The Components of the Ethical Behaviour of Virtuous Nurses in Medical Teams

Zahra Nikkhah Farkhani^1*, Fariborz Rahimnia², Mostafa Kazemi³, Ali Shirazi⁴

¹Department of Management, Assistant Professor, Faculty of Humanities, Bojnord University, Bojnord, Iran.

²Department of Management, Professor, Faculty of Administrative Sciences and Economics, Ferdosi University of Mashhad, Mashhad, Iran.

³Department of Management, Professor, Faculty of Administrative Sciences and Economics, Ferdosi University of Mashhad, Mashhad, Iran

⁴Department of Management, Associate Professor, Faculty of Administrative Sciences and Economics, Ferdosi University of Mashhad, Mashhad, Iran.

*Corresponding author: Faculty of Humanities, Bojnord University, Bojnord, Iran.

E-mail: nikkhah.hrm@gmail.com

Received: 2015July 04; Accepted: 2016March 15

Introduction

Nursing is a profession that encompasses ethical behaviour; it is by nature a moral and ethical effort [1]. Ethical behaviour is a fundamental feature of professional nursing [2], and adherence to it is regarded as an essential part of nurses’ job responsibilities [3, 4]. In the current era, owing to the rapid development of healthcare and related technologies as well as increasing concerns associated with unethical behaviour and its underlying factors, it is highly important to note the ethical behaviour of nurses [5–7]. However, a unified concept of ethical behaviour has not yet been presented by intellectuals and experts in this field. Three main theories in the field of ethics and morality include deontological (duty-based), result-oriented, and virtue-oriented ethics [8]. According to duty-oriented ethics theory, ethical rules are universal and moral activism acts in accordance with practical reason and the requirements of their autonomy. This approach provides general moral rules that one should follow [9].

In contrast, result-oriented ethics focus on the consequences of any action. On this basis, a good practice involves the acquisition of maximum fun and profit, which includes the two concepts of self-centeredness and utilitarianism [10]. Virtue-oriented ethics is based on the belief that we not only need the ethical principles, but must also strive after creating moral virtues [11]. This theory, which seeks to establish ethics based on personal characteristics [12], is more comprehensive than other moral rules [13].

Considering that virtue-oriented ethics encompass two approaches—ethics of care and justice—it is suitable for the field of health and nursing ethics [14]. In this approach, ethical nursing occurs when a good nurse does the right thing [15]. However, less attention has been paid to the special nature of the relationship in the ethical behaviour of nurses. The nature of this relationship encompasses three different areas, namely the ethical behaviour of nurses with the patient, the ethical behaviour of nurses with the patient’s family, and the moral conduct of nurses with the medical team comprising physicians, nurses, and the head nurses. Several studies have been conducted regarding the ethical behaviour of nurses with patients and their families (accompanying) [16–18], while only a few studies have been conducted regarding the ethical behaviour of nurses with medical teams [19]. It should be noted that one of the most important causes of anxiety in the nursing profession is the lack of good professional relationship and tension in professional nursing relationships with other colleagues [20]. It has been shown that good relationships result in improving healthcare and increasing the efficiency and success of physicians and nurses [21]. This can improve the condition of patients; it can also reduce the length of patients’ hospital stay and consequently their treatment-related costs [22]. Considering the stressful nature of the nursing profession [23], the ethical behaviour of nurses with medical teams can provide a synergistic working environment in the hospital [24]. This can reduce the burnout and intention of nurses for leaving their job, which can have a negative impact on their performance [25]; this also can lead to increased job satisfaction, thereby improving the quality of care given to patients and their families [26]. Given that the ethical behaviour of nurses with the treatment team in terms of virtue and by understanding the communicative nature of this ethic has not been studied qualitatively so far, the aim of this study is to investigate the components of the ethical behaviour of nurses through qualitative research by exploring medical teams in hospitals affiliated with the Mashhad University of Medical Sciences.

