The relationship between ethical sensitivity, caring behavior and quality of care in nurses: A systematic review

The current study was reported in accordance with the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [19], which ensures comprehensive and standardized reporting. The process of gathering the studies involved conducting systematic searches on reliable databases, which included Web of Science, PubMed, Scopus, Google Scholar, and ProQuest. In addition, we conducted searches in popular local databases such as SID, MagIran, IranDoc, and IranMedex. Table 1 illustrates the search strategy.

The study inclusion criteria were carefully defined to ensure a comprehensive selection of papers. These criteria encompassed papers written in both Persian and English languages, with an observational design. The inclusion criteria specified that the papers needed to be published between January 1, 2000, and August 31, 2024.

Our comprehensive review encompassed all studies that examined how ethical sensitivity influences caring behavior and the quality of care provided by nurses. The exclusion criteria for this study involved not having access to full-text articles, articles written in languages other than Persian and English, interventional studies, protocol studies, case studies, brief reports, reviews, and qualitative studies.

Different authors were involved in both the initial development and subsequent testing of the search syntax. Following that, the primary searches were carried out. We have successfully completed the process of eliminating duplicate entries. One author, A.N. was responsible for carrying out the search process, which involved reviewing the titles and abstracts of the studies. The final studies were obtained through a process that includes the independent evaluation of complete texts. This evaluation is conducted by two authors, A.N. and H.B. In situations where there were disagreements about whether to include specific studies, we consistently prioritized the need for thorough discussions, ensuring that all perspectives were considered and a consensus was ultimately reached.

By utilizing the JBI critical appraisal tool, this systematic study conducted a thorough examination of the risk of bias. Two researchers, S.B. and M.GH. executed the quality evaluation of the articles, independently. In the event of disagreements, resolution is reached through discussion.

Two reviewers, A.N. and H.B. independently extracted data and compared the results. The following data was extracted in an Excel spreadsheet: Author name, country, published year, design, sample size, mean age, participant characteristics, measurement tools, and key results.

A comprehensive search, encompassing both electronic databases (Web of Science, PubMed, Scopus, Google Scholar, and ProQuest for English studies) and Persian databases (such as SID, MagIran, IranDoc, and IranMedex for Persian studies), was conducted. The manual review of citations from relevant studies further contributed to the retrieval of a total of 2,957 articles. After removing duplicate studies, 1,785 articles were excluded. Following a detailed assessment of the titles and abstracts of the remaining 1,172 studies, 29 articles were considered potentially eligible for inclusion in the next stages of the review process. Upon full-text analysis, 11 studies were selected for final inclusion in the analysis (Fig. 1). This selection process was uniformly applied to both English and Persian studies, ensuring consistency in the evaluation criteria across both languages. Studies published in both languages were assessed using the same inclusion and exclusion criteria, as well as quality assessment tools.

The basic characteristics of the included studies are shown in Table 2.

The JBI Critical Appraisal Checklist was applied consistently across all included studies, regardless of language, to assess the quality of the cross-sectional studies [28]. The checklist that was provided contained a total of 8 questions. The checklist’s scoring method utilizes a pattern where a score of 1 is given for a “Yes” response, while a score of 0 is assigned for a “No” response or if the item is deemed “Not applicable/not clear”. According to the quality assessment, it was found that a total of 9 studies [2, 17, 18, 20‐24, 26] were deemed to have high quality, with scores of 6 and above. However, it should be noted that two of the studies received lower quality scores of 4 and 5 [25, 27]. The results of the included studies’ quality assessment are presented in Table 3.

Ethical sensitivity is a crucial attribute that allows individuals to recognize ethical challenges, understand the emotional and mental states of those in vulnerable situations, and anticipate the ethical ramifications of choices made by others [29‐31]. Ethical sensitivity is characterized by a keen awareness of the ethical dimensions inherent within conflict-ridden situations, coupled with a profound understanding of one’s own position and accountability within those circumstances [32]. In fact, ethical sensitivity as a personal predisposition guiding ethical decision-making, involves a complex interplay of cognitive capacities—including feelings, sentiments, moral knowledge, skills, and inter-relational processes [32].

Caring in nursing is the purposeful and tangible presence of a nurse who is acknowledged as an individual who possesses love, compassion, and an ongoing improvement in their ability to care [33]. Caring behavior is defined as actions that show concern for the well-being of a patient. These actions include empathy, comfort, attentive listening, honesty, and non-judgmental acceptance. Caring behavior also includes the behaviors and gestures with which a professional nurse expresses concern, safety, and attentiveness to a patient [34].

The concept of Quality of Nursing Care encompasses the provision of adequate and safe care, expressing empathy, engaging in effective communication, and maintaining a respectful attitude towards the patient [35]. Professional nurses must be capable of providing high-quality care as a way to fulfill the healthcare demands of patients in their profession [36].

