Introduction

Observing the professional and ethical standards in providing care for patient is considered as vital principle in protection of human health and dignity¹. Paying attention to the concept of conscience in organizations is in fact paying attention to ethics and human relations, since ethics creates commitment and makes individuals sensitive to their duties and behaviors. Ethical conscience in an organization leads to increased level of productivity, realized sustainable development, human cultural development, management stability and economic order. The care ethics is strongly based on the relationship between the caregiver and patient. The most important ethical characteristic in this regard is personal and social conscience, which is a state of spiritual awareness³. Conscience is an element, which can direct a person toward the right path and right behavior. Conscience is the cornerstone of ethics and affects private and professional life of individuals. Conscience plays an important role in nursing practices and affects the patients and their caregivers and reduces their low-quality practices. Conscience is involved in nursing activities and makes nurses to be insightful and careful in providing care to prevent causing harm to humans⁴. Therefore, in line with providing high-quality care, it is necessary to explore the effect of conscience on nursing activity⁵. Conscience perception is different among health care personnel. The findings of the study conducted by Jalali et al showed that conscience perception in nursing experiences includes four key concepts of conscience existence, conscience promotion, conscience actions, and conscientious establishment. Conscience existence is the same as vocative conscience without speech, which is viewed as inner call. The promotion of conscience refers to the multiplicity of factors affecting conscience, such as the effect of outcomes, community educational courses, and individual motivation. Therefore, it has various behavioral and emotional effects⁷. Conscience actions consider conscience to be judger and guardian. This type of conscience perception makes nurses to be aware of the low-quality actions performed for the patient and his relatives⁸. In the establishment of conscience, nurses expressed their perception in the form of loss of conscience. Bad deeds sometimes suppress the conscience and this occurs when conscience still has not recognized the reality, it has not judged and it has not established its position. Accordingly, the concept of nursing conscience in the 5-dimenstional questionnaire of Jalali et al includes 5 components of ethical conscience, guardian (preventive) conscience, director (observer) conscience, caring conscience, and conscience reflection. Using these five dimensions, it is possible to understand the dimensions of nursing conscience⁹. When nurses are asked to state the ethical problems when providing care for their patients, they often refer this challenge, so that conscience inhibits them from some actions and orders them to perform some other actions. For example, in the treatment system, there are some issues such as abortion, suicide attempts, and refusal of treatment, which are directed differently by conscience6.

Thus, the question is how conscience is perceived by caregivers. Depending on the fact that how they perceive conscience, some of the nurses leave serving, some of them suffer from long-term ethical distress, but some others manage this ethical stress in different ways. Nurses' views on the quality and role of conscience are helpful in understanding the meaning of conscience. Paying attention to the working conscience in the health care system should be prioritized. Dahlqvist et al showed that perception of conscience is significantly different among Swedish healthcare personnel and it can be a stimulus to provide high-quality care⁷. With regard to ethical conscience, Kant argues that ethical conscience invites man to perfection rather than prosperity. Jean-Jacques Rousseau claims that anything accepted by ethical conscience is good, and anything that is incompatible with the ethical conscience of humans and hurts their conscience is bad⁵. Our human resources need to strengthen and identify working conscience and change the culture of work, since committed human resources help the organization achieve its goals. Ethics in the nursing profession is more necessary, since ethics plays key role in improving the health of patients. Therefore, observing the professional ethics in clinical functions is more important than other care cases. Negligence is the most important consequence of lack of conscience among the staff of centers. The normal result of this situation is the low level of productivity. Thus, recognizing the dimensions and concepts related to perception of nursing conscience is very important⁹. Unfortunately, despite the importance of the ethics issue in nursing care, nursing ethics studies are very limited in Iran and our knowledge of nurses' conscience is very limited at present time. The issue of using nurses' conscience perception tools is a relatively new field of study. Accordingly, the researcher aims to determine the status of understanding the dimensions of conscience among nurses working in hospitals in Arak.