Materials and Methods

In this qualitative study, the study population included all the nurses working in the public hospitals in Mashhad. The target sample was selected using purposive sampling. In this method, the researcher seeks people who have a rich experience of research topics and are capable of expressing it and who have willingness to participate in the study [27]. A virtue-oriented approach was used for defining the component of the ethical behaviour of nurses in this study. Since from this point of view the ethical behaviour happens when a good nurse performs the right thing, the samples in this study included national representative nurses working in hospitals affiliated with the Mashhad University of Medical Sciences, who are identified and introduced each year. The number of subjects in the qualitative part of present study was based on sampling adequacy [28]. After 14 interviews, a theoretical saturation was achieved, while the resultant data did not help to complete existing categories or develop the concepts of a new category after the twelfth interview. In this study, ethical considerations during evaluation included: obtaining permission to carry out the research, explaining the objectives of this research and methods to the participants, obtaining written consents, and assuring participants regarding the confidentiality of their information and that they can withdraw from the study at any time for any reason. The in-depth semi-structured interview form was used to collect data; it is a suitable way to gather information on ethics-related research. The pivotal questions of the interview were: “What kind of ethical behaviour you have shown to the medical team (nurses, physicians, and administrators)?” and “What representations of that experiences do you remember?” The average interview time was 55 minutes, and the interviews were carried out with previous coordination in the head nurse room in the hospital. All the interviews were recorded and transcribed verbatim. In addition to questions about ethical behaviour in relation to the treatment team, demographic information, such as age, gender, work experience, and level of education, was investigated. Also, qualitative content analysis was used to analyse and identify the components and sub-components of the ethical behaviour by nurses.

In the present study, this approach was used to prove the validity of the research process. Thus, a total of 14 participants were interviewed. Among them, five were men and nine women with at least nine years of work experience and a maximum of 28 years of age. In terms of workplace diversity, each of the participants was working in one of the specialized units. The reliability of this study was obtained using interviews as a research instrument for completely accurate and in-depth data recording, completely accurate diverse coding, and data reproducibility [31]. To evaluate the reliability of the coding process of interviews, two indices including retest reliability (stability) and inter-coder reliability (consistency index) can be used in qualitative research. The stability index refers to the classification compatibility of data over time; this index can be calculated when a text is coded by a transcoder at two different times. In this study, five interviews were selected and evaluated within 10 days and the stability index was calculated to be 0.98, which approves the stability index of coding. Reliability among coders means a level of agreement reached by independent coders while evaluating the features of a text or a message [32]. Such reliability is often considered as a measure of research quality—in fact, its absence indicates poor quality of research and the possibility of poor operational definitions [33]. The value of the reproducibility index for this study was calculated to be 0.87, which indicates the reliability of the coding process.

Results

The study population included 14 representative nurses who were working in public hospitals of Mashhad. The participants consisted of five men and nine women aged 40–50 years with 20 years of work experience on average. In terms of workplace and by considering the specialty of hospitals in Mashhad, each nurse was engaged in one of the specialized units. The final findings of the study comprise five main components, each containing several sub-components. The main components included deontology, emotional support, attention and respect, benevolent training, and benevolent monitoring.

Deontology

Deontology means to be present at the workplace on time, compliance with laws and regulations, maintaining professional boundaries with physicians and nurses, establishing relationships based on trust, and efforts to apply modern science and its achievements in patient care. Deontology in nursing is not only a legal obligation, but also a moral value. Virtuous nurses try to understand the working conditions of their colleagues and responsibly improve the organizational climate; they also promote the spirit of cooperation among members of the medical team.

1. Time presence at the workplace: To be present at the workplace on time is a type of ethical behaviour that can be effective in establishing a model of representative nurses. In this regard, one of the nurses said: ‘I'm always on time at the hospital. So far, I’ve not been late even for five minutes.’
2. Regulatory compliance: According to the interviewees, compliance and adherence to regulations in the nursing profession is not only a necessity, but also a moral value. In this regard, one of the nurses said: ‘Adherence to regulations and hierarchy is really a kind of ethical behaviour. When my shift ends at 2 p.m., my colleague must be present here to take over. Similarly, I must go to work on time.’
3. Maintaining a professional boundary: Attention and respect to professional boundaries and the effort to enhance the professional self-image are types of ethical behaviours expressed by the interviewees. In this regard, several nurses stated that the relationship with physicians must be within the framework and professional boundaries. Nurses should not have much communication with physicians or any relationship out of the norm, they added.
4. Trust the replaced person and notification of absence: One of the nurses said ethical behaviour, which reflects deontology, informed others about their absence and ensured that a replacement could perform the duties fully during his absence. One of the nurses in this regard stated: ‘If something makes me to hand over the shift even with a half-an-hour delay, I would inform the nursing head about and certainly talked about it with my colleague because he might have an urgent issue too.’
5.  Establishing relationships based on trust: Trust in colleagues is another manifestation of the ethical behaviour of nurses towards the medical team. One of the nurses said: ‘I behave with doctors in such a way that they can trust me. This is the most important principle in my relationship with them.’
6. Acceptability: Since nurses are associated with the human life and health, their willingness to learn and stay away from selfishness and arrogance in the care process is necessary. Most of the interviewees mentioned that receiving information from colleagues at work and avoiding persecution of patients because of the lack of sufficient professional information was a type of ethical behaviour. In this regard, one of the nurses said: ‘I try not to be stubborn and arrogant. When I do not know something, I ask my colleague about it.’

