Empathy and ethical sensitivity among intensive and critical care nurses: A path analysis

Abstract

Background

Intensive and critical care nurses need to demonstrate ethical sensitivity especially in recognizing and dealing with ethical dilemmas particularly as they often care for patients living with life-threatening conditions. Theories suggest that there is a convergence between nurses’ empathy and ethical sensitivity. Evidence in the literature indicates that nurses’ emotional, demographic, and work characteristics are associated with their level of empathy and ethical sensitivity.

Aim

To investigate the relationship between nurses’ empathy and ethical sensitivity, considering their emotional states (depression, anxiety, and stress), demographic and work characteristics, and test an empirical model describing potential predictors of empathy (as a mediator) and ethical sensitivity using path analysis.

Research design

Using a cross-sectional design, the philosophical theory of care ethics and empathy was extended and adopted as a conceptual framework for this study and tested by path analysis.

Participants and research context

Data were collected from 347 intensive care nurses recruited by ten educational-medical hospitals in Iran using a questionnaire between February and March 2021.

Ethical considerations

The study was reviewed by the Ethical Advisory Board in Iran and conducted according to the Declaration of Helsinki.

Findings

Study participants demonstrated a mild level of stress, anxiety, and depression, alongside a relatively high level of empathy and ethical sensitivity. Nurses with good socioeconomic status had higher empathetic behavior with patients than those with weak status. Nurses aged over 40 who had received ethics training and had higher work experience were associated with higher ethical sensitivity compared to nurses under 20 years of age. Empathy directly affected ethical sensitivity; however, anxiety had an indirect effect on ethical sensitivity through empathy. Among demographic factors, age had a positive direct effect on ethical sensitivity.

Conclusions

Less anxiety and a high level of empathy contribute to higher levels of ethical sensitivity among intensive and critical care nurses.

Keywords

critical care nursing ethical sensitivity empathy intensive care units moral development nursing ethics path analysis

Highlights

• Critical care nurses showed a mild level of depression, anxiety, and stress. Appropriate strategies should be planned to reduce these negative emotional states among nurses.

• Anxiety had an indirect effect on ethical sensitivity through empathy, while age had a direct positive effect on ethical sensitivity. Leaders should focus their effort on reducing negative emotions like anxiety to improve ethical sensitivity levels through empathy in novice nurses.

• Empathy had a direct positive effect on ethical sensitivity; therefore, empathy needs to be improved to ameliorate nurses’ ethical sensitivity.

Introduction

Intensive and critical care nurses routinely confront ethical issues as they care for patients living with life-threatening conditions.^1,2 Nurses witness ethical dilemmas, as they come across sundry situations, which may occur at unexpected times and require ethical decisions regarding life-sustaining treatments and end-of-life interventions.³ Ethical dilemmas occur due to the high frequency of critical situations in clinical practice and require decisions that may conflict with nurses professional responsibilities and individual values.⁴

Intensive care nurses must be ethically sensitive to recognize moral values in the ethical decision-making process for patients with vulnerable situations and resolve ethical conflicts in clinical practice.^2,5 Ethical sensitivity can be defined as “the nurses' awareness of the patients’ vulnerability and their insight into the moral consequences of decisions made for the patients.”⁶ Ethical sensitivity enables nurses to recognize ethical issues based on respect for patients, empathy, and recognition of professional responsibility to resolve ethical conflicts and provide the best nursing practice for the patients.^3,7

Theories and supportive literature demonstrate that there is a confluence between nurses’ empathy and ethical sensitivity.^8–11 Care ethics is a moral theory that emphasizes the importance of caring relationships and the moral significance of our interdependence with others. In care ethics, our moral obligations arise from our interconnectedness with others and our responsibility to care for them.¹² Numerous theories on care ethics focused on empathy as an associated key concept.¹³ Philosopher Slote argues in “The ethics of care and empathy” that sincere empathy serves as a moral compass to guide moral decisions.^8,14,15 Empathy is defined as an emotional, cognitive, and moral attribute to understanding patients’ concerns, experiences, and sensations, along with a capacity to communicate this understanding to provide moral deliberations.^16,17 Empathic care behaviors such as taking the patient’s perspective, walking in the patient’s shoes, and providing compassionate care are crucial to participating in the nurse-patient mutual trusting relationship and include respecting the patients’ values and incorporating them in the decision-making process in situations.¹⁸ Nurses’ empathetic behavior is a key driver of positive patient outcomes because it motivates them to act selflessly. Empathy is a multidimensional construct, which is strongly associated with human emotions, cognition, morals, and behaviors.^17,19 To gain more insight into the significance of empathy in care ethics, a precise understanding of its relational dimensions is needed.¹³

Care ethics literature introduces empathy as a moral sentiment, which can use emotional states to increase sensitivity in situations of an ethical nature.¹³ Since empathy is rooted in one’s emotions, it is, therefore, essential to consider nurses’ emotional characteristics associated with their level of empathy.²⁰ Empathy as an inner incentive can help nurses employ emotions to improve ethical sensitivity and deal with ethical issues.¹³ Traditionally, care ethics has focused on positive emotions such as empathy, compassion, and love, which motivate us to care for others. However, negative emotional states such as stress and anxiety also play a crucial role in caring relationships. Stress and anxiety are often experienced by caregivers who are responsible for the care of others, whether that be in a personal or professional capacity. These emotions can arise from a sense of responsibility, worry, and concern for the well-being of the person being cared for.²¹ When we experience stress and anxiety in caring relationships, they can have significant impacts on our ability to provide care. For example, they can lead to burnout, reduced quality of care, and even harm to the person being cared for. Therefore, extending care ethics to include negative emotional states of stress and anxiety is important because it acknowledges the complexity of caring relationships and the challenges faced by caregivers. By recognizing the importance of addressing and managing these negative emotions, we can better support caregivers and improve the quality of care provided to those in need.