In a series of 6 studies [17, 21, 22, 25‐27], researchers examined the connection between ethical sensitivity and the caring behavior exhibited by nurses. According to the findings of Afrasiabifar et al.’s study, there is a statistically significant positive correlation (r = 0.4, P = 0.001) between nurses’ caring behavior and their ethical sensitivity [21]. Furthermore, in their study, Hajibabaee et al. highlighted a significant positive correlation between ethical sensitivity and caring behavior (r = 0.164, P = 0.001). They also explored the dimensions of caring behavior, identifying notable correlations in key aspects, including Respect for others (r = 0.146, P = 0.003), Assurance of human presence (r = 0.143, P = 0.004), Communication and positive trend (r = 0.188, P = 0.001), and Attention to the experience of others (r = 0.168, P = 0.001) [17]. Also, Phuong et al. conducted another study that revealed a noteworthy correlation between moral sensitivity and caring behaviors (r = 0.739, P < 0.001) [25]. Taylan et al.’s study demonstrated that caring behaviors are strongly associated with ethical sensitivity, as indicated by several dimensions. Specifically, assurance was found to have a significant negative correlation with autonomy (β=−0.299, P = 0.000), while a positive relationship was observed with expressing approach (β = 0.157, P = 0.000) and expressing conflict (β = 0.131, P = 0.000). Similarly, knowledge and skill showed a strong negative association with autonomy (β=−0.517, P = 0.000). Respectfulness was inversely correlated with autonomy (β=−0.683, P = 0.000) but positively associated with expressing conflict (β = 0.049, P = 0.002).

Connectedness demonstrated substantial negative correlations with expressing benevolence (β=−0.930, P = 0.002), autonomy (β=−0.654, P = 0.000), and expressing conflict (β=−0.048, P = 0.002). Finally, caring behaviors showed significant negative associations with both following praxis (β=−0.251, P = 0.002) and expressing benevolence (β=−0.940, P = 0.000). These findings highlight the nuanced interplay between various subscales of ethical sensitivity and caring behaviors [26]. However, Yıldız et al. in their study concluded that there is a reverse and significant relationship (r=-259; P = 0.001) between the total score averages of moral sensitivity and caring behaviors scale [27]. Also, the results of Izadi et al.’s study indicated that there was no significant correlation (P > 0.05) between the average scores of these variables [22].

Adding to this complexity, a study revealed a negative significant relationship between the total scores of the Caring Behaviors Inventory-24 and the Ethical Sensitivity Questionnaire (r=-0.162; P = 0.009). Moreover, a negative association was observed between nurses’ duration of work in their current clinical settings and specific subscales of ethical sensitivity, including providing benefits, a holistic approach, and orientation. These findings underscore the intricate interplay between ethical sensitivity and caring behaviors and suggest that work-related factors may also influence this relationship [24].

A total of five studies [2, 18, 20, 23, 24] have been conducted to evaluate the correlation between ethical sensitivity and the quality of care provided by nurses. The study conducted by Darzi-Ramandi revealed a weak inverse relationship between the components of moral sensitivity and the overall quality of nursing care (P < 0.001). Similarly, a weak inverse relationship was observed between the total moral sensitivity score of nurses and various components of nursing care quality, with the exception of nurse characteristics (P < 0.001). Furthermore, the analysis showed a significant linear relationship between the total scores of moral sensitivity and nursing care quality, as evidenced by a Pearson correlation coefficient of − 0.528. This result indicates a moderate inverse relationship between these two variables (P < 0.001), highlighting the complex interplay between nurses’ moral sensitivity and the perceived quality of care they provide [20].

Also, Khorany et al. conducted another study where they found that ethical sensitivity had a significant impact on the quality of nursing care (β = 0.43, P < 0.001), making it the most influential predictor [23].

Nazari’s studies revealed intriguing findings, demonstrating a nuanced relationship between moral sensitivity and the quality of patient care across various dimensions. Specifically, moral sensitivity in modifying autonomy was negatively associated with the psychosocial aspects of patient care (β=−0.42, P = 0.004) and showed a weaker negative relationship with communicational aspects (β=−0.31, P = 0.06). Moreover, a significant negative relationship was found between moral sensitivity in interpersonal orientation and the psychosocial aspects of care (β=−0.61, P < 0.001). In contrast, experiencing moral conflict was positively correlated with the psychosocial aspects of patient care (β = 0.40, P = 0.006). Additionally, structuring moral meaning exhibited a negative relationship with the physical aspects of care (β=−0.19, P = 0.02), while expressing benevolence showed a positive association with the physical aspects of patient care (β = 0.28, P = 0.04). These findings emphasize the complex interplay between dimensions of moral sensitivity and the quality of care provided by nurses [18].

Amiri et al.’s study revealed no significant correlation between nurses’ overall moral sensitivity and the quality of care received by patients (r = − 0.14, P = 0.05). However, a notable inverse relationship was identified between the “Experiencing moral conflicts” dimension of moral sensitivity and the total nursing care quality score (r = − 0.50, P = 0.04). This inverse relationship was also significant within the psychosocial (r = − 0.50, P = 0.04) and physical dimensions of care (r = − 0.50, P = 0.03), highlighting the specific impact of moral conflicts on various aspects of care quality [2].