Introduction
Nursing is a health discipline consisting of science and art, responsible for the planning, organization, implementation and evaluation of care for the purpose of protecting, developing and healing the health and well-being of the individual, family, and society in case of illness [1]. Nursing is based on human behavior and the phenomenon of care. The concept that distinguishes the nursing profession from other health professions is the concept of “caregiving”. Care is a concept with a moral dimension based on bilateral relations and trust [2‐4]. Care includes establishing empathy with patients, providing support with them and individualizing nursing practices. Nursing care aims to provide transcultural care that is appropriate to patients’ needs, respectful of their cultural values and lifestyle, and humanistic [5, 6]. Care, which is the focus of nursing practice, is very important for the development of trust between the patient and the nurse [7, 8]. Nursing care is the most important role of the nurse [9]. Nursing care is the ability of nurses to combine and present their current knowledge, practical intelligence, judgment and specialized psychomotor skills in line with ethical principles and professional values [10, 11]. Medical errors made due to reasons such as lack of knowledge and skills, lack of development of decision-making and problem-solving skills, negligence or carelessness cause very serious problems in individuals [12]. Examples of errors that can cause serious life-threatening problems include giving the wrong medication to a patient, administering the medication in the wrong way, administering too much medication without calculating the dosage, and administering high doses of insulin to diabetics. Medical errors can result in harm to individuals and are against patient rights and ethical principles. They cause a decrease in patient safety and the quality of care. For this reason, nurses need to be aware of their moral responsibilities while providing care and be more sensitive to the care needs of individuals [13‐15]. Nurses may encounter some ethical problems while providing nursing care. Ethical problems are situations where hesitations or objections arise regarding the goodness of the behavior. They can be the case both in the mental process that determines the behavior and in the social environment in which the behavior is exhibited. There are two main categories of problematic situations related to ethics: “dilemma” and “violation” Ethical dilemmas are when health professionals are undecided between options and are in conflict about which action is more appropriate for the individual. Ethical violation is when individuals, groups or organizations abandon ethical rules and principles that society and/or the profession deems good, beautiful and correct and act contrary to these rules and principles. In this context, negligence, discrimination, bribery, etc. can be given as examples of ethical violations/unethical behaviors [16, 17]. Differences of opinion with health care professionals regarding the care and treatment of patients, protection of patient rights, care of patients in terminal stages, obtaining consent, sharing limited resources, and unethical attitudes of colleagues are ethical problems that nurses frequently encounter. The ethical dilemmas that nurses experience most frequently include; doctor’s orders, failure to provide information to the patient and family about diagnosis, treatment and prognosis, uncertainty about duties, authorities and responsibilities, administering the wrong medication to the patient, disregarding the patient’s independence, and conducting unauthorized research on the patient [18, 19]. It is imperative to develop ethical decision-making mechanisms to solve ethical problems in the care provided by nurses to patients. Nurses need to make the right decisions for health care and take professional responsibility for these decisions [20]. One of the valuable criteria for being a professional is to receive a qualified and sufficient education, and the other is to adopt professional ethical principles. The ethical principles adopted for the nursing profession are; providing benefit – do not harm, autonomy/respect for the individual, justice, equality, privacy, and confidentiality. It is thought that mutual respect will be seen, communication problems between health disciplines will be prevented and the quality of care will increase thanks to the health service provided with the ethical behavior to be implemented within the framework of these principles [21‐24].
