Revelation of the mediation role of moral sensitivity on safety attitude and personality traits among critical care nurses

Every individual is inherently entitled to the right to health, ensuring access to affordable, secure, and high-quality healthcare devoid of any impediments based on geographic location or healthcare providers [1]. Healthcare organizations now place a high premium on patient safety, which presents a challenge to hospital management. Nurses encompass a multifaceted construct, encapsulating their collective beliefs, perceptions, and values regarding patient safety and the surrounding work environment. This paradigm reflects the approach of nurses towards safety practices, ranging from positive safety-conscious attitudes to attitudes that may be less conducive to maintaining a safe environment [2].

Nurses’ safety attitudes impact the quality of patient care and the overall health of healthcare environments [3]. A positive safety attitude cultivates a sense of accountability and responsibility among nurses, engendering a collaborative and supportive atmosphere conducive to optimal patient outcomes. It is imperative to recognize and comprehend the influential factors shaping safety attitudes among nurses [4, 5].

Nurses’ ethical values and personalities are the most essential factors affecting nurses’ safety attitudes. Disparities in personality traits, such as conscientiousness or risk aversion, shape how nurses perceive and prioritize safety measures. Additionally, nurses’ moral values and ethical considerations influence commitment to patient safety [6].

Personality is the distinctive set of patterns influencing an individual’s actions, behavior, motivations, and emotions across various contexts and plays a crucial role in shaping moral decision-making. The Big Five Personality Traits Model categorizes these traits as Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness [9‐10]. According to Abbasi-Asl, Naderi, and Akbari (2016) [11], these personality traits play a crucial role in evaluating moral foundations such as authority, purity/sanctity, and loyalty.

Moral sensitivity denotes the capacity to discern patient vulnerabilities, anticipate the ethical implications of challenging decisions, and enable nurses to deliver more fitting and ethically sound care. Moral sensitivity augments proficiency in resolving conflicts arising from differing values. As highlighted by Esmaelzadeh et al. in 2017 [3], nurses endowed with refined empathetic skills tend to excel in moral sensitivity (Türkmen et al., 2023) [12].

The development of moral awareness, sensitivity, and attitudes typically occurs during nursing education, as indicated by studies such as Shayestehfard et al. in 2020 and Lim, Park, and Shin in 2017 [7‐8]. Overall, moral sensitivity empowers nurses to recognize moral dilemmas, intuitively understand the vulnerable position of patients in different situations, and comprehend the ethical ramifications of healthcare decisions, correlating with their personality traits that contribute to safety attitudes in nursing practice (Darzi-Ramandi et al., 2023) [13].

Moral judgment, when faced with ethical dilemmas, can be influenced by differences in personality traits [14]. Recent research has delved into the connections between fundamental personality traits and various factors that impact moral judgments [14‐15]. Our study uses the CNI model as a framework to quantify an individual’s characteristics and moral norms. This model includes three parameters: consequence sensitivity (C), norm sensitivity (N), and generalized action versus inaction preferences (I). The CNI model, when applied to moral dilemmas, has shown systematic relationships between sensitivity to moral norms and personality traits as measured by the Personality Inventory and Big Five trait models [16‐17].

Critical care nurses, in particular, are likely to confront moral challenges, making moral sensitivity crucial in their decision-making processes [18]. Critically ill patients confront the peril of injuries, fatalities, or disabilities due to the reception of substandard medical care, with a staggering 2.6 million patient deaths reported because of failing to meet safety criteria [19]. Consequently, there is an escalating imperative for nurses to exhibit adeptness in making ethical decisions and to prioritize the ethical dimensions of patient care, necessitating a heightened awareness of moral issues inherent to their professional domain [20].