To date, literature has shown the influence of several intrinsic and extrinsic factors like individual and work-related characteristics on nurses’ empathy and ethical sensitivity.^22,23 These factors may contribute to the association between these two variables; however, most of the studies in ethics and empathy are theoretically based research.¹³ To provide an empirical and informative framework for understanding the potential process of the association between empathy and ethical sensitivity, consideration of their complex predictors and pathways is required. Therefore, determining the precise mechanisms of these pathways is critical for executing effective interventions for improving ethical sensitivity among nurses. Relying on this theoretical framework, emotional, demographic, and work characteristics, along with empathy and ethical sensitivity, were examined among intensive and critical care nurses.

The study

Conceptual framework

The philosophical theory of ethics of care and empathy was adopted as a conceptual framework for this study.⁸ This theory focuses on empathy as a key concept in care ethics.¹³ In “The ethics of care and empathy,” philosopher Michael Slote contends that care ethics offers a unique perspective on morality and challenges traditional ethical frameworks. Drawing on sentimentalism and psychological research on empathy, Slote argues that care ethics can develop its own account of respect, autonomy, social justice, and deontology. He further suggests that care ethics provides a more compelling explanation of these concepts than contemporary Kantian liberalism. By emphasizing empathy, Slote also provides care ethics with a comprehensive account of moral education and argues that care ethics is not counterproductive to feminist goals, as some suggest. Instead, Slote believes that care ethics, with its emphasis on empathy, can effectively critique patriarchal ideas and institutions. “The ethics of care and empathy” is a thought-provoking exploration of care ethics that demonstrates the connections between philosophical issues and other fields like psychology, education, and women’s studies.^8,14,15 We extended this theory to include negative emotional states of stress, anxiety, and depression along with demographic, and work characteristics related to empathy and ethical sensitivity based on literature that supports these relationships.^20–23 Demographic factors included age, gender, marital status, socioeconomic status, and educational level. Work factors included hospital and clinical settings, work experience, and receiving ethics training.

Aims

The aims of this study were to (a) investigate the relationship between nurses’ empathy and ethical sensitivity, considering their emotional states (depression, anxiety, and stress), demographic, and work characteristics; (b) test an empirical model describing potential predictors of empathy (as a mediator) and ethical sensitivity using path analysis.

Materials and methods

Design

A cross-sectional design was utilized to collect data from intensive and critical care nurses recruited in ten educational-medical hospitals in Iran. The study and its procedures were reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies,²⁴ and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES)²⁵ developed by the EQUATOR network (Enhancing the QUAlity and Transparency Of health Research).

Participants

Participants for this study included approximately 1600 nurses from 10 hospitals who worked in critical care units including, ICU (Intensive care unit), CCU (Cardiac care unit), Dialysis (Hemodialysis and Peritoneal Dialysis), and Emergency department. The inclusion criteria were as follows: Registered nurses who (a) had a minimum of 1 year experience in critical care units, (b) had formal employment, and (c) did not have a chronic and debilitating physical disorder (cancer, physical disabilities, etc.), (d) did not have a known psychological disorder such as major depression and the like, and (e) had not experienced severe stressful events in the last 6 months.

Sample size calculation

Recommendations for the sample size for performing a path analysis have been identified as 20 participants for each parameter.²⁶ The sample size was calculated based on 13 parameters and allowing for attrition of 20%, 347 participants were considered to be adequate.

Recruitment

A proportional quota sampling method was used to recruit participants for the study.

Permission to collect data was obtained by the researcher from the nursing managers of the critical care units of each hospital. Furthermore, a list of the number of nurses in each critical care unit by gender was obtained from the manager. Recruitment was undertaken in three phases. Phase 1: The study population of 1600 Registered Nurses were stratified based on two strata, gender, and department. Phase 2: After stratification, based on the sample size calculation, 347 registered nurses were proportionally divided into ten hospitals. Phase 3: Study participants were recruited from the critical care units of each hospital using social networks and paper surveys.

Data collection

After obtaining the necessary ethical approval from the university in February 2021, data were collected using two methods to optimize response rates. Firstly, the link to the study survey was sent to the nursing groups of participating wards through social networks including Whatsapp and Telegram by the first investigator (AS). Secondly, paper surveys were distributed in the participating wards and a collection box for completed surveys was placed in each ward to enable those without social networks to participate in the study. The surveys sent to participating wards in both online and paper formats included eligibility criteria for the study, the number of nurses required by gender in each ward, and informed consent written on the first page of the survey to ensure that their participation was voluntary. Participants were assigned a unique identification code, which was used to track whether they had completed the survey or not. This code was generated and distributed to participants when they first began the survey and was used to prevent duplicate submissions. They were also asked to only complete the survey once, and reminders were sent to them not to complete it more than once in both the electronic and paper versions of the survey. Reminders were sent by the first investigator (AS) 2 weeks after the initial dissemination of the survey. Data collection was carried out over 4 weeks, from February 2021 to March 2021.