Methods

This correlation study was conducted for 7 months in 2017. The research population included all nurses working in hospitals affiliated to Arak University of Medical Sciences. To determine the sample size, the sampling formula is used in correlation studies. The initial sample of the statistical population included total number of 600 nurses working in hospitals affiliated to Arak University of Medical Sciences. As samples were selected from 5 different hospitals, samples were selected using proportional allocation method. This number was selected by using simple random sampling method from the research environment. The research inclusion criteria included having nursing academic education for the personnel, while unwillingness of nurses to continue the research to complete the questionnaires and incomplete questionnaires were considered as exclusion criteria. The data collection tool included a demographic questionnaire and 5-dimensional conscience perception questionnaire of Jalali et al. The total score of conscience questionnaire is derived from the sum of scores of dimensions of ethical conscience (7 questions), guardian conscience (5 items), director conscience (4 questions), caring conscience (3 questions) and conscience reflection (5 questions)¹⁰. In this study, the same version will be used with permission of the author. Questionnaires are developed in five-point Likert scale, ranging from completely disagrees to completely agree. The reliability of conscience questionnaire in the Jalali studies was obtained 0.94 and 0.917 using Cronbach's alpha and split half methods, respectively¹¹. This research was conducted in compliance with ethical standards and with the license of the Research Deputy of Arak University of Medical Sciences and the head of hospitals. In order to observe ethical considerations, the goal of the research was explained to all nurses by researcher and they were ensured that all their information would remain confidential. The data were analyzed by SPSS software. To calculate the descriptive parameters, descriptive statistics (frequency, percentage of frequency, standard deviation, mean) and inferential statistics (Chi-square and Fisher) were used for the relationship between conscience perceptions and demographic variables.

Results

The research results showed that out of 194 nurses working in hospitals of Arak, most of the participants were female, employed in contract form, and had bachelor level of education and work experience of less than 7 years (Tables 1, 2, 3). The results of Table 4 also showed that the total score of nursing conscience was 68.19 ± 4.3. The maximum mean score was related to ethical conscience (29.7 ± 4.3) and the minimum mean score was related to caring conscience (2.06 ± 12.6). Results of Table 5 showed that among the demographic variables, only the variable of age had a significant relationship with dimensions of conscience, so that total score of nursing conscience increased as age increased.

Discussion

The results of this research conducted with the aim of evaluating the level of perception of nurses working in hospitals affiliated to Arak University of Medical Sciences indicate that among dimensions of conscience, ethical conscience dimension has the highest mean. With increasing ethical conscience, nurses' interventional care level becomes more desirable. Providing care is closely correlated with ethical principles. Kelly considers care and clinical practice as a complex phenomenon and recommends that the care process involves ethical, cognitive, and emotional components¹². Similarly, Lemonid et al observed that in the nurse-patient relationship, ethical commitment of care is an important task in nursing practice and recommended that the commitment and observing ethical principles to be prioritized to care. The principles and observing ethical care are an essential part of the nursing profession¹³. Jensen et al studies on the effect of conscience on nurses with the aim of nurses' perception of the effect of conscience in providing the nursing care showed that nurses considered conscience as an important component in the way of performing the professional tasks¹⁴. In a study entitled "Conscience and clinical practice", Keline et al showed that the role of conscience in clinical practices was unavoidable¹². Dahlqvist et al found that conscience plays a role in nursing practices and affects the patients and their relatives¹⁰. Conscience is involved in nursing activities and makes nurses to be careful in providing the care in order to prevent causing harm for humans. The results of this study are consistent with those of the above-mentioned studies. Naminom and Lino argue that the interpersonal relationships and nurses' perceptions of their role as nurse are one of the important factors affecting their ethical decision-making ability⁸. In a phenomenological study entitled "nurses' experience of the factors leading to perform an action in contrast to conscience", Jalali et al showed that individual, organizational, human factors can lead to perform an action in contrast to conscience¹⁴. Analyzing the results suggests that fatigue, high workload, time constraints, individual characteristics, lack of experience, lack of management and facilities in the form of individual, organizational, human factors can reduce the conscience in nurses¹⁵. According to Strodior, workload is the most important factor in causing stress¹⁶. Studies have also shown that there is a significant relationship between mood disorders and workload. In addition, high work shifts and fatigue have been reported as a source of performing the actions in contrast to conscience¹⁷. These factors cause stress in the workplace and lead to burnout and job dissatisfaction¹⁸. As the researcher conducted the study only on nurses working in hospitals of Arak, it is recommended for other researchers to conduct this type of studies on larger populations such as the emergencies department, military hospitals and so on to generalize the results of this study.