The literature highlights several key findings of Mohammadi, Borhani, and Roshanzadeh in 2017 [21], which identified that critical care nurses who lack sufficient executive power for moral performance may experience moral distress, irrespective of their varying levels of moral sensitivity. Additionally, Salih et al., in 2021 [22], noted a neutral attitude among nurses toward patient safety at an Egyptian University Hospital, highlighting strong associations with educational level, years of experience, and participation in training courses on patient safety. Despite these insights, there remains a notable gap in the literature concerning the relationship between personality traits and moral sensitivity among critical care nurses in shaping their attitudes toward safety.

The revealing of the role of moral sensitivity on safety attitudes and personality traits among critical care nurses offers a nuanced understanding of the intricate interplay between these variables. Through a deeper understanding of moral sensitivity’s impact, nurses will be more likely to respond to ethical dilemmas and moral distress to improve safety practices and patient outcomes. Lastly, by illuminating the factors influencing moral sensitivity, this study can provide critical support for ethical decision-making in nursing practice, equipping nurses with the necessary tools to navigate complex ethical dilemmas and uphold the highest standards of patient care. Our study has two aims: first, to assess the mediation role of moral sensitivity on personality traits and the safety attitude of critical care nurses; second, to assess the correlation type between personality traits and moral sensitivity; and third, to assess the safety attitude of critical care nurses. Two hypotheses are presented in this study (Fig. 1).

Table (1) shows that 55.2% of the studied nurses were aged between 40 and 50 years and older, with a mean age of 41.45 ± 6.41. 55.6% were female, 69.8% were married, and 40.9% had a baccalaureate degree in nursing. In addition, 57.8% of studied nurses worked in the ICU, and 50% had ≥ 10 years of working experience with a mean ± SD 9.84 ± 3.26, 84.5%. 71.6% of them did not have training courses related to safety attitudes.

Table (2) Presents the personality profile of the studied nurses, where the total mean score of personality traits was (150.012 ± 9.628) with an average score (of 3.4094 ± 0.21883). The higher mean scores of personality traits were at conscientiousness (34.59 ± 2.765) followed by openness (36.163 ± 4.620), then extraversion (25.887 ± 2.284) compared to the lowest mean scores that were related to agreeableness (27.86 ± 3.1039) and neuroticism (25.508 ± 2.628).

Table (3) Reveals descriptive statistics of moral sensitivity subscales, where the mean score for total moral sensitivity was (121.73 ± 13.861) with a moderate average score (4.5088 ± 0.51338). The highest mean scores of moral sensitivity subscales were for interpersonal orientation (22.76 ± 3.339) and moral meaning (26.97 ± 4.279). While the lowest mean scores were for expressing benevolence (16.39 ± 3.889) and modifying autonomy (24.33 ± 6.712).

Table (4) Displays that the mean score of total safety attitude was (73.254 ± 11.368) with a low average score (2.4418 ± 0.37894). The highest mean scores of safety attitude subscales were related to perceptions of management (10.413 ± 2.613), followed by working conditions. While the lowest mean scores were related to safety climate (15.620 ± 3.046) and stress recognition (11.47 ± 2.819).

Table (5) clarifies the Pearson analysis results of the correlation among personality traits, moral sensitivity, and safety attitude. Pearson analysis reported a positive correlation between personality traits, moral sensitivity, and safety attitude (r = .214**, r = .218**, & r = .365**), respectively.

Figure (2) and Table (6) depict the mediation analysis of moral sensitivity in relation to the relationship between personality traits and safety attitude. The pathway from personality traits to moral sensitivity (B = 0.285, P = .002) and the pathway from moral sensitivity to safety attitude (B = 0.272, P < .0001) was positive and statistically significant. Moreover, the pathway from explicit personality traits to a safety attitude is positive and significant (B = 0.168, P = .024). Also, Model Fit Coefficients parameters were (χ2 = 224.157; P = .001; χ2/df < 1.546; GFI = 0.940; RMSEA = 0.018; NNFI = 0.956; SRMR = 0.165; CFI = 0.970; AGFI = 0.921, IFI = 0.915 & TLI = 0.965). These results clarified the positive direct effect of moral sensitivity and personality traits on safety attitude while the positive indirect effect of personality traits on safety attitude.