The data collected included information relating to (1) work and demographic characteristics, (2) ethical sensitivity, (3) empathy, and (4) emotional states (depression, anxiety, and stress).

Work and demographic characteristics

Nurses’ work and demographic characteristics included age, gender, marital status, educational level, perceived socioeconomic status (SES), receiving ethics training (yes/no), experience working as a nurse, and type of clinical setting. Perceived SES was measured with the question “How well off do you think your family is?” with five response alternatives: “not at all,” “not particularly,” “fairly,” “rather,” and “very”. The five response alternatives were clustered into three categories: weak (“not at all” and “not particularly”), medium (“fairly”), and good (“rather” and “very”).²⁷

Ethical sensitivity

Ethical sensitivity was assessed using the Iranian version of the Modified Moral Sensitivity Questionnaire (MMSQ).²⁸ The MMSQ is a 25-item self-report instrument that evaluates the moral sensitivity of nurses and scores based on 5 points Likert scale from 0 (Totally disagree) to 4 (Totally agree). The total score varies from 0 to 100. The cutoff scores of “25–50”, “50–70”, and “70–100” indicate low, moderate, and high moral sensitivity, respectively.^28,29 The reliability of the Iranian version of the MMSQ has been reported with Cronbach’s alpha of 0.77.²⁹

Empathy

The Persian Version of the 20-item Jefferson Scale of Empathy-Health Professional version (JSE-HP) was used to assess empathy.³⁰ The JSE-HP is a self-report instrument that assesses empathy using a 7-point Likert scale from 1 (“strongly disagree”) to 7 (“strongly agree”). The minimum and maximum total score obtainable is 20 and 140, respectively, with higher scores indicating higher empathy. According to Hojat, determining cutoff scores for JSE-HP could be helpful for assessment purposes. Therefore, the cutoff scores of “50–80”, “80–104”, “and 104–140” were considered as low, moderate, and high empathy, respectively. This scale has been used in different studies and has had good validity and reliability with Cronbach’s alpha above 0.7.^31,32

Emotional states (depression, anxiety, and stress)

Emotional states were assessed using the Persian Version of the Depression, Anxiety, and Stress Scale (DASS-21) which is a 21-item self-report questionnaire consisting of 3 subscales and seven items per subscale that was used to assess the Depression (DASS-21-D), Anxiety (DASS21-A), and Stress (DASS21-S) of the participants. On this scale, each item contains a phrase and is rated from 0 (Did not apply to me at all) to 3 (Applied to me very much). The total score of each scale is calculated by adding the scores of the items and multiplying them by two, with scores varying from 0 to 42. Cutoff scores are used for the total DASS-21 and each subscale to show severity by labels: “Normal, Mild”, “Moderate”, “Severe”, and “Very severe”. The reliability of the Iranian version of the DASS for depression, anxiety, and stress has been reported with Cronbach’s alpha of 0.85, 0.85, and 0.87, respectively.³³

Ethical considerations

Approvals for the study were obtained from the Ethics committee and research administration of Khomein University of Medical Sciences and Isfahan University of Medical Sciences (code: IR.KHOMEIN.REC.1399.011). Informed consent was obtained from all participants on the first page of the survey and their participation was voluntary. They were ensured of the confidentiality of their data and their freedom to withdraw from the study unilaterally.

Data analysis

Statistical analysis was conducted with SPSS v26 to address the study hypothesis. Data cleaning was undertaken and participants who responded to at least 80% of the survey questions were retained. Descriptive analysis (Mean, Frequency, Percentages, and Standard deviation [SD]) were used to display the distribution of study variables in the overall sample (n = 326) and by main variables (empathy and Ethical sensitivity). For inferential analysis, empathy and ethical sensitivity were analyzed according to the general characteristics of the study participants using one way-ANOVA and independent t-test. Inequality of variances between groups was detected with Levene’s test and was reported using Welch’s T-test. Post-hoc analysis for significant differences between groups was performed with the Tucky test. Bivariate correlations between the study’s main variables were analyzed using Pearson correlation coefficients. Assessments of the statistical tests’ assumptions included Cronbach’s alpha coefficient with the acceptance criterion of ≥0.70 for evaluating the internal homogeneity of the scales,³⁴ skewness and kurtosis below +1.5 and above −1.5 for testing normality distribution of the study variables.³⁵ Statistical assumptions were confirmed for all study variables. Standardized (β) path coefficients were used to display the direct and indirect effects between study variables, and a p-value of ≤0.05 was considered statistically significant.