Ethical behavior means that nurses should always prioritize the benefit of patients over their personal interests when performing their duties and should not enter into relationships (monetary or other self-interested relationships) that would make them dependent on others in relation to their duties. Ethical behavior in the nursing profession is behavior that is honest, fair, impartial, transparent for the individual and society, and requires respect for the values, differences and freedoms of all individuals [25‐27]. The ethical principles and ethical codes of the nursing profession guide nurses to provide the most appropriate care and make the right decisions for individuals from a professional perspective. Therefore, they play an active role in the development of correct ethical behaviors in nursing practices [28, 29]. The adoption of ethical behaviors and their becoming logical and consistent is likely to occur when nurses continuously use their theoretical knowledge and skills in their practices [30]. In relation to this situation, ICN (International Council of Nurses) recommends that nurses practice frequently about solving ethical problems [24]. The benefits of care ethics behaviors in nursing care are that correct sharing of professional knowledge and skills by nurses, as a result of which errors or deficiencies that may occur are determined in advance, correct practices are repeated continuously, and effective care is provided, resulting in job satisfaction and self-confidence in nurses. Ethical behaviors in nursing care aim to create a suitable environment for high-quality and low-cost healthcare services for individuals and to establish ethical behaviors in nurses [29‐32]. Ethical behaviors in nursing care contribute to the increase in satisfaction of individuals, to receive better nursing care, to reduce incorrect nursing practices and to reduce incorrect reporting. It is stated that ethical attitudes and behaviors in the care of nurses provide better services to individuals [33]. Incorrect nursing practices increase the cost of care for individuals, endanger patient safety and cause individuals to be dissatisfied. It is emphasized that ethical behaviors in nursing care increase the motivation of nurses, make them role models for their colleagues, make nurses feel safe, and strengthen them [34], increase moral sensitivity and contribute to the decrease in the intention to leave the nursing profession. It is stated that ethical behaviors exhibited in nursing care will contribute to the development and progress of the profession [35, 36]. For all these reasons, a significant change can be experienced for nursing in terms of developing ethical behavior, and it has been seen that certain scales need to be prepared for this approach, which will set an example for many professional groups, to become widespread and find a place in the literature. When the literature was examined, it was discussed that nurses experienced ethical problems and dilemmas at different levels during their practice, but it was determined that there was no scale development study examining whether the behaviors exhibited by nurses in their practices were ethical behavior. This scale development study was carried out to reveal the denominators that are effective in nurses’ ethical decision-making, especially in the nursing profession, and to reveal the extent to which they adhere to ethical values. It is important to measure the ethical behavior levels of nurses in order to provide effective ethical education for nurses and nursing students, to provide care with awareness of ethical values and to treat individuals in line with these values. Accordingly, this study aimed to develop a measurement instrument with valid and reliable criteria for determining nurses’ ethical behavior.
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Research question
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Is the “Ethical Behavior Scale in Nursing” valid for determining ethical behavior in nursing?
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Is the “Ethical Behavior Scale in Nursing” reliable for determining ethical behavior in nursing?
Methods
Study design and sample
This methodological mixed methods study with the GRAMMS criteria (Good Reporting of A Mixed Methods Study) was conducted at a state university in four hospital and three health faculty in Kocaeli, Turkey, between March 2020 and December 2022 [37, 38]. The study population consisted of 714 volunteer participants who were nurses employed in internal/surgical units, intensive care, and intern nurse who having recently received ethics training and completed clinical practice hospital where the study was conducted. The fourth-year nursing intern nurse in the final semester of the undergraduate program were included in the sample because they had spent a long time in the clinical area and were thought to have up-to-date knowledge about comparing what they learned during their education with what was applied in the field.
The research was carried out in two stages: qualitative and quantitative. The phenomenology method was used to holistically understand the individual expressions, opinions, and perspectives of nurses regarding the care ethical behavior in nursing practices [39]. In order to examine the views of nurses on care ethical behavior in detailed, the “individual in-depth interview method” was used. Then, the validity and reliability of the developed draft scale were evaluated.
Research process
The development of scales, which is of critical importance, is a process that has more than one stage and must be carried out meticulously [40]. In this context, various processes have been stated by different researchers regarding scale development. Carpenter (2018) states that literature review, at least one type of qualitative research, expert feedback and a pre-test are required at a minimum level in scale development studies [41]. Although there are relatively different perspectives on the scale development process in the literature, they appear to have many common points [42‐45].
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The development process of the Ethical Behavior Scale in Nursing (EBSN).
1.
Defining the structure to be measured.
2.
Reviewing the scales in the literature and appropriate wording was included in the draft form.
3.
Conducting in-depth interviews.
4.
Forming a item pool.
5.
Determining the type of measurement.
6.
Reviewing the statements by experts and making adjustments.