Conclusion

Given the results of the research on determining the level of nursing conscience, the most successful organizations have a culture in line with strong ethical values, so that nurses with a high ethical conscience can have many benefits in the work environment, such as creation of individual comfort and security and increased clinical practice. Moreover, the high level of conscience can lead to mutual understanding among nurses, hospital and staff, reduced absenteeism among work forces, and increased commitment and productivity. It also increases nurses' practice in the high-stress environment of hospital. Thus, in order to enhance clinical practice, it is recommended that the educations needed to enhance the knowledge of nurses on identifying the factors inhibiting or enhancing conscience to be provided for nurses by senior managers.

References

1. Sulmasy DP. What is conscience and why is respect for it so important? Theoretical medicine and bioethics. 2008;29(3):135-49.

2. Dehghani A, Ordoubadi N, Shamsizadeh M, Parviniyan Nasab A, Talebi M. Perspective of patients about compliance with standards of professional ethics in nursing practice. Journal of Nursing Education. 2014;3(2):76-84.

3. Etemadi R, Jafari N. Study the responsibility of nurses (professional ethics and human), the recovery rate of patients. Military Caring Sciences. 2014;1(1):57-62.

4. Pazargadi M, Zagheri Tafreshi M, Abed Saeedi Z. Nurses' perspectives on quality of nursing care: a qualitative study. Research in Medicine. 2007;31(2):155-8.

5. Bahreini M, Moattari M, Kaveh MH, Ahmadi F. A comparison of nurses' clinical competences in two hospitals affiliated to Shiraz and Boushehr Universities of Medical Sciences: a self-assessment. Iranian Journal of Medical Education. 2010;10(2):101-10.

6. Pourbandbani M, Sadeghi R, Salsali M, Borhani F. Effective factors on active participation of clinical nurses to solution of ethical issues: master nursing students' perspective. Journal of Nursing and Midwifery Urmia University of Medical Sciences. 2013;11(1):0-.

7. Dahlqvist V, Söderberg A, Norberg A. Facing inadequacy and being good enough: psychiatric care providers' narratives about experiencing and coping with troubled conscience. Journal of Psychiatric and Mental Health Nursing. 2009;16(3):242-7.

8. Ericson-Lidman E, Strandberg G. Learning to deal constructively with troubled conscience related to care providers’ perceptions of not providing sufficient activities for residents. Clinical nursing research. 2013:1054773813500139.

9. Dehghani A, Dastpak M, Gharib A. Barriers to Respect Professional Ethics Standards in Clinical Care; Viewpoints of Nurses. Iranian Journal of Medical Education. 2013;13(5):421-30.

10. khosravani M,khosravani Mo, rafiei F, Mohsenpour M.Moral intelligence and its dimensions in nurses working in hospitals in Arak city. Medical Ethics Journal.2017;41(11):37-44.

11. Jalali R, Hasani P, Abedsaeedi Z. Nurses’ experiences of the factors leading to commit unconscionable acts: A phenomenological study.

12. Dahlqvist V, Eriksson S, Glasberg A-L, Lindahl E, Strandberg G, Soderberg A, et al. Development of the perceptions of conscience questionnaire. Nursing Ethics. 2007;14(2):181-93.

13. Mohajjel Aghdam A, Hassankhani H, Zamanzadeh V, Khameneh S, Moghaddam S. Nurses' Performance on Iranian Nursing Code of Ethics from Patients' Perspective. Iran Journal of Nursing. 2013;26(84):1-11.

14. Berggren I, Severinsson E. Nurse supervisors' actions in relation to their decision‐making style and ethical approach to clinical supervision. Journal of Advanced Nursing. 2003;41(6):615-22.

15. khosravani M,Abedi H, lak s,rafiei f,rahzani k.The association between conscience understanding and clinical performance among nurses working at education hospital of Arak. Annals of Tropical Medicine and Public Health journal.2017;10(6): 1587-1590[persian].

16. Jensen A, Lidell E. The influence of conscience in nursing. Nursing Ethics. 2009;16(1):31-42.

17. Glasberg AL, Eriksson S, Norberg A. Factors associated with ‘stress of conscience’in healthcare. Scandinavian Journal of Caring Sciences. 2008;22(2):249-58.

18. Khosravani M, Khosravani Mo, Fatemeh Rafiei F, Mohsenpour M. Organizational Commitment and Its Dimensions in Nurses working in Arak’s Hospitals. Medical Ethics Journal, April 2017; 11(39): 37-44[persian].