A path analysis was performed using the AMOS v26 to test the study’s conceptual and hypothesized model. The following three criteria were used for model selection of the appropriate model: (a) Compliance with the results of the Univariate analysis, (b) confirmation of the basic conceptual and theoretical framework, and (c) adequate and good fit indices. Variance Inflation Factor (VIF) ≥ 5 was used for detecting multicollinearity between independent variables in the path model,³⁶ and binary variables were dummy coded. The following indices were considered to examine whether data fit the hypothesized model:³⁷ (a) non-significant Chi-square of model fit divided by degree of freedom (x²/df) < 5 (Although it is sensitive to large sample size >200), we also considered alternative fit indices such as (b) Root-mean-square error approximation (RMSEA) < 0.08, (c) Goodness-of-fit index (GFI) > 0.90, (d) Comparative fit index (CFI) > 0.90, (e) Tucker–Lewis’s index (TLI) > 0.90, and (f) Standardized root-mean-square residual (SRMR) ≤ 0.08.^26,38,39

Results

Work and demographic characteristics of participants

Data were obtained from a total of 347 nurses; however, following data cleaning, only 326 nurses provided full data for analysis. Approximately a third of the nurses (29.1%) were aged ≤30 years and the majority were female (82.7%), married (74.5%), had a bachelor’s degree (90.3%), and had a medium socioeconomic status (62.6%). Only 7.3% had experience working more than 21 years as a nurse and approximately one-third (34.8%) of all participants worked in the emergency department. Most nurses (62.1%) reported that they had not received ethics training (Table 1).

Table 1.

Work and demographic characteristics of nurses (n = 326).

Characteristics	Number	%	Mean (SD)
Age (years)			35.65 (6.53)
$\leq 30$	96	29.1
31–35	77	23.3
36–40	84	25.5
$\geq 41$	73	22.1
Gender
Male	57	17.3
Female	273	82.7
Marital status
Married	246	74.5
Single	80	24.2
Divorced	4	1.2
Level of education
BSN	298	90.3
MSN	32	9.7
Socioeconomic status
Weak	32	9.8
Medium	204	62.6
Good	90	27.6
Ethics training
Received ethics training
Yes	125	37.9
No	205	62.1
Experience working as a nurse (years)			11.37 (6.07)
$\leq 5$	66	20
6–10	98	29.7
11–15	86	26.1
16–20	56	17
≥21	24	7.3
Clinical setting
ICU	175	53
CCU	28	8.5
ER	115	34.8
Dialysis	12	3.6

ICU: Intensive care unit; CCU: Cardiac care unit; ER: Emergency room.

Emotional states, empathy, and ethical sensitivity of the participants

The mean total scores for empathy and ethical sensitivity were 107.24 (SD 14.68) and 73.37 (SD 9.78), respectively. The emotional states included depression, anxiety, and stress and their mean scores were 6.43 (SD 6.80), 5.28 (SD 6), and 9.49 (SD 7.69), respectively. All the variables met the internal homogeneity assumption with Cronbach s α ≥ 0.73 (Table 2).

Table 2.

Depression, anxiety, stress, empathy, and ethical sensitivity (n = 326).

Variable	Total score	Min.-Max.	Range of total score	Skew.	Kurt.	Cronbach s α
Variable	Mean (SD)	Min.-Max.	Range of total score	Skew.	Kurt.	Cronbach s α
1. Depression	6.43 (6.80)	0–20	0–42	0.90	−0.52	0.85
2. Anxiety	5.28 (6.00)	0–20	0–42	1.19	0.38	0.83
3. Stress	9.49 (7.69)	0–32	0–42	0.82	0.21	0.81
4. Empathy	107.24 (14.68)	67–140	20–140	−0.23	−0.51	0.83
5. Ethical sensitivity	73.37 (9.78)	46–94	0–100	−0.03	−0.30	0.73

Differences in empathy and ethical sensitivity according to the general characteristics of the participants

Empathy scores differed significantly according to socioeconomic status (F = 3.023, p = .05), and the results of the post-hoc analysis showed nurses with good socioeconomic status, showed more empathy than those with low socioeconomic status. There were no significant differences according to age, gender, marital status, educational level, ethics training, work experience, and clinical setting for empathy. The ethical sensitivity differed significantly in terms of the ethics training (t = −2.593, p = .01). Further, the results demonstrated significant differences in ethical sensitivity depending on the age group, and based on the post-hoc analysis, nurses in their 40s showed higher ethical sensitivity than those in their 20s. There were also significant differences according to the work experience (F = 2.499, p = .043), and the results of the post-hoc analysis showed no differences between groups. There were no significant differences in terms of gender, marital status, educational level, socioeconomic status, and clinical setting for ethical sensitivity (Table 3).

Table 3.

Differences in empathy and ethical sensitivity according to the general characteristics of the nurses (n = 326).