7.
Examining the edited statements by conducting cognitive interviews.
8.
Conducting a pilot application and eliminating statements.
9.
Conducting the final field application.
10.
Analyzing the obtained data.
11.
Reaching the final scale.
Conducting in-depth interviews
Qualitative data was collected by asking open-ended questions to nurses between March and November 2020. The first author is a female with a PhD in nursing who is experienced in qualitative research. The second author is a nurse who is a Professor at the Faculty of Health. The researchers had no prior relationship with the nurses. Interview process: First of all, nurses were informed about the purpose of the research, that it was voluntary, the confidentiality of the data, and how the qualitative interview would be conducted. Then, permission was obtained from the participants by informing them that a recording device would be used during the interviews. The first author conducted an all interviews face-to face in a meeting room on a specific day and time at the hospital where the study was conducted. Before starting the meeting, short speeches were made about the nursing profession. Then the interviewer asked, “What do you think nursing care means?” In order to determine nurses’ behaviors towards ethical care, the question was asked “How do you define ethical behavior?” During the interviews with the voice recorder, nurses were reminded that they could turn off the device whenever they wanted. In addition, permission was obtained from the hospital management for the voice records. Appropriate interview techniques were used to ensure that participants answered the questions asked in detail. Each interview lasted 30–60 min, with the average duration being 45 min. Interviews were terminated when data saturation was reached. Saturation refers to a point at which the researcher finds out that all the needed data have been collected and there is no any new relevant information or data that can be collected from the respondents or subjects of the study [46, 47]. Discussions were terminated when similar statements started to be repeated with 40 nurse. Considering that the students would be affected by the teacher in a phenomenological dimension, no in-depth interviews were conducted with intern nurse during the collection of qualitative data.
Forming the item pool
In scale development studies, techniques used in the expression pool creation phase include literature review, experience surveys, using insightful examples [48] or conducting in-depth interviews [49]. At this point, the structures included in the conceptual framework become the focus of this stage [42]. The statement pool should have a rich structure from which a scale can emerge and should contain many items related to the relevant content [44]. Within the scope of the expression development process of the study, firstly the scales encountered in the literature regarding the concepts of ethical behavior, ethical sensitivity, and ethical care were examined. During the statement development process, the scales in the literature were first examined by a researcher and a nursing academic who is an expert in the field, and 21 statements that were considered appropriate for the scale to be developed were identified [50]. As a result of the in-depth interviews conducted within the scope of the research, the transcriptions were examined and 41 statements appropriate to the context of the study were developed. As a result of all these studies, a pool was created with a total of 61 expressions.
Determining the type of measurement
Determining the type of measurement has an important place in scale development studies, and within the scope of the research, the stages of creating the expression pool and determining the type of measurement were carried out simultaneously. In the scale developed within the scope of the study, the Likert Additive Scale was preferred as the measurement type. The preference for this measurement type was influenced by the fact that it is more commonly encountered by participants in data collection practices in general [45] and that Likert-type measurement has a wide range of use in measurement tools to measure phenomena that cannot be measured directly, such as ideas, beliefs, and attitudes [44]. Ethical Behavior Scale in Nursing which is planned to be developed in a five-point Likert type (strongly disagree, disagree, undecided, agree, strongly agree). Additionally, multiple choice questions were added to the study to determine the demographic characteristics of the participants such as gender, marital status, age, occupation, education and income.
Review of statements by experts and making edits
During the creation of the study’s statement pool, 61-item were put forward by the researcher and an expert academician in the field as a result of existing scales, written sources and in-depth interview data, and were evaluated by ten academicians who are experts in the field of nursing. Content Validity Index (CVI) was used as a rating criterion for the items to be proven with numerical values and for the healthy evaluation of expert opinions. In this criterion, experts evaluated each scale item by scoring it between 1 and 4 according to the Davis (1992) technique [51]. The values of the scores are;
1.
Point: not appropriate
2.
Points: the item needs to be brought into an appropriate form,
3.
Points: appropriate but minor changes are required,
4.
Points: very appropriate.
