Examination of ethical intelligence and cognitive flexibility of nurses and their role in predicting the level of patient privacy protection

One of the most important aspects of health services is the ethics and adherence to ethical principles by the providers of these services [1]. Since the promotion of health and prevention of future diseases in any society is the responsibility of medical professionals, it is necessary to adopt the best educational paths to maintain health security [2]. Education is not only about theoretical and practical lessons but also requires teaching a series of principles that are the foundation of every matter; one of these principles is ethics and ethical considerations [3]. In treatment, to achieve the main goal of the care team, which is the health of the patient, the patient’s trust in the treatment team is essential, and the prerequisite for trust is adherence to ethical principles. Therefore, to enhance community health, it is necessary for ethical principles to be seriously observed among healthcare staff to achieve therapeutic goals by gaining the trust of patients [4].

A hospital is an organizational structure with specialized personnel having diverse orientations participating in various aspects of patient care [5]. One of the most significant service providers in this organization is nurses [6]. Since nurses constantly face numerous ethical decisions throughout the care and treatment of patients, they are more susceptible to ethical issues in their workplace compared to other healthcare professionals [7]. Ethical intelligence, as a foundation for proper human performance, is one dimension of intelligence and can predict behavior [8]. It entails the ability to perceive right from wrong, possess strong moral beliefs, and act on them [9]. Ethical intelligence plays a constructive role in improving the job and psychological status of nurses [10]. Nurses with high ethical intelligence can discern pain and suffering in others, control ruthlessness and temptation within themselves, listen impartially, accept differences, explore various human values, reject unethical options, fight injustice, understand others, and treat them respectfully [11]. Nurses with high ethical intelligence can ensure the health institutions’ well-being and optimize their position [12]. Furthermore, by enhancing their ethical intelligence, nurses can effectively interact with colleagues and patients [13]. High ethical intelligence of nurses helps them adhere to ethical standards in their performance and positively impacts nursing services, the quality of nurses’ work, and the improvement of patients’ recovery processes [14]. Having desirable ethical intelligence and adhering to ethical principles enable patients to receive nursing care with greater confidence and trust [8]. Any breach of ethical standards by nurses can affect even the most scientific and best nursing care [12]. Additionally, ethics and ethical values derived from appropriate ethical intelligence in nurses can reduce costs associated with control and improvement of relationships, increase understanding, and reduce conflicts [15]. On the other hand, the results of some studies indicate the impact of ethical intelligence on certain variables. A study by Sadeghi and colleagues demonstrated a positive and significant relationship between nurses’ ethical intelligence and patient satisfaction, indicating that patients were more satisfied with nurses who had higher ethical intelligence [16]. The findings of a review study by Yousefi and colleagues indicated that identifying ethical intelligence is considered a fundamental and essential requirement in nursing, as becoming a good nurse is not solely dependent on theoretical knowledge and clinical skills but also on the development of ethical experiences in the application of this knowledge and ethical responsibility [17]. Therefore, adherence to ethical criteria in the performance of nurses is more sensitive and important in comparison to other aspects of care, as ethical behavior combined with nurses’ responsibility can be considered an effective factor in the improvement and recovery of the health of patients and beneficiaries [18].

In today’s rapidly changing world, another determinant factor for desirable nursing performance in the hospital environment is having an adequate level of cognitive flexibility [19]. Cognitive flexibility is the ability to adapt cognitive and behavioral strategies in response to constant environmental changes [20]. In fact, cognitive flexibility refers to the ability to understand the controllable aspects of challenging and complex situations, provide interpretations and diverse solutions for these situations, and not avoid challenging situations [21]. This concept is defined as a dynamic process, responsible for creating positive adaptation despite opposing experiences in an individual [22]. New theories view cognitive flexibility as a multidimensional structure that includes fundamental variables such as personality, specific skills, and problem-solving skills [23]. Cognitive flexibility also plays an important role in health-related behaviors [24]. Flexible individuals are curious both internally and externally, enriching their lives with a variety of experiences [25]. They enjoy and seek out new opportunities, actively confronting and exploring different types of experiences [25]. Nurses belong to the category of professionals responsible for the health and well-being of individuals, bearing a set of relatively challenging responsibilities in the fields of physical health and mental hygiene, facing a number of physical and psychological stressors in the workplace, including long working hours, heavy workload, required and unrequired overtime, among others. Long-term activity of nurses in such an environment can lead to their disorder and incorrect performance [26]. The result of this condition may endanger their physical and mental health, including the risk of developing cardiovascular and gastrointestinal diseases, reduced immunity, chronic fatigue, job burnout, and depression [27]. Indirect consequences include a reduction in the quality of care provided by nurses, more frequent medical errors, and thus decreased patient satisfaction [28]. In this context, cognitive flexibility can play a significant role in managing and controlling these conditions [29]. According to some studies, nurses’ cognitive flexibility can help improve and enhance their quality of work and personal life, thereby ensuring the provision of high-quality services by nurses in work environments such as hospitals [30‐32]. Studies conducted in Iran have shown that the average cognitive flexibility score (with a score range of 20–140) of nurses working in hospitals ranges from 73.66 [33] to 93.32 [34], indicating the need for improvement in this essential component among nurses.