Characteristics	Categories	Empathy			Ethical sensitivity
Characteristics	Categories	Mean (SD)	t/F	p	Mean (SD)	t/F	p
Age (years)	$\leq 30$ ^a	106.51 (14.28)	2.04	0.108	71.43 (9.08)	3.03	0.029 (d > a)
	31–35^b	104.56 (14.85)			73.11 (9.00)
	36–40^c	107.82 (15.22)			73.58 (10.59)
	$\geq 41$ ^d	110.31 (14.07)			75.95 (10.07)
Gender	Male	104.18 (14.78)	1.716	0.087	71.98 (8.87)	1.172	0.242
Gender	Female	107.87 (14.60)	1.716	0.087	73.66 (9.94)	1.172	0.242
Marital status	Married	107.22 (14.47)	0.08	0.923	73.54 (9.85)	0.287	0.751
	Single	107.42 (15.32)			72.75 (9.63)
	Divorced	104.41 (18.03)			75.44 (9.92)
Level of education	BSN	106.76 (14.54)	−1.781	0.076	73.03 (9.88)	−1.882	0.061
Level of education	MSN	111.61 (15.42)	−1.781	0.076	76.45 (8.31)	−1.882	0.061
Socioeconomic status	Weak^a	102.31 (15.65)	3.023	0.050 (c > a)	74.61 (11.23)	1.20	0.303
	Medium^b	106.98 (14.10)			72.72 (9.25)
	Good^c	109.59 (15.26)			74.39 (10.35)
Ethics training (received ethics training)	No	106.44 (15.05)	−1.265	0.207	72.28 (9.84)	−2.593	0.010
Ethics training (received ethics training)	Yes	108.56 (14.00)	−1.265	0.207	75.16 (9.44)	−2.593	0.010
Experience working as a nurse (years)	$\leq 5$ ^a	107.87 (14.90)	1.691	0.152	70.67 (8.96)	2.499	0.043 (a = b = c = d)
	6–10^b	104.12 (13.96)			72.70 (8.88)
	11–15^c	108.15 (16.29)			74.28 (10.67)
	16–20^d	109.50 (12.83)			75.28 (9.86)
	≥21^e	109.54 (14.06)			75.81 (10.63)
Clinical setting	ICU	106.97 (15.66)	0.685 (W)	0.566 (W)	73.61 (9.70)	1.895	0.130
	CCU	104.28 (15.28)			75.01 (9.75)
	ER	108.03 (12.99)			72.07 (9.95)
	Dialysis	110.31 (13.99)			77.88 (8.06)

Note: p-value is based on the comparison of the means of two (Parametric t-test) or more independent(One-Vay ANOVA) groups test with equal or unequal variances. F-value and p-values for unequal variances (Welch’s t-test) are indicated by W sign in front of them.

Correlations among major variables in the study

Bivariate correlation showed a significantly positive relationship between empathy and ethical sensitivity (r = 0.330, p < .01). There was a significantly negative relationship between empathy and depression (r = −0.190, p < .01), anxiety (r = −0.207, p < .01), and stress (r = −0.138, p < .01). Age had a positive correlation with ethical sensitivity (r = 0.181, p < .01) and a strong correlation with work experience (r = 0.918, p < .01). There was a significantly positive correlation between work experience and ethical sensitivity (r = 0.179, p < .01). Depression, anxiety, and stress had a strong positive correlation (Table 4).

Table 4.

Correlations among depression, anxiety, stress, empathy, and ethical sensitivity (n = 326).

Variable	Age	Work experience	Depression	Anxiety	Stress	Empathy	Ethical sensitivity
1. Age	—
2. Work experience	0.918^**	—
3. Depression	0.008	−0.004	—
4. Anxiety	−0.034	−0.42	0.709^**	—
5. Stress	−0.069	−0.67	0.766^**	0.741^**	—
6. Empathy	0.070	0.73	−0.190^**	−0.207^**	−0.138^*	—
7. Ethical sensitivity	0.181^**	0.179^**	−0.022	−0.090	−0.073	0.330^**	—

Note: **p < .01.

Effect of emotional states, demographic, and work characteristics on nurse’s empathy and ethical sensitivity

To identify predictors of empathy and ethical sensitivity among emotional states, demographic, and work characteristics, path analysis was performed. Age, work experience, and ethics training were variables that showed significant differences in the univariate analysis of the differences in ethical sensitivity according to demographic and work characteristics and were entered as independent variables for ethical sensitivity. All the emotional states including depression, anxiety, and stress had a significant correlation with empathy and were entered accompanied by socioeconomic status (based on the results of univariate analysis) as independent variables for empathy. According to the results of the multicollinearity test between intended independent variables, the variance inflation index (VIF) was 6.42 and 6.57 for age and work experience, respectively, which shows collinearity between these two variables. Thus, to avoid multicollinearity, “age” was entered instead of “work experience,” based on the results of the extant literature that revealed increasing age as a predictor for higher ethical sensitivity.⁴⁰ After omitting work experience, the VIF was between 1.008 and 2.994 for all the independent variables, which shows no problems with multicollinearity. The hypothesized model of the potential predictors of empathy and ethical sensitivity is illustrated in Figure 1.

Figure 1.

Hypothesized model with path coefficients. Note: Standardized (β) path coefficients were used to display the direct and indirect effects between study variables; Dummy variables (reference): Good Socioeconomic status (Weak), Ethics training (no).

Path analysis results of the hypothesized tested model indicated good fit indices (Table 5). The results showed a strong positive association between nurses’ empathy and ethical sensitivity (regression coefficient {beta} = 0.31, p < .001). There was a significant negative association between anxiety and empathy ({beta} = −0.19, p < .001). There was also a significant positive association between age and ethical sensitivity ({beta} = 0.14, p < .01). Results of the path analysis showed that anxiety has an indirect effect on ethical sensitivity through empathy. Among the predictors of ethical sensitivity, empathy was the most influential factor. All variables accounted for 13% of the total variance of ethical sensitivity Figure 1.

Table 5.

Goodness-of-fit indices for a hypothesized path model.

Category	Chi-square (X²⁾	Degrees of freedom (df)	p-value	X²/df	RMSEA	GFI	TLI	CFI	SRMR
Criteria	—	—	>0.05	<5.00	<0.08	>0.90	>0.90	>0.90	≤0.08
Hypothesized model	22.964	17	0.150	1.351	0.033	0.983	0.985	0.991	0.0470

Discussion

This study investigated the impact of emotional, demographic, and work characteristics on empathy and ethical sensitivity among intensive and critical care nurses. Consistent with a theory of ethics of care and empathy,⁸ this study found that empathy was directly related to ethical sensitivity, and that anxiety indirectly affects ethical sensitivity through empathy. Furthermore, the findings of this study identified that among demographic factors, age had a direct effect on ethical sensitivity.