By evaluating the scores given by the experts for each item, the items with 1 and 2 points were removed and rearranged. In the scope validity stage, if the experts evaluate 80% of the items between 3 and 4 points, the CVI score is determined as 0.80. In order to say that the scale has scope validity, the score must be 0.80 and above [52, 53]. The content validity of the EBSN was evaluated using four groups of experts: (1) professor doctor (n = 4); (2) associate professor (n = 2); (3) assistant professor (n = 4). Content validity was determined by the proportion of experts who scored items as 3 or 4. By evaluating the scores given by each expert for each item, the CVI score was determined as 1.00. A CVI score above 0.80 showed that scope validity was achieved. According to the expert opinions and the Davis analysis results, the draft scale was prepared with 61 items to be applied to the sample group.
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Examining the edited statements by conducting cognitive ınterviews
Cognitive interviewing is a qualitative method used in scale development processes to determine how potential participants interpret and understand the statements developed. The basic idea in this method is to learn what potential participants included in cognitive interviews understand from the statements directed to them and how they respond to these statements [44]. A combination of think-aloud protocols and probes are used in cognitive interviews. In the think-aloud protocol, the test taker is asked to verbalize his or her thought processes while responding to each test item [41, 43]. In order to observe whether the scale is understandable by people who have the characteristics that could be included in the sample that is planned to be determined within the scope of the research, the evaluations of 8 participants, four men and four women, were consulted. At this stage, one-on-one interviews were conducted with the participants and the statements were presented to them without any prior guidance and they were asked to express their opinions and evaluations verbally about what they understood from the statements and how they would respond to these statements.
Conducting the pilot ımplementation
Participants included in the pilot implementation should be asked to respond to the scale, as well as comment on the difficulties they encountered during this process, and to offer suggestions for improvement, including indicating statements they think are missing or should be deleted. Afterwards, the results of the pilot implementation should be examined and appropriate adjustments should be made to the scale based on the observations of the participants [42, 54]. It is generally recommended that the small sample group in pilot implementation [55, 56]. For this purpose, the pilot implementation was conducted with 30 participants. The data of the participants who underwent the pilot application were excluded from the sample.
Final field application
At this stage, it is necessary to obtain sufficient data from a suitably sized participant group to determine whether the statements developed have sufficient statistical quality [42, 44]. In the literature, it is recommended that the item ratio to be taken into account for the sample size should be 10/1 and it is argued that this ratio should be at least 2/1 [56‐58]. Appropriate samples can be selected as many as 5–10 times the total number of items [56‐59]. The quality or power of statistical analyses depends on the size of the selected sample [42, 60]. Comrey describes a sample size of 50 as very weak, 100 as weak, 200 as average, 300 as good, 500 as very good and 1000 as excellent [61]. Ultimately, the study was completed with 714 participants (330 nurse and 384 intern nurse).
Ethical consideration
Ethical approval
for this study was obtained from the Marmara University Health Sciences Ethics Committee (Approval no. 20.06.2019-133). In addition, the necessary permissions for conducting the study were received the hospitals and health faculties where the study was conducted. Participants were informed about the study, and their consent was obtained. All methods were conducted in accordance with the Declaration of Helsinki ethical guidelines.
Data analysis
The data was completed by transferring to IBM SPSS Statistics 23 (Statistical Package for the Social Sciences) and IBM SPSS AMOS 23 programs. While evaluating the study data, frequency distribution (number, percentage) is given for categorical variables and descriptive statistics (mean, standard deviation) are given for numerical variables. The validity of the EBSN was evaluated with tests of content validity and structure validity. Content validity was assessed based on experts’scoring in the of the expert consultation, item-level content validity index (I-CVI). Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed to assess the structural validity of the EBSN. Cronbach’s alpha coefficient was calculated to assess internal consistency reliability. The 6-week later, intraclass correlation coefficient (ICC) was used for test-retest compliance. Pearson correlation analysis was used for the relationship between scales and dimensions. P < 0.05 was accepted for significance.