In the scientific literature on the issue, personality traits are considered a pattern of nurse behavior that is manifested and then practiced in everyday life. They affect patient safety attitudes as they are associated with how nurses’ moral sensitivity characteristics interfere with ethical patient issues and moral reasoning, which is an essential aspect for nurses every day and is affected by personality traits [31‐32]. So, this study was designed to assess the role of moral sensitivity of critical care nurses on their safety attitude and personality traits.

Firstly, personality traits were examined based on the personality profile of the participants. The means score of total personality traits was neutral toward positive traits among participants. The highest mean scores were related to conscientiousness, followed by openness and extraversion, while the lowest mean score was related to agreeableness and neuroticism. This may be explained by a high level of conscientiousness among nurses in the critical care units or intensive care unit, which is related to their degree of commitment to their work and the amount of impulse control they possess related to the critical patient’s case in this unit.

This result is supported by many previous studies [31, 32, 33‐34‐35], which reported that the highest mean score was for conscientiousness and the lowest score was for neuroticism. According to John and Srivastava in 1999 [26], conscientious people are achievement-oriented, have good impulse control, are rule-conforming, and are consistent. Nurses in critical care units, mainly in the ICU, must have a high level of conscientiousness. That reflects their degree of commitment to their work and the amount of impulse control they possess related to critical patients.

Neurotic individuals have a predisposition to experiencing negative emotions, such as anxiety, angry hostility, depression, self-consciousness, impulsiveness, and vulnerability. Wang and colleagues (2017) indicated that nurses got the lowest score for neuroticism [36]. Besides that, a recent study in Japan supported the current study results that neuroticism hurt critical care nurses’ competencies [26].

Agreeableness is characterized by pleasantness and a desire to preserve interpersonal harmony [26]. A highly agreeable person is thought to be cooperative. The lowest mean score for agreeableness may be attributed to the critical care unit’s high workload and stress levels. The constant influx of diverse cases and unexpected changes in patient’s conditions leave little time or energy for nurses to offer support or assistance to their colleagues [37, 38].

A scoping review of dominant personality types among nurses and paramedics revealed that the prevalent traits among them are characterized by low neuroticism and higher extraversion [39]. In the current study, nurses were characterized as having low extroversion, which means they tend to spend time alone without social stimulation. This is congruent with a previous study finding that nurses need less social connection in the work environment related to high workload and no time to develop social relations with other team members (Li et al., 2023) [40].

Second, we examined nurses’ moral sensitivity based on our findings, clarifying that from total mean scores, the participants had an average level of moral sensitivity. The highest mean score of the moral sensitivity subscale was for interpersonal orientation and moral meaning. The lowest mean score was for modifying autonomy, expressing benevolence, reliance on medical authority, and experiencing conflict.

The highest mean score on the moral sensitivity subscale was observed in the areas of interpersonal orientation and moral meaning. This result implies that participants are particularly attuned to the interpersonal dynamics of ethical situations and place a high value on the moral significance of their actions. This orientation towards interpersonal relationships and moral significance aligns with the nature of nursing practice, which often involves complex ethical dilemmas and requires a deep understanding of the impact of one’s actions on others. Consistent with earlier research by Dalcali and Şendir in 2016 and Yildiz and Yildirim in 2023 [41‐42], our study indicates that nurses exhibit moderate levels of moral sensitivity. This aligns with the findings of Arslan and Calpbinici in 2018 [43], who reported a similar mean score for moral sensitivity (95.89 ± 24.34) among pediatric nurses, suggesting a moderate level of moral sensitivity in this population.