Theoretically, empathy is assumed to be a key concept in care ethics; philosophers, Slote and Hamington argue this theory.^8,41 Even though recent studies reported several factors related to empathy and ethics, limited studies empirically substantiate this theory. According to this theory and supportive literature, this study tested whether empathy mediates the relationship between emotional, demographic, and work characteristics with nurses' ethical sensitivity. Consistent with this theory, this study found that the influence of anxiety on ethical sensitivity was indirectly through empathy. Intensive and critical care nurses who experienced low levels of anxiety demonstrated higher levels of empathy. In turn, this was positively associated with ethical sensitivity. Age, in this study, was also found to have a positive direct effect on ethical sensitivity, with older-aged nurses exhibiting higher levels of ethical sensitivity.

The results of this study showed that empathy affects ethical sensitivity, supporting the main theoretical framework of the study and aligning with the existing literature.^10,23,40 However, empathy does not mediate the influence of emotional, demographic, and work factors on ethical sensitivity. Similarly, not all demographic and work factors affected ethical sensitivity. While the results of this study indicate a correlation between nurses' empathy and all the negative emotional states of depression, anxiety, and stress, empathy was found to be significantly affected by anxiety. Unlike demographic and work characteristics, emotional variables are modifiable factors, and study results provide remarkable evidence that such modifiable factors like anxiety should be diminished to ameliorate nurses’ empathy and ethical sensitivity.

Intensive and critical care nurses in this study demonstrated relatively high levels of ethical sensitivity and empathy, which is significantly higher than the levels found among Chinese nurses²³ However, it is important to note that among the Chinese nurses, there was variance in the clinical units they worked in demonstrating different levels of stress. In this current study, participating nurses worked in high-stress units, including intensive and critical care. Intensive and critical care nurses indicated mild levels of stress, anxiety, and depression related to their work units, and this may be due to the study being conducted during the COVID-19 pandemic.

Despite being confronted with the pandemic, experienced intensive and critical care nurses and those who received ethics training reported significantly higher levels of ethical sensitivity than novice nurses. This may be due to them already dealing with substantial stress and anxiety in previous years, therefore the more experienced nurse you are the more likely you are to have developed resilience, empathy, and ethical sensitivity. Moral complexity is inextricably entwined in the nursing profession, with nurses commonly confronted by ethical conflicts in navigating intricate relationships with colleagues, families, patients, and healthcare team members. Nurses must be equipped with solid knowledge to detect ethical issues and act judiciously in any situation with ethical nature.⁴² The trend toward incorporating ethics training in the nursing curricula is notable in this context.

Empathic behaviors increase the emotional burden on nurses and, if misused, can lead to negative emotions like depression.^43,44 A review aimed at identifying the effectiveness of empathy educational interventions for nurses showed the effectiveness of such training in increasing the level of empathy for nurses and nursing students.¹⁹ The role of emotional management training should be considered in nursing training programs. Nurses must distinguish when and where to use empathy and how to manage their emotions in this regard. Strategies to improve coping skills such as mindfulness, and procedures such as clinical supervision, have been effective in managing and reducing nurses’ negative emotions like stress, anxiety, and depression.^19,45,46

The findings of this study can be used to assist in solving ethical dilemmas by equipping nurses with special valences like ethical sensitivity and empathy by providing tailored educational interventions, diminishing negative emotional states as modifiable factors, and striving for organizational development, especially for intensive care units based on personal characteristics.

Organizational development based on personal characteristics is common practice to drive performance. Identifying and selecting the best candidates that meet the requirements and needs for a particular job is crucial for top development organizations.⁴⁷ An appropriate approach for the organization is to consider personal characteristics along with job-related functional skills to hire qualified individuals for each specific clinical situation. The results of this study indicate that older nurses with more work experience are more ethically sensitive than novice nurses, and perhaps this is a reflection that ethical sensitivity is a skill acquired over time, rather than something that can be achieved in initial nursing education.

A recently published structural model on Iranian nurses has highlighted the importance of empathy in care ethics, showing the mediation role of empathy between mindfulness and ethical sensitivity.¹⁰ Although this current study did not consider mindfulness a predictor of empathy and ethical sensitivity, the literature demonstrates the effectiveness of mindfulness educational interventions in reducing depression, anxiety, and stress and improving mental health in nurses,⁴⁸ supporting the findings of this study. Similarly, a study based on Sohee’s work shows that age and empathy are predictors of ethical sensitivity;⁴⁰ however, in contrast, a study conducted among Chinese nurses reports that gender and work experience in conjunction with empathy are predictors of ethical sensitivity.²³ These studies show the complexity of the association between empathy and ethical sensitivity that can be affected by a wide range of variables.

In this study, nurses with good socioeconomic status (SES) were found to report higher empathy than nurses classified as having a weak SES. SES is a multidimensional concept that encompasses both the objective (i.e., income, educational level, and occupation) and subjective (subjective ranking of individuals from their position in the socioeconomic spectrum) dimensions. Unlike objective markers of SES, which are not interchangeable, a subjective construct is rectifiable and utterly related to human well-being.⁴⁹ Efforts should centralize on nurses’ subjective SES to attain better outcomes for nurses and their patients.