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Results
Qualitative analysis
Qualitative data were used using deductive methods and content analysis. Within the scope of content analysis, interviews were documented, meaningful data were determined, an analysis matrix was created, data were analyzed and results were reported. After each interview, the voice recordings were listened to and the non-verbal information was included, and the raw data was transcribed verbatim into a Microsoft Word document. The audio recordings were listened to repeatedly, and the written document was checked. After all the data was transcribed, it was first read from beginning to end several times by the researcher. After the interviews, the data was listed, coding was done, and themes and sub-themes were created in line with the codes that came together in meaning.
Quantitative analysis
In totaly, 714 participants were included in the study. 53.8% (n = 384) of the participants are intern nurses and 46.2% (n = 330) are nurses. The mean age was 26.7 (SD = 11) and the majority (83%) were female. Educational status of nurses: 73.9% had a Bachelor’s level, 11.8% Associate level, 8.5% Health Vocational Qualification level and 5.8% Postgraduate level. The participants in the study work in medical/surgical units. Over half (66.1%) of all participants had satisfied with choosing the nursing profession (Table 1).
Table 1
Nurses’ characteristics of quantitative data (N = 714)
N | % | |||
|---|---|---|---|---|
18–28 | 143 | 43,3 | ||
Nurse | 29–39 | 87 | 26,3 | |
Age | 40 and plus | 100 | 30,4 | |
18–22 | 370 | 96,3 | ||
Intern Nurse | 23–27 | 13 | 3,3 | |
28–32 | 1 | 0,4 | ||
Nurse | Female | 318 | 96,3 | |
Gender | Man | 12 | 3,7 | |
Intern Nurse | Female | 273 | 71 | |
Man | 111 | 29 | ||
Participants | Nurse | 330 | 46,2 | |
Intern Nurse | 384 | 53,8 | ||
Nurse | Married | 174 | 52,7 | |
Marital status | Single | 156 | 47,3 | |
Intern Nurse | Married | 7 | 2 | |
Single | 377 | 98 | ||
Health Vocational Qualification | 28 | 8,5 | ||
Nurse | Associate level | 39 | 11,8 | |
Bachelor’s level | 244 | 73,9 | ||
Educational | Postgraduate level | 19 | 5,8 | |
Health Vocational Qualification | 64 | 16,6 | ||
Intern Nurse | Anatolian High School | 300 | 78 | |
Associate level | 17 | 4,4 | ||
Bachelor’s level | 3 | 1 |
Validity analysis
Validity is the degree to which a measuring tool can accurately measure the property it aims to measure without confusing any other feature [62]. In this study, the construct validity was tested by factor analysis. Factor analysis is defined as a multivariate statistic that aims to find or discover a small number of conceptually significant new variables (factors or dimensions) by bringing together a large number of interrelated variables. An exploratory factor analysis (EFA) was conducted to determine the factorial structure of the 61-item Ethical Behavior Scale In Nursing draft form. EFA is the most used and most basic factor analysis method in the scale development process [56, 62]. First, Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of Sphericity were applied to determine the suitability of the sample size and the instrument for factor analysis. In the study, the Kaiser-Meyer-Olkin (KMO) coefficient was determined as 0.95 and the result of Bartlett’s sphericity was χ2:8915,124, df:190 and statistically significant (p < 0.001). As a result of the KMO and Bartlett tests, exploratory factor analysis was first applied to the data set and the “Principal Components Method” was preferred as the factor extraction method. A limitation was imposed on the number of factors and they were collected in 5 dimensions. As a result of factor analysis, the number of items decreased from 61 to 20. It was observed that these 20 items were collected into 5 factors and all factor loadings were above 0.40. It was determined that the factor loads of 20 items varied between 0.461 and 0.786, and the item-total correlations were between 0.437 and 0.799.
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As a result of the variance analysis, it was determined that the items constituting the scale exhibited a five-factor structure with an eigenvalue above 1 and that these five factors explained 70.45% of the average variance extracted (AVE). It was determined that the variance explained by the first factor was 18.23%; the variance explained by the second factor was 14.07%; the variance explained by the third factor was 13.14%; the variance explained by the fourth factor was 12.71%; and the variance explained by the fifth factor was 12.30%.