In hospital environments, one of the most critical relationships that is consistently emphasized and stressed is the nurse-patient relationship, as this relationship plays a significant role in the recovery of patients’ health and the provision of quality services [35]. According to previous studies, among the factors that can facilitate and enhance this relationship, the ethical intelligence of nurses [36, 37], and their cognitive flexibility [29] can be mentioned. Nurses with desirable ethical intelligence and cognitive flexibility are likely to establish a comprehensive relationship with their patients, taking into account the preservation of human dignity and understanding different conditions and situations from simple to complex, guiding them on the path to recovery [29, 36, 37]. Alongside other factors, what matters on this path is the preservation of patients’ privacy. The need to preserve privacy is one of the fundamental human rights [38], and the human personality, in terms of beliefs, culture, moral standards, plays a significant and fundamental role in the recovery from illness [39]. Therefore, privacy must be considered as one of the key concepts in nursing [38]. Patients need to feel comfortable revealing information to nurses and other healthcare professionals, and without trust in them, they may refrain from giving essential information for their care or distort information [40]. In other words, the need to preserve privacy and, consequently, the preservation of dignity is one of the fundamental needs of patients. Since one of the critical aspects of nursing is striving to meet the needs of beneficiaries, nurses, along with other healthcare team members, should pay full attention to the positive and respectful behavior of beneficiaries to meet their four essential needs: solitude, independence, security, and identity. This is because preserving privacy can have consequences such as fostering positive relationships with employees, creating a sense of security, reducing the duration of hospitalization by reducing psychological problems caused by privacy violations [41]. Based on studies, nearly one-fourth of admitted patients in hospitals report that their privacy has not been respected [42]. Findings from a study by Sadeghi indicate that privacy was not respected in one-third of cases in Iranian hospitals [43]. A study by Kuzu and colleagues in Turkey showed that the right to solitude and personal privacy of patients was preserved in 68.1% of cases [44]. The results of Erdil and Korkmaz also revealed that some patients’ boundaries were disregarded [45]. The findings of a study by Nayeri and colleagues in Iran indicated that respecting privacy was weak to moderate in 50.6% of patients [46].

A review of past studies shows that the three variables of ethical intelligence, cognitive flexibility of nurses, and patient privacy protection have mostly been examined separately, and few studies have simultaneously examined two or all three mentioned variables. Also, Considering the importance of ethical intelligence and cognitive flexibility of nurses in the hospital environment to provide quality health services, accelerate the treatment and recovery process of patients, as well as the significant role that respecting patients’ privacy has in their satisfaction and comfort during their hospitalization, this study aimed to examine the ethical intelligence and cognitive flexibility of nurses and their role in predicting the extent of respecting patients’ privacy.

According to the descriptive findings, the majority of patients included in the study were in the age group of 20–35 years (35.80%), male (56.98%), urban residents (55.58%), married (47.71%), with a diploma or higher education (64.94%), and with a monthly income level of ten to twenty million Iranian Rials (51.45%). There was a statistically significant positive correlation between the age of patients and their level of patient privacy compliance (p = 0.04). As patients’ age increased, their level of patient privacy compliance also increased. The mean score of patient privacy compliance was significantly higher among women (45.82 ± 15.31) compared to men (42.02 ± 13.65), urban residents (46.29 ± 16.14) compared to rural residents (41.55 ± 14.28), and those with a diploma or higher education (44.62 ± 14.16) compared to others. Furthermore, with an increase in the monthly income level of patients, the mean score of patient privacy compliance significantly increased (p < 0.05) (Table 2).

Furthermore, the average age of participating nurses was 30.23 ± 6.46 years, with the majority (52.65%) being under 30 years old. The average work experience was 7.23 ± 6.45 years, with most (63.82%) having less than 10 years of experience. The majority of participants were female (60.88%), held a bachelor’s degree (87.06%), worked more than 20 shifts per month (70%), and had more than 3 patients under their care during each shift (80.59%).

Significant correlations were also found between the age and work experience of nurses and their cognitive flexibility. As age and work experience increased, the cognitive flexibility of nurses also increased (p < 0.05). Moreover, the average score of cognitive flexibility among nurses varied significantly based on their educational level (p = 0.04), the number of shifts per month (p = 0.01), and the number of patients under their care during each shift (p = 0.003). Nurses with a master’s degree had a higher average score of cognitive flexibility (77.38 ± 17.24) compared to those with a bachelor’s degree (71.74 ± 15.46), and this average score decreased with an increase in the number of shifts per month and the number of patients under their care during each shift (Table 3).

