.65	0.55	0.65	20
Nurses should be patients’ voices	3.38	0.62	2.71	0.65	0.69	0.65	10
Prioritise patients’ survival	3.44	0.62	3.29	0.59	0.22	0.43	28
Decide on treatment strategies in a timely manner as to not negatively impact patient care	3.35	0.63	2.44	0.62	0.92	0.73	3
Litigation risks should be taken into account	3.42	0.63	2.85	0.75	0.6	0.69	16
Care should not be changed because of manpower	3.36	0.64	2.41	0.7	0.96	0.82	2
All information should be disclosed to the patient	3.04	0.67	2.41	0.62	0.68	0.68	11
Nurses’ personal beliefs should not affect their professional practice	3.01	0.71	2.63	0.61	0.44	0.6	26
Do not perform invasive procedures on patients for the purpose of educating medical staff	3.19	0.73	2.76	0.69	0.47	0.64	24
Keep hospital management and evaluation in mind	2.88	0.76	2.37	0.7	0.58	0.68	19

SD: standard deviation; QOL: quality of life.

The three items with the highest mean score for self-perception of behaviour in ethical practice were ‘Prioritise patients’ survival’ (3.29 ± 0.59), ‘Obtain consent from family members’ (3.17 ± 0.65) and ‘Provide patient information to family members’ (3.13 ± 0.61). The three items with the lowest mean score for self-perception of behaviour were ‘Keep hospital management and evaluation in mind’ (2.27 ± 0.70), ‘Care should not be changed because of manpower’ (2.41 ± 0.70) and ‘All information should be disclosed to the patient’ (2.41 ± 0.62). More than half of the items had a mean score for self-perception of less than 3.

Items with a large difference in value from others

The five items with the highest SD, that is, the items with the widest range of responses, were ‘Keep hospital management and evaluation in mind’ (2.88 ± 0.76), ‘Do not perform invasive procedures on patients for the purpose of educating medical staff’ (3.19 ± 0.73), ‘Nurses’ personal beliefs should not affect their professional practice’ (3.01 ± 0.71), ‘All information should be disclosed to the patient’ (3.04 ± 0.67) and ‘Care should not be changed because of manpower’ (3.36 ± 0.64).

Items with a large difference between value and self-perception of behaviour scores

The five items with the highest mean of the difference between value and self-perception of behaviour scores, that is, the items with the greatest risk of causing moral distress, were ‘Focus on working hours and [quality of life] QOL of medical staff’ (1.10 ± 0.96), ‘Care should not be changed because of manpower’ (0.96 ± 0.82), ‘Decide on treatment strategies in a timely manner as to not negatively impact patient care’ (0.92 ± 0.73), ‘The highest priority is to respect patients’ wishes’ (0.91 ± 0.67) and ‘Nurses should continue to learn and update their knowledge and skills’ (0.88 ± 0.70).

Discussion

In this study, we determined items that are likely to cause conflict with other nurses and items that can lead to moral distress from the viewpoint of value and self-perception of behaviour. The results revealed that some items are associated with particularly high risks for conflicts and moral distress. The results of this study can help individual nurses understand differences in how their values relate to those of other nurses and can help promote understanding. In addition, the results can help nursing managers develop educational and practical methods to reduce the moral distress of ICU nurses.

Of the 28 items included, 27 had a mean value score of three or more, which indicates that those items are important to the nurses. However, only half of the self-perception scores exceeded 3, which suggests that many nurses could not act based on their values. In addition, the problems in clinical practice were identified as the items where there was a difference between value and self-perception of behaviour, and the items for which there was a large range of responses and the possibility of conflicting values with others.

Items with a large difference between value and self-perception of behaviour

The items ‘Care should not be changed because of manpower’ and ‘Focus on working hours and QOL of medical staff’ relate to the staffing and working environment of nurses. It seems that nurses may not be able to provide adequate care due to work environment issues and may feel that they are sacrificing their QOL due to overwork. In Japan, one standard of the ICU is that the patient: nurse ratio is 2:1 or more.³⁸ In previous research, despite more staffing compared to general wards, the working environment of critical care nurses was related to the large number of patient replacements and the sense of duty associated with saving lives, which adds to the large workload. It has been reported that heavy pressure is exerted.³⁹ Nurses’ working environment and an increased risk of burnout may affect patient prognosis.⁴⁰ Environmental factors that increase burnout among staff nurses include a lack of sense of control for holidays and relationship problems with nurses and doctors in managerial positions.⁴¹ It is imperative to improve the working environment for medical personnel in critical care.

The items ‘The highest priority is to respect patients’ wishes’ and ‘Decide on treatment strategies in a timely manner as to not negatively impact patient care’ are important for supporting the decision making regarding patients. However, the rate of preparation of advance directives in Japan is only around 5%,⁴² and it is difficult for medical staff to gauge patients’ intentions, especially if these lack the ability to make decisions regarding their treatment. In addition, it is known that Japanese medical professionals tend to consult patients’ families when a decision needs to be made, regardless of whether or not patients are capable of making those decisions by themselves.⁴³ In such workplace cultures, it may be difficult to prioritise the patient’s will. Therefore, it is important for medical staff to estimate the patient’s current intentions in daily practice.