Borhani, Abbaszadeh, and Hoseinabadi-Farahani in 2016 [44] identified that among nurses, the lowest mean scores were related to the dimensions expressing benevolence and autonomy. “Expressing benevolence” encompasses concepts such as honesty, trust in nurse-patient relationships, consideration of patient reactions to care, and patient knowledge about their illness. Similarly, Charles (2017) [45] found that nurses had low autonomy, which involves respecting patient autonomy and avoiding medical paternalism. This suggests that nurses may feel disempowered by medical paternalism or lack the skills needed for shared decision-making, potentially leading to increased patient dependency on passive relationships.

Third, we examined nurses’ safety attitudes based on our findings; the mean scores for total safety attitudes indicated that nurses’ safety attitudes were nearly neutral. This result is supported by a previous Egyptian study in 2017 [21]. Regarding the mean score for its subscales, the highest mean score was related to perceptions of management, working conditions, and teamwork climate; however, the lowest mean score was related to stress recognition and safety climate.

The highest mean score was observed in perceptions of management, indicating that participants generally perceive their management as supportive of safety practices. This positive perception of management is crucial, as leadership support is known to be a key factor in promoting a culture of safety and influencing frontline staff’s safety behaviors. Moreover, the high mean scores for teamwork climate and working conditions indicate that participants perceive a positive teamwork climate and favorable working conditions within their units [46‐47].

The current study revealed that the lowest score was related to stress recognition. It can be reasoned that nurses need to have the needed skills to assess their own internal and external stressors and recognize the stress when it occurs. This is in line with those of Raftopoulos and Pavlakis (2013) and Henry, Hunt, Kroetch, and Yang (2012) [48‐49] in that the lowest attitude score was in the domain of stress recognition. Besides that, the safety climate subscale was at a lower score. The safety climate is the perception of strong and constructive organizational commitment to safety. This result is consistent with a previous study by Gambashidze, Hammer, Ernstmann, & Manser in 2020 [50], which identified the safety climate as one of the weakest factors. This can be proved as the studied nurses did not receive any training courses related to safety, which reflected a negative organizational commitment to safety.

This result is supported by related studies [51]. Also, other studies [52‐53] showed a moderate level of professional attitude regarding patient safety, which is lower than the international standards attitude regarding patients’ safety. In a previous study by Saberi et al. in 2017 [53] showed that the highest rate of positive attitudes toward the patient safety culture belonged to the dimension of ‘management perception’. Furthermore, Al-Mugheed et al., in 2022, indicated that overall patient safety attitudes among doctors and nurses were negative [54].

The current study’s findings align with research conducted among doctors and nurses in Saudi Arabia, revealing negative attitudes toward all safety domains, which pose challenges for developing a safety culture [55]. This is consistent with studies by Lee et al. in 2010 and Mahfoozpour et al. in 2012 [56‐57], which reported a high percentage of positive attitudes among healthcare providers toward the perception of management. The positive perception in this dimension may be attributed to unit management rather than hospital management, indicating that unit management is more supportive of a patient safety culture, which ideally should be reflected throughout the entire hospital. The safety climate score of 17.49 (SD = 4.09) reflects the perception of a strong and constructive organizational commitment to safety [21].

Fourth, we examined the correlation between personality traits, moral sensitivity, and safety attitude; based on our findings, Pearson analysis reported a positive correlation.

This study’s findings are consistent with research conducted in the United Kingdom, which found that moral sensitivity, encompassing concepts such as authority, loyalty, sanctity, fairness, and care, is related to individual differences in personality traits [58]. Additionally, Jeong, Nam, Kim, and Son in 2021 [59] discovered a significant positive correlation between safety nursing activities and moral sensitivity, indicating that moral sensitivity positively influences safety nursing activities. These findings are in line with a previous Iranian study among nurses, which also showed a significant positive correlation between moral sensitivity, care behavior, and various dimensions [60]. Nurses’ moral sensitivity was observed alongside a notable degree of missed care, which poses risks to patient safety [61].