According to Table 4, the overall average scores for nurses’ ethical intelligence and cognitive flexibility were 98.33 ± 18.06 (out of 200) and 74.56 ± 16.76 (out of 140), respectively. These scores indicate a moderate level of these two variables among the nurses in the study.

The overall average scores for patients’ privacy preservation regarding both the preservation of human territory and the preservation of personal space were 38.26 ± 4.25 (out of 60) and 41.48 ± 6.49 (out of 90), respectively, as shown in Tables 5 and 6. In the preservation of human territory and the preservation of personal space, the highest average was related to " moving chairs or other items from the patient’s room without permission (3.44 ± 0.39 (out of 5)) " and " Respecting the privacy of patients during discharge (2.61 ± 0.31 (out of 5)) “, respectively. Furthermore, the overall average score for patients’ privacy preservation was 79.74 ± 14.53 (out of 150), indicating a moderate level of privacy preservation among the patients.

In accordance with Table 7, a statistically significant correlation was observed between nurses’ moral intelligence and cognitive flexibility with the level of patient privacy preservation. (Table 7).

The results of multiple linear regression analysis, aimed at determining the simultaneous impact of various dimensions of nurses’ moral intelligence on the level of patient privacy preservation, indicated that the significant variables in the model determined using the Enter method were, in order of importance: “perseverance and insistence on rights, action based on principles, values, and beliefs, responsibility for personal decisions, taking responsibility for serving others, the ability to forgive one’s own mistakes, the ability to forgive the mistakes of others, honesty, acknowledgment of mistakes and failures, commitment to promises, and empathy for others.” This suggests that these dimensions had a meaningful impact on the level of patient privacy preservation.

Additionally, regression analysis to determine the simultaneous effect of different dimensions of nurses’ cognitive flexibility on the level of patient privacy preservation indicated a significant influence of the dimensions of these variables, namely perception of control, perception of multiple solutions, and perception of justifications.

The β values for the influential variables, which indicate the priority of their impact on the level of patient privacy preservation, are presented in Table 8. Furthermore, this analysis showed that the adjusted model determination coefficient (R² Adjusted) for the level of patient privacy preservation based on the variables of nurses’ moral intelligence and cognitive flexibility is 0.51 and 0.62, respectively. This means that 51% and 62% of the variation in the patient privacy preservation score can be explained by the variables in the model.

The linear equations for the patient privacy preservation score based on the variables in the explanatory model are as follows:

(Where Y represents the patient privacy preservation score, and X₁ to X₁₀ are the influential variables, with moral intelligence of nurses as the reference variable).

(Where Y represents the patient privacy preservation score, and X₁₁ to X₁₃ are the influential variables, with cognitive flexibility of nurses as the reference variable).

The study estimated nurses’ ethical intelligence at a moderate level. Contrasting findings were observed in other studies: Sadri Damirchi et al. (2019) reported weak ethical intelligence [52], Amini et al. (2015) found it above average [53], and Saied et al. (2018) and Nehrir et al. (2015) reported it at a moderate level [54, 55]. Further, Gorzin et al. (2015), Khajavi et al. (2020), and Tarazoj et al. (2017) indicated good to high levels [56‐58], while Dehghani et al. (2022) found very good scores in specialized care [59]. Variations in findings may be attributed to differences in research settings and populations. Given the moderate ethical intelligence in this study, enhancing nurses’ capabilities through training is essential, as it benefits stakeholders’ interests, workplace understanding, team performance, commitment, efficiency, and effectiveness [55].

The study revealed that ethical intelligence increases with age, corroborated by Nehrir et al. (2015), Dehghani et al. (2022), Ansari Shahidi et al. (2018), Majidi et al. (2018), Mohammadi et al. (2014), and Khajavi et al. (2020) [8, 55, 57, 59‐61]. Lapointe and Langlois (2007) and Bahrami et al. (2012) also reported a positive relationship between age and ethical intelligence [47, 62]. However, Saied et al. (2018) and Amini et al. (2015) found no significant correlation [53, 54]. This suggests that ethical intelligence, being acquirable, likely increases with age and experience, helping nurses distinguish between correct and incorrect actions through repeated exposure to various challenges.