Strengths

This was the first known study to investigate the association between empathy and ethical sensitivity and their potential predictors and pathways among intensive and critical care nurses. It corroborates theoretical models of care ethics and empathy providing preliminary and fundamental knowledge for understanding the potential association process between these two variables. Path analysis was proper to evaluate and illustrate a causal model of the study variables. Also, to improve the generalizability of the research, a proportional quota sampling method based on gender and department was used.

Limitations

Current theories cover complex pathways for the association between empathy and ethical sensitivity. This study’s model exclusively focuses on potential predictors of these two variables. Connecting additional variables to this model goes beyond the scope of this current study. The model was tested using cross-sectional data from Iranian intensive care nurses during a coronavirus pandemic; therefore, the results may have been influenced by this situation. Further studies using the longitudinal design to confirm these results are suggested.

Conclusion

This study showed that empathy is directly related to ethical sensitivity and anxiety indirectly affects ethical sensitivity through empathy. Furthermore, age has a direct positive effect on ethical sensitivity. The effect of empathy on ethical sensitivity was greater than the age variable influence. The results show that intensive care nurses who have less anxiety have higher ethical sensitivity by increasing their level of empathy. The findings of this study can help promote nurses’ ethical sensitivity through empathy using emotional, demographic, and work characteristics. Further research for expanding this theoretical model and incorporating other associated variables is needed.

Footnotes

Acknowledgments

We would like to express our thanks to all the critical care nurses who participated in this study, the supervisors and head nurses of Intensive care units who kindly helped us during the data gathering.

Authorship contribution statement

Amir Masoud Sharifnia: Conceptualization, Methodology, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review and Editing. Heidi Green: Investigation, Writing - Original Draft, Writing - Review and Editing. Ritin Fernandez: Investigation, Writing - Original Draft, Writing - Review and Editing, Supervision, Project administration. Ibrahim Alananzeh: Investigation, Writing - Original Draft, Writing - Review and Editing.

Conflict of interest

The author declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Data availability statement

Data available on request due to privacy/ethical restrictions.

ORCID iD

Amir Masoud Sharifnia

References

Park

Moon

, et al. Ethical issues recognized by critical care nurses in the intensive care units of a tertiary hospital during two separate periods. J Korean Med Sci 2015; 30(4): 495–501.

Kavurmacı

Tan

. Determining the moral sensitivities of intensive care nurses. Crit Care Nurs Q 2019; 42(3): 278–284.

Basar

Cilingir

. Evaluating ethical sensitivity in surgical intensive care nurses. Nurs Ethics 2019; 26(7–8): 2384–2397.

Leuter

La Cerra

Calisse

, et al. Ethical difficulties in healthcare: a comparison between physicians and nurses. Nurs Ethics 2018; 25(8): 1064–1074.

Tuvesson

Lützén

. Demographic factors associated with moral sensitivity among nursing students. Nurs Ethics 2017; 24(7): 847–855.

Lützén

Cronqvist

Magnusson

, et al. Moral stress: synthesis of a concept. Nurs Ethics 2003; 10(3): 312–322.

Kim

. Influence of moral sensitivity and ethical values on biomedical ethics awareness of nursing students. J Korean Acad Soc Nurs Educ 2015; 21(3): 382–392.

Slote

. The ethics of care and empathy. Oxford, UK: Routledge, 2007.

Rushton

Kaszniak

Halifax

. A framework for understanding moral distress among palliative care clinicians. J Palliat Med 2013; 16(9): 1074–1079.

10.

Rezapour-Mirsaleh

Aghabagheri

Choobforoushzadeh

, et al. Mindfulness, empathy and moral sensitivity in nurses: a structural equation modeling analysis. BMC Nurs 2021; 21.

11.

Kim

. Moral sensitivity, empathy and perceived ethical climate of psychiatric nurses working in the national mental hospitals. J Korean Acad Psychiatr Ment Health Nurs 2017; 26(2): 204. DOI: 10.12934/jkpmhn.2017.26.2.204

12.

Zhao

Xia

. Nurses’ negative affective states, moral disengagement, and knowledge hiding: The moderating role of ethical leadership. J Nurs Manag 2019; 27(2): 357–370.

13.

van Dijke

van Nistelrooij

Bos

, et al.

Care ethics: an ethics of empathy?

Nurs Ethics 2019; 26(5): 1282–1291.

14.

Slote

. Caring, empathy, and moral education. Oxford, UK: Oxford Academic, 2009.

15.

Slote

. The mandate of empathy. Dao 2010; 9: 303–307.

16.

Hojat

. Empathy in health professions education and patient care. Berlin, Germany: Springer, 2016.

17.

Kirk

. Evaluation of empathy measurement tools in nursing: systematic review. J Adv Nurs 2009; 65(9): 1790–1806.

18.

Adams

. Empathy as an ethical imperative. Creat Nurs 2018; 24(3): 166–172.

19.

Brunero

Lamont

Coates

. A review of empathy education in nursing. Nurs Inq 2010; 17(1): 65–74.

20.

Shamay-Tsoory

Aharon-Peretz

Perry

. Two systems for empathy: a double dissociation between emotional and cognitive empathy in inferior frontal gyrus versus ventromedial prefrontal lesions. Brain 2009; 132(3): 617–627.