The load value in factor analysis is the critical value used to determine whether an item should be included in the sub-dimension where it is defined. An item is usually expected to have a load value ≥ 0.45 [53, 56]. The load values of items are deemed important in terms of their representativeness, and removing items with load values < 0.45 may be important for building a stronger structure for the scale. When the 41 items with load values < 0.45 were removed from the scale, the percentage of variance explained by the five factor structure 70.45%. Hence, it may be stated that the percentage of the variance explained by the scale was very high and sufficient. The minimum required value for the item-total test correlation to be sufficient is specified as 0.30 [56, 62]. Items below 0.30 among the scale items whose item correlations we examined were not included in the analysis. The item-total test correlation values of the remaining items varied between 0.46 and 0.78 (Table 2).
Table 2
EBSN items factor loading results
Factor Load | Variance Explanation Rate | Eigen Value | Naming | ||
|---|---|---|---|---|---|
I52. | I take care to allocate sufficient time to individuals for nursing care. | 0,744 | |||
I39. | I take enough time to listen to individuals. | 0,727 | |||
I45. | I attach importance to the satisfaction of individuals in qualified nursing care. | 0,696 | 18,23 | 3,647 | Attitude |
I56. | I take care to ensure the comfort of individuals. | 0,640 | |||
I54. | I allow individuals to express their feelings and thoughts about health/illness. | 0,614 | |||
I19. | I provide care taking into account individuals’ values and beliefs. | 0,777 | |||
I20. | I strive to provide holistic and humanistic nursing care to individuals. | 0,738 | 14,07 | 2,815 | Moral Value |
I18. | I respect the privacy of individuals in nursing care. | 0,710 | |||
I13. | I respect the decisions individuals make. | 0,461 | |||
I1. | I help meet the needs of individuals in nursing care. | 0,764 | |||
I4. | I listen to individuals carefully. | 0,738 | 13,14 | 2,630 | Behavior |
I5. | I explain individuals’ questions in understandable language. | 0,732 | (Activity) | ||
I29. | I report cases of neglect or abuse to the competent authorities when I suspect them. | 0,719 | |||
I30. | I ensure the safety of individuals and implement initiatives to take the necessary precautions. | 0,706 | 12,71 | 2,542 | Patient Safety |
I31. | I ensure that individuals are informed about their care in an accurate, adequate and understandable way. | 0,589 | |||
I26. | I assume the necessary responsibility for the nursing care of individuals in need of protection. | 0,509 | |||
I60. | I believe that nurses’ compassion fatigue/burnout has a negative impact on nursing care. | 0,786 | |||
I61. | I believe that supporting and motivating nurses by their managers will have a positive impact on nursing care. | 0,750 | 12,30 | 2,462 | Belief (Believe) |
I49. | I think that professional experience will affect the quality of nursing care. | 0,591 | |||
I50. | I believe that the professional values of the nurse will affect the quality of nursing care. | 0,562 | |||
EBSN | 70,45 |
For the construct validity of the scale, the “goodness-of-fit” applied in the confirmatory factor analysis must be at the desired level. The instrument’ construct validity was examined using CFA which tests the validity of the factor model and the goodness-of-fit indices that indicate a good fit between the structural model and data (RMSEA = 0.05; SRMR = 0.03; GFI = 0.93; IFI = 0.95; CFI = 0.95; NFI = 0.94; TLI = 0.95). Fit measurements (goodness-of-fit indices x²/df value) were evaluated for the dimensions included in the model. The x²/df value for model fit was found to be 3.33 (Table 3).