Female nurses in this study exhibited higher ethical intelligence than males, supported by Nehrir et al. (2015) and Majidi et al. (2018) [55, 61], but contradicted by Amini et al. (2015), Ansari Shahidi et al. (2018), and Khajavi et al. (2020) who found no gender difference [53, 57, 60]. Saied et al. (2018) reported higher ethical intelligence in men [54]. These differences may stem from personality traits and women’s dual professional and household roles. The study also found that ethical intelligence decreased with an increase in shifts and patient load, consistent with Saied et al. (2018) who observed a negative relationship between moral intelligence and overtime hours [54]. This might result from the emotional and physical demands of clinical environments, affecting ethical decision-making. Married nurses demonstrated higher ethical intelligence, potentially due to increased responsibilities and sensitivity to ethical issues. However, Saied et al. (2018) and Khajavi et al. (2020) reported no significant difference based on marital status [54, 57]. Nurses with a master’s degree had higher ethical intelligence, as also found by Saied et al. (2018), Majidi et al. (2018), Pierce and Sweeney (2010), Hernandez and McGee (2013), and Goldman and Tabak (2010) [54, 61, 63‐65]. Conversely, Amini et al. (2015), Nehrir et al. (2015), and Khajavi et al. (2020) found no significant relationship with education level [53, 55, 57]. The variations could be due to different study environments, suggesting that ethical intelligence evolves with education and age.

Cognitive flexibility among nurses was also moderate, aligning with Mirkamali et al. (2021), Sadri Damirchi et al. (2019), Shams (2020), and Veismoradi et al. (2023) [52, 66‐68]. Bahari (2021) and Fallah Madvari et al. (2022) found high levels [50, 69], while Feshangchi and Ranjbar Noushari (2020) reported low levels [70]. Differences may be due to varying hospital settings and personality traits. Cognitive flexibility helps nurses manage stress and maintain positive emotions, aiding in patient care. Cognitive flexibility increased with age in this study, contradicting Entezari et al. (2018) who found it decreases with age [71], but aligning with Holmberg et al. (2020) who found no significant relationship [72]. Older nurses may adapt better to changing environments, enhancing their cognitive flexibility and control over patient care.

Patient privacy preservation by nurses was moderate, similar to findings by Dehghani et al. (2016), Hajbaghery et al. (2014), and Sabet Sarvestani et al. (2019) [73‐75]. Moogahi et al. (2020) reported high levels [76], while Rasti et al. (2014) found it moderate [51]. Differences may stem from varying patient expectations and cultural norms. Privacy preservation increased with patient age, differing from Rasti et al. (2014) and Sabet Sarvestani et al. (2019) who found no significant difference [51, 75]. Zihaghi et al. (2016) reported an inverse relationship [77], while Harorani et al. (2017) found a significant correlation [78]. Variations may be due to different cultural backgrounds and societal norms. Female patients perceived higher privacy preservation than males, supported by Noorian et al. (2016) [79], but contradicted by Aghajani and Dehghannayeri (2010) and Rasti and Jahanpour (2014) [51, 80]. Differences may arise from varying perceptions and expectations between genders. Urban residents reported higher privacy preservation than rural ones, aligning with Rasti and Jahanpour (2014) [51] but contradicting Zirak et al. (2015) [81]. Differences in awareness and expectations may contribute to these variations. Patients with higher education perceived better privacy preservation, supported by Rasti and Jahanpour (2014) and Harorani et al. (2017) [51, 78], but not by Noorian et al. (2016) or Zirak et al. (2015) [79, 81]. Education may influence patients’ expectations and perceptions of privacy.

A positive correlation was found between nurses’ emotional intelligence, cognitive flexibility, and patient privacy preservation, aligning with Kalantari et al. (2020) and Mahdiyoun et al. (2017) [82, 83]. Higher emotional and cognitive skills in nurses enhance their sensitivity to ethical and privacy issues. Regression analysis identified emotional intelligence dimensions (resilience, principle-based action, responsibility, honesty, commitment) and cognitive flexibility dimensions (control perception, perception of multiple solutions, perception of justifications) as significant predictors of patient privacy protection. Sadeghi et al. (2015) and Mohammadi et al. (2014) also found similar predictors for patient satisfaction and education [8, 16]. Nazem et al. (2022) noted a direct relationship between cognitive flexibility and ethical sensitivity [84]. Enhanced cognitive flexibility aids nurses in managing ethical decisions, fostering trust and better patient care. In conclusion, ethical and cognitive skills in nurses are crucial for patient care quality. Enhancing these skills through targeted training and education can improve patient satisfaction and ethical standards in healthcare settings. Future studies should explore these relationships further across diverse healthcare environments.

The level of patient privacy protection is influenced by the level of ethical intelligence and cognitive flexibility of nurses. As the dimensions of ethical intelligence and cognitive flexibility of nurses increase, the level of patient privacy protection also increases. Therefore, to strengthen and improve patient privacy protection, it is necessary to take action to enhance the ethical intelligence and cognitive flexibility of nurses through educational, welfare, managerial, motivational, and occupational policies.