The item ‘Nurses should continue to learn and update their knowledge and skills’ is related to nurses’ specialties. In critical care, nurses need knowledge and skills about patient management methods and new medical equipment, so collaboration with other occupations is required. However, it might be difficult to learn everything in a short period of time, and many nurses might feel that they have not fully met the expectations of other staff. It has also been found that many nurses feel that it is necessary to work with colleagues who do not have the ability to care for a patient,⁴⁴ so maintaining and improving knowledge and skills are major issues for nurses working in critical care units.

Items with a large difference in value from others

‘Keep hospital management and evaluation in mind’ and ‘Do not perform invasive procedures on patients for the purpose of educating medical staff’ involve the dual role of being a patient advocate and being a member of the organisation. The results suggest that the two positions that exist at the same time sometimes lead to different policies and judgements, and the nurse determines which role has priority. Nurses are more likely to experience conflict with other nurses when they disagree on which values should be prioritised and which choices should be made in the context of their clinical practice; this can lead to moral distress.¹³ A previous study that focused on nurses’ roles as patient advocate indicated that nurses sometimes present this role.⁴⁵ ‘Decide on treatment strategies in a timely manner as to not negatively impact patient care’ indicates that nurses are advocates and protect patient rights.⁴⁵ Patients staying in the ICU change their condition rapidly and have limited time to make treatment decisions.⁴⁶ Nurses need to take time to estimate their intentions because the patients are sometimes unconscious,⁴⁷ which is an important factor in determining treatment policy. Therefore, nurses may have different values due to the limited time environment.

The item ‘Nurses’ personal beliefs should not affect their professional practice’ concerns patients’/families’ expectations for aggressive treatment, which is not recommended. There can sometimes be confusion about whether to prioritise medical judgement or the will of the patient/family; therefore, policies have been developed for nurses to reference in such situations.¹⁶ However, the actual treatment depends on the individual case and requires discussion in each case. Thus, the policy is like a joint statement from different organisations that does not give an answer to each case. In this way, when multiple values are presented at the same time, each individual will make decisions based on their prioritised value.

The item ‘All information should be disclosed to the patient’ is related to patient autonomy and decision support. In critical care, many patients are intubated, and communication is often difficult due to the use of analgesics and sedatives, delirium, or coma.^48,49 In previous research, medical personnel, including nurses, have judged that the clearer the consciousness level is, the more they have the ability to make decisions and confuse consciousness with the ability to make decisions.⁵⁰ There is a possibility that the provision of information to patients will differ due to different judgements of decision-making ability depending on the medical staff. This different judgement may lead to conflicts between nurses who think it is important to disclose information to patients and nurses who do not.

‘Litigation risks should be kept in mind’ is a unique item to critical care. Critical care units have a higher risk of medical litigation and the associated costs than other areas of healthcare.⁵¹ The risk of litigation needs to be addressed on a large scale,⁵² and solutions such as consulting a Clinical Ethics Committee (CEC) may be beneficial. The CEC makes some decisions in accordance with principles, but it is not aimed at mutual agreement of the staff concerned, and it is considered that the staff tend to be instructive to follow the decisions; therefore, care for patients might be delayed.⁵³ Relying solely on CEC to resolve ethical issues can lead to conflicts with other values, such as delays in patient intervention and inability to respect the patient’s will. Nurses want to protect patients’ rights, but at the same time, they must sometimes disagree with patients and their families to protect their organisation.

Strengths and limitations

To our knowledge, this study is the first nationwide survey to investigate specific values and behaviours in ethical practice among critical care nurses. The items with differences between value and self-perception of behaviour and items with a large range in value are significant findings that can contribute to increase mutual understanding and improve nurses’ work environment.

This study has some limitations. First, there are possibilities of self-selection bias and non-response bias because this study was a self-administered questionnaire survey, and only the subjects who were interested in this study answered. Although previous studies have shown that many nurses in critical care feel moral distress and are at high risk of burnout and turnover,²² we cannot confirm that such subjects participated in this study. However, since sampling was conducted from various facilities across the country, we believe that the target population generally reflects the population in terms of area and hospital size. Second, recall bias may also exist. Self-perception of behaviour in ethical practice might be affected based on the timing of the survey. Third, all participants are Japanese, so the results may not be generalised in a global context.

Future perspectives

Future research is needed to investigate how the items extracted in this study affect moral distress. Therefore, it is necessary to consider the reliability and validity of the 28 items that compose the scale so it can be used as a tool to measure moral distress in the future. Existing moral distress scales do not provide an insight into the values that underlie moral distress in nurses.³¹ In addition, a support programme to reduce moral distress should be created to verify its effect.

Conclusion

This study identified items that may cause moral distress among nurses working in critical care units in Japan. It is considered to be one of the important findings in the future to better understand moral distress and develop appropriate response strategies.

Footnotes

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 supported by the Yamaji Fumiko Nursing Research Fund, Tokyo, Japan (grant number siba079-No. 5-2).

ORCID iD

Kaoru Ashida

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