Attention and respect

Attention and respect is kind of a voluntary behaviour towards colleagues and members of medical teams; it improves the workplace atmosphere and can prevent problems in the organization. Attention and respect is a type of moral behaviour; it is also considered as a kind of organizational citizenship behaviour (OCB) because of its voluntary nature.

1. Courteous behaviour: Politeness and courteous behaviour is not only a type of moral behaviour, but also a human value adherence to which is one of the necessities. In this regard, one of the interviewees stated: ‘I think one must communicate with colleagues politely. Only intimacy should not cause such politeness. This can strengthen the cooperation between colleagues, and they can help each other when needed.’ 
2. Respectful treatment: Respect for the personality of others and respectful behaviour is essentially a type of moral behaviour. All nurses noted that respectful behaviour towards the treatment team is very important. They stated that nurses must treat physicians and colleagues with respect and value each other’s opinion.
3. Fair treatment: According to the interviewees, lack of attention to ethnic and racial differences and impartial behaviour and judgement towards the members of the treatment team is a type of ethical behaviour. One of the nurses in this regard stated: ‘I never admire the physician who is from my hometown in front of patients and their families. I do not urge them to perform their surgery with this doctor. I always consider fairness.’

Emotional support

Emotional support means providing love, compassion, and respect to colleagues and reassuring them to give them a sense of their own value and consideration (esteemed). This component includes the subcomponents of family relationships, reassurance, wishing birthday and holiday greetings to colleagues, and listening to the problems and feelings of colleagues.

1. Establishing family relationships: Nursing is a stressful career, and family support is one of the solutions for reducing the stress of nurses. According to the interviewees, establishing family relationships with colleagues can give the family members a better insight into this profession, enhance their support for nurses, and reduce family conflicts. One of the nurses stated: ‘I have a family relationship with my colleagues, as this helps our families to become familiar with our profession and understand better that others also experience the same situations. For example, my son was always upset because of my night shift, especially during holidays, but since he started talking with the children of other colleagues, he has started to realize that this is the nature of my job and now he complains less.’
2. Providing reassurance: Reassuring colleagues means giving them encouragement to reduce fatigue and job-related stress and to their increase self-worth and emotional improvement. One interviewee said: ‘When my colleague performs his job well I admire him. When the names of representative nurses are announced I congratulate them and praise their performance.’

Another type of ethical behaviour is to participate in weddings or mourning ceremonies of colleagues. In this regard, one of the interviewees said: ‘When my colleagues have a wedding ceremony or funeral (God forbid), I definitely participate in it if I am not doing shift duty. And when I am on shift, I call them to congratulate or to offer my condolences.’

3. Listening to the problems and feelings of colleagues: Active listening to the feelings of colleagues not only lessens the stress burden and anxiety, but also strengthens supportive relationships between colleagues. It is an effort to solve problems in times of need. In this regard, one of the interviewees said: ‘I communicate with colleagues. They are comfortable with me and tell me about their personal things. In this way we often can help each other. Besides, we mentally feel relaxed too.’
4. Birthday and holidays greeting: Nurses believe that birthday and holidays greeting even by a short text message can be a sign of respect that creates intimate and motivational atmosphere among colleagues and the members of a medical team. In this regard, one of the nurses said: ‘I have established an emotional relationship with my colleagues. I congratulate them on their birthdays, and we try to make the hospital a better place for ourselves.’

Benevolent monitoring

Benevolent surveillance means monitoring the performance of colleagues and physicians to provide more convenient service to patients. Its purpose is to boost the understanding of colleagues and help to improve service delivery along with providing a learning and growing atmosphere in the hospital.