Table 3
EBSN Goodnes-of-fit indicate
Index | Good-fit | Acceptable-fit | Values |
|---|---|---|---|
χ2/df | 0 ≤ χ2/df ≤ 3 | 3 ≤ χ2/df ≤ 4 | 3,334 |
GFI | 0.95 ≤ GFI ≤ 1 | 0.90 ≤ GFI ≤ 0.95 | 0,930 |
NFI | 0.95 ≤ NFI ≤ 1 | 0.90 ≤ NFI ≤ 0.95 | 0,941 |
TLI | 0.95 ≤ TLI ≤ 1 | 0.90 ≤ TLI ≤ 0.95 | 0,950 |
IFI | 0.95 ≤ IFI ≤ 1 | 0.90 ≤ IFI ≤ 0.95 | 0,958 |
CFI | 0.95 ≤ CFI ≤ 1 | 0.90 ≤ CFI ≤ 0.95 | 0,958 |
RMSEA | 0 ≤ RMSEA ≤ 0.05 | 0.05 ≤ RMSEA ≤ 0.08 | 0,057 |
SRMR | 0 ≤ SRMR ≤ 0.08 | 0.05 ≤ SRMR ≤ 0.10 | 0,036 |
Finally, the final version of the questionnaire was developed with 5 dimensions: attitude (5 items), ethical value (4 items), behaviour (3 items), patient safety (4 items) and belief (4 items) (Fig. 1).
Fig. 1
5 Dimension 1. CFA Model
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Cronbach’s alpha reliability coefficient is an ideal method for determining internal consistency in Likert-type scales, and it shows the agreement of the items in the scale [63]. The Cronbach’s alpha for the five factors or subscales ranged between 0.78 and 0.87. The overall Cronbach’s alpha coefficient was 0.94. The highest Cronbach’s alpha was found in the “attitude” subscale 0.87 and the lowest in the “belief” subscale 0.78. Test-retest was conducted 6 weeks later with 50 nurses who could be reached. The Pearson correlation analysis for the test-retest reliability of the scale showed a strong, positive, and statistically significant relationship (r = 0.97; p < 0.001).
Finally, the Ethical Behavior Scale In Nursing is a five-factor, 20-item scale using a 5-point Likert-type format with responses ranging from absolutely disagree to absolutely agree. The minimum score that may be obtained is 20, and the maximum possible score is 100. Higher scores indicate that nurses’ attentive care behaviors regarding ethical behavior increase.
Discussion
In the study, content validity and construct validity were used to evaluate the validity of the scale. One of the logical methods used to test content validity is to present the scale items to the opinion of experts [56]. The 61-item draft scale was submitted to the opinion of 10 experts and the I-CVI was found to be 1.00. According to Veneziano and Hooper (1997) [64], the minimum value of I-CVI for 10 experts is 0.62 at the 0.05 significance level. This finding shows that the content validity of the scale is high and that the scale is a tool that can measure nurses’ care ethics behaviors. The construct validity of the EBSN was conducted with explanatory and confirmatory factor analysis. Kaiser-Meyer-Olkin (KMO) adequacy measurement and Bartlett Sphericity test were used to measure the applicability of the sample size for factor analysis. Bartlett’s sphericity test being significant (p < 0.05) shows that the data set has multivariate normality. KMO takes a value between 0 and 1. If this value approaches one, it indicates that it is appropriate to perform factor analysis on the data group. In this study, the KMO sample adequacy measurement value was determined as 0.956. This value shows that the sample size is perfect for factor analysis and that it is extremely appropriate to analyze the relevant data group. Thus, it can be seen that the factor analysis results applied to the data will be useful and usable. Bartlet’s Test of Sphericity was used to test the hypothesis whether the correlation matrix is a similar matrix, and the fact that Bartlett’s value was p = 0.000 shows that the factor analysis is interpretable. When the distribution of items to factors is examined using the Varimax rotation technique, it explains 70.45% of the total variance of the five-factor structure. The total variance explained in multi-factor scales is expected to be over 30%, and each subscale is expected to have at least 10% variance [62, 65]. The higher the variance ratios obtained as a result of the analysis, the stronger the factor structure of the scale. It was observed that the total variance explained by the five-factor structure of the scale and the variance explained by each sub-factor were high. Therefore, according to the research results, the variance value determined for the scale is appropriate. As a result of factor analysis, 61 items with factor loadings below 0.40 were removed from the scale. When the factor analysis was repeated with the remaining items, it was seen that the scale exhibited a five-factor structure. It was determined that the factor loads of 20 items varied between 0.461 and 0.786. The item-total correlations were between 0.437 and 0.799. In this case, it was seen that the items of the scale were sufficient to distinguish the feature to be measured.