21.

Abu‐Horirrah

Rayan

Eshah

, et al. The association of mindfulness with professional quality of life and negative emotional states among critical care nurses during COVID‐19 pandemic. Nursing Forum. Hoboken, NJ: Wiley Online Library, 2022, pp. 1381–1389.

22.

Elayyan

Rankin

Chaarani

. Factors affecting empathetic patient care behaviour among medical doctors and nurses: an integrative literature review. East Mediterr Heal J 2018; 24(3): 311–318.

23.

Chen

Fei Huang

Zhang

, et al. Tertiary hospital nurses’ ethical sensitivity and its influencing factors: a cross-sectional study. Nurs Ethics 2021; 29: 104–113.

24.

von Elm

Altman

Egger

STROBE Initiative , et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61(4): 344–349.

25.

Eysenbach

. Improving the quality of web surveys: the checklist for reporting results of internet E-surveys (CHERRIES). Journal of Medical Internet Research 2004; 6.

26.

Kline

. Principles and practice of structural equation modeling. New York, NY: Guilford Publications, 2015.

27.

Svedberg

Nygren

Staland-Nyman

, et al. The validity of socioeconomic status measures among adolescents based on self-reported information about parents occupations, FAS and perceived SES; implication for health related quality of life studies. BMC Med Res Methodol 2016; 16(1): 48–49.

28.

Abbaszadeh

Borhan

Nematallahi

. Comparison of nursing students and nurses’ moral sensitivity in kerman university of medical sciences. Iran JMed Eth 2010; 4(12): 39–54.

29.

Borhani

Abbaszadeh

Mohamadi

, et al. Moral sensitivity and moral distress in Iranian critical care nurses. Nurs Ethics 2017; 24(4): 474–482. https://pubmed.ncbi.nlm.nih.gov/26419438/

30.

Shariat

Eshtad

Ansari

. Empathy and its correlates in Iranian physicians: a preliminary psychometric study of the Jefferson scale of physician empathy. Med Teach 2010; 32(10): e417–e421.

31.

Fashami

Nili

Mottaghi

, et al. Measuring empathy in Iranian pharmacy students: using the Jefferson scale of empathy-health profession students. Am J Pharm Educ 2023; 87: ajpe8687.

32.

Sedaghati Kesbakhi

Rohani

Mohtashami

, et al. Validity and reliability of the Jefferson scale of empathy, nursing student version R in a sample of Iranian oncology nurses. Nurs Midwifery Stud 2016; 6(2): e39505.

33.

Asghari

Saed

Dibajnia

. Psychometric properties of the depression anxiety stress scales-21 (DASS-21) in a non-clinical Iranian sample. Int J Psychol 2008; 2(2): 82–102.

34.

Cortina

. What is coefficient alpha? an examination of theory and applications. J Appl Psychol 1993; 78(1): 98–104.

35.

Tabachnick

Fidell

. Using multivariate statistics. Boston, MA: Pearson/Allyn and Bacon, 2007.

36.

Shrestha

. Detecting multicollinearity in regression analysis. Am J Appl Math Stat 2020; 8(2): 39–42.

37.

Stage

Carter

Nora

. Path analysis: an introduction and analysis of a decade of research. J Educ Res 2004; 98(1): 5–13.

38.

Hooper

Coughlan

Mullen

. Evaluating model fit: a synthesis of the structural equation modelling literature. In: 7th European Conference on research methodology for business and management studies, London, UK, 2008, pp. 195–200.

39.

Bentler

. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Modeling Multidiscip J 1999; 6(1): 1–55.

40.

Eom

Kim

S-S

. Factors associated with nurses’ moral sensitivity. J Korean Acad Psychiatr Ment Heal Nurs 2018; 27(3): 199–207.

41.

Hamington

. Empathy and care ethics. The Routledge handbook of philosophy of empathy. Oxford, UK: Routledge, 2017, pp. 264–272.

42.

Hoskins

Grady

Ulrich

. Ethics education in nursing: instruction for future generations of nurses. Online J Issues Nurs 2018; 23(1).

43.

Hojat

Gonnella

Nasca

, et al. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiatry 2002; 159(9): 1563–1569.

44.

Abstract

. Emotional labour: skill and work in the social regulation of feelings. Sociol Rev 1989; 37(1): 15–42.

45.

Brunero

Stein-Parbury

. The effectiveness of clinical supervision in nursing: an evidenced based literature review. Aust J Adv Nursing 2008; 25(3): 86–94.

46.

Aloufi

Jarden

Gerdtz

, et al. Reducing stress, anxiety and depression in undergraduate nursing students: systematic review. Nurse Educ Today 2021; 102: 104877.

47.

Church

Rotolo

Marguilies

, et al. The role of personality in organization development: a multi-level framework for applying personality to individual, team, and organizational change. J Organ Chang Dev 2015; 23: 91–166.

48.

Guillaumie

Boiral

Champagne

. A mixed‐methods systematic review of the effects of mindfulness on nurses. J Adv Nurs 2017; 73(5): 1017–1034.

49.

Navarro-Carrillo

Alonso-Ferres

Moya

, et al. Socioeconomic status and psychological well-being: revisiting the role of subjective socioeconomic status. Front Psychol 2020; 11: 1303.