In a study conducted in Korea by Han, Seo, Kim, and Kim in 2018 [62] on moral sensitivity and compliance with infection standard precautions among 214 general hospital nurses, it was found that compliance with infection-related standard precautions increased significantly with higher levels of moral sensitivity. This suggests that nurses’ adherence to patient safety-related behavior is influenced by their internal sense of responsibility and ethics. Therefore, customized strategies to enhance moral sensitivity and promote quality safety nursing activities are essential.

Similarly, Mohammadi et al. in 2022 [63] highlighted the significance of moral sensitivity in ensuring ethical decisions and safe care, particularly in special care units where critical patients are treated. The authors suggested that moral sensitivity plays a crucial role in providing safe and ethical care in challenging situations.

In the broader literature, moral sensitivity is consistently identified as a critical attribute for nurses, enabling them to deliver high-quality and safe care, especially in critical patient care settings where they frequently encounter ethical and moral dilemmas. The ability to identify and respond to these challenges is essential, as moral insensitivity or an inability to recognize ethical issues may lead to inappropriate care behavior. Nurses’ decisions and actions are heavily influenced by their level of moral sensitivity, making it a key factor in ensuring responsive and ethical care delivery, particularly in complex healthcare environments [64].

Finally, the findings demonstrated that moral sensitivity acted as a mediating factor between personality traits and safety attitude. These findings confirm the positive direct effects of moral sensitivity and personality traits on safety attitude, as well as the positive direct effects of personality traits on moral sensitivity.

However, we could not directly compare our findings to the literature due to the rarity of studies that examined the mediating effects of moral sensitivity on the relationship between personality traits and safety attitude. According to Rezapour-Mirsaleh et al. in 2022 [65], personality traits such as conscientiousness, empathy, and mindfulness have a direct effect on moral sensitivity, and nurses who possess enough moral sensitivity could create an atmosphere in which patients not only have their rights respected but also feel safe in these conditions, and the goals of healthcare can be accomplished [21].

Any moral or clinical decision-making in nursing is directly influenced by nurses’ personality traits that involve cognitive processes and depend on the way nurses estimate the importance of received messages, their priorities, and their capability of recognizing and responding to the often ambiguous clinical and nonclinical scenarios in the workplace [66‐67].

According to Dalla., Zoboli., & Vieira, in 2016 [68], moral sensitivity is not just an issue of feeling, that is, trusting your own emotions for identifying a moral conflict, but it is related to– a personality component acquired through each one’s experience, which allows one to perceive the moral meaning of a specified situation. Moral sensitivity may be understood as a type of emotional response, being a personal component, which is necessary when one deals with ethical problems. In addition, the moral sensitivity of nurses is correlated with a higher level of compliance with standard precautions, which is a safety nursing protocol [69], and this leads to increased nurses’ attention to ethical considerations in the quality of care [70].

Critical care nurses in emergency and intensive care unit care for patients generally attend to the emergency unit due to acute diseases or injuries that require rapid treatment. Thus, nurses working in the emergency unit are occasionally obliged to initiate immediate treatment without obtaining a detailed history from patients [71]. Emergency unit nurses experience problems, especially when the patient is unconscious due to not being able to obtain sufficient information on the patient’s medical condition, so it is very vital to have positive personality traits with high moral sensitivity [72] because moral sensitivity has a positive effect on safety nursing activities [62, 73].

The study found that more than half of the participants have positive personality traits; also, higher mean scores were in conscientiousness followed by openness and extraversion compared to the lowest mean score related to agreeableness and neuroticism. Studied nurses had average levels of moral sensitivity; the highest mean score of moral sensitivity subscale was on interpersonal orientation and moral meaning, while the lowest mean score was for modifying autonomy and reliance on medical authority, expressing benevolence. Nearly half of the participants’ nurses have a positive safety attitude. Regarding safety attitude subscales, the highest mean score was related to perceptions of management, while the lowest mean score was related to safety climate and job satisfaction. There was a positive correlation between personality traits, moral sensitivity, and safety attitude. Finally, the findings demonstrated that moral sensitivity acted as a mediating factor between personality traits and safety attitude.