CFA was performed to test the construct validity of the scale. When examining the adequacy of the fit indices of the CFA model, care should be taken to ensure that the RMSEA and SRMR fit measurements are below 0.10. The fact that χ2/df is 0 < χ2/df < 4 indicates good fit, proving that the model is confirmed [66, 67]. According to the confirmatory factor analysis results; RMSEA fit measurement is 0.05, SRMR 0.03 and χ2/df is 3.33 indicating acceptable fit. It should be said that the fit indices of the scale are acceptable.
Cronbach’s alpha coefficient was calculated for internal consistency reliability to determine whether all aspects of the scale were capable of measuring. Cronbach’s alpha value for the entire scale was determined as 0.94. When the Cronbah’s alpha values of the sub-dimensions are examined respectively, the attitude is 0.87; ethical value 0.85; behavior is 0.84; patient safety is 0.86; belief is 0.78. In scale development studies, the Cronbah’s alpha value, which is the reliability coefficient, is 0.70 and above, indicating that the scale is considered reliable [68, 69]. Cronbach’s alpha values for the definition and sub-dimensions of the scale were found to be quite high. These values show that the scale is a reliable measurement tool. An item total score correlation coefficient of 0.30 or above is interpreted as good for reliability. However, it is not used alone to eliminate items below this value; the decision is made by evaluating the effect of the item on the Cronbach’s alpha coefficient [42, 48, 53]. In this study, no item was found to be below 0.30. According to the item analysis results, the item-total score correlations of the 20 items ranged between 0.43 and 0.79. It was found that the item-total score correlations of the items in the scale had high distinctiveness. The test-retest method for the reliability analysis of the scale is performed to measure the invariance of the scale over time and the correlation value is expected to be over 0.70. A correlation value between 0.70 and 1.00 indicates a high level of relationship, and a correlation between 0.30 and 0.70 indicates a medium level relationship. Another method for analyzing the reliability of a scale is the test-retest method, where a correlation of scores is obtained by applying the same test on the same group two times within a certain interval. Test–retest reliability measures the temporal stability of scores from the scale. In this method, the correlation value is expected to be > 0.70 [62], with a correlation value between 0.70 and 1.00 indicating a strong relationship [56]. As a result of the test-retest, a high, positive and significant relationship was found between the total score averages obtained in the test and retest application, which were applied six weeks apart. The correlation values of the EBSN shows a high level of relationship and prove the invariance of the scale over time. According to these data, the scale is always applicable and reliable.
Limitations
This scale reveals nurses’ own opinions about whether their care behaviors are ethical or not. It can be used to measure whether nurses and intern nurses’ behavior in accordance with the ethical care. In the qualitative part of the research, intern nurses were not included because there was a teacher-student relationship between the interviewer and the intern nurses.
Conclusions
The findings of the analyses show that the items constituting the Ethical Behavior in Nursing (EBSN) have validity and reliability criteria that can measure the ethical behavior of nurses related to ethical care. EBSN can be used to determine the extent to which nurses perform their nursing care practices autonomously, respectfully, and taking into account the ethics of care. It can help nurses develop interventions that will promote quality nursing care with dignity and ethical principles. Nurse educators can plan and perform more effective and useful ethic lessons in this regard, thereby reducing the incidence of medical errors and increasing patient safety. It is recommended to use this scale in future studies to evaluate how nurses’ ethical behavior management affects patient outcomes. It is of great importance to take nurses’ knowledge and skills into account when developing their professional care behaviors. Studies regarding the development of nursing ethics codes still continue. Nurses’ practice of caring behaviors by paying attention to ethical codes may be useful in supporting nursing care.
Acknowledgements
We would like to thank all participating nurses and nursing students for sharing their knowledge and experiences.
Declarations
Ethics approval and consent to participate
All procedures were performed according to the ethical standards of the Declaration of Helsinki and the National Research Committee. This study was approved by the Ethics Committee of Marmara University, Health Sciences Ethics Committee (approval number: 133, date: June 20, 2019). Written informed consent was obtained from all participants or their legal representatives.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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