1.  Monitoring the performance of colleagues for promoting the quality of the care process : The participant nurses believed that the nursing profession cannot be monitored by anyone other than God. Therefore, when the performance of nurses is to be monitored by other nurses and colleagues only to control them, it has no persistent and positive effect on their performance. In fact, it can reduce their productivity. Monitoring the performance of colleagues is considered a type of moral behaviour when its aim is to improve the quality of care and to provide a basis for learning and growth of caregivers. One of the interviewees in this respect said: ‘If my colleague does a wrong thing, I will definitely notify him.’

2. Monitoring the performance of physicians and providing the experience without tension: Benevolent surveillance also involves monitoring the performances of physicians. Some of the interviewees believed that monitoring the performance of the physicians and their accuracy in diagnosing patients’ disease is an ethical behaviour to save the lives of patients as some physicians have less experience than nurses. In this regard one of the nurses stated: “before the physician visit the patient I try to gain sufficient understanding of the patient’s condition to help the physician in the diagnostic process and when the physician makes a mistake, based on my experience I will notify him”.

Benevolent training

Although training colleagues, especially nurses who have recently engaged in the field of nursing, is one of the duties of experienced nurses, sometimes this does not completely happen. Benevolent training means trying to transfer all the experience and knowledge acquired not only to those who directly interact with nurses (e.g. colleagues), but also to all those who are willing to learn this profession.

1. Succession planning: Virtuous nurses not only maintain their moral virtues and professional merits, but are also concerned with the training and preparation of future workforce. In this respect, one of the nurses said: ‘My aim is to train alternative (succession) nursing staff because people are often ignorant about nursing. Recent graduates are not qualified both scientifically and in terms of skills and capabilities. I think the national university entrance exam is not an appropriate way for the selection of right candidates for the professions like nursing and medicine. However, I try to train my less-experienced colleagues so that they can take my position in the future.’
2. Training all nurses who are eager to learn: According to the interviewees, sharing knowledge and personal experiences with all nurses who are eager to learn is an ethical behaviour. One of the nurses in this regard said: ‘I worked for a few years in the ICU and a few years in the operating room. Thus, I know how to use these devices. I teach whatever I know to my colleagues. I even hold training classes for them. I have also opened a website for all nurses across the country so that they can make use of the information.’
3. Offering individual experiences: Providing colleagues and newcomers nurses with all knowledge and experiences that have been acquired during the service period is another type of ethical behaviour. One of the nurses stated: ‘I try to pass on others all the information I acquired. Some people always keep some tricks to themselves, but I would say that our profession is highly sensitive. For instance, if I get sick and someone nurses me without sufficient knowledge and experience, I do not know what will happen to me.’
4. Efforts for accumulating knowledge and its dissemination: Attempt for knowledge accumulation is a type of ethical behaviour. However, from the perspective of the interviewees, a virtuous nurse is not only constantly in search of knowledge accumulation and updating her personal and professional knowledge, but also tries to share the acquired knowledge and offer it to other colleagues. One of the nurses in this regard said: ‘I try to keep my knowledge up-to-date and share it with those colleagues who wish to know more.’
5. Utilizing personal knowledge to improve hospital services: Some of the nurses, in addition to the professional knowledge, have good knowledge of other sciences. From the perspective of virtuous nurses, one type of the ethical behaviour of nurses towards the medical team is utilizing their capabilities to provide more convenient hospital services to patients. In this regard, one of the nurses said: ‘I have good knowledge of computer. I designed a computer system for the hospital. It enables staff members to properly classify the names of patients and their care procedures. Although this is not my field, I choose to offer my information to others and to the environment. I even provided other hospitals with this system for free, although I am not their employee.’

Discussion

This qualitative study was performed in accordance with the perspective that if phenomena are to be investigated in the context of occurrence and from the viewpoint of those who are experiencing it, many of the hidden aspects are revealed. This can result in acquiring new knowledge and insights; it can also provide suitable conditions for further research and applicability of abstract concepts.

In this study, the ethical behaviour of nurses was investigated in relation to the medical team and five main components with various subcomponents were abstracted. However, it should be noted that the considered concepts are usually scrambled (intertwined) and there is no clear border. In fact, sometimes the concepts present slight overlapping. The model of the ethical behaviour of nurses with the medical team is shown in Figure 1.

According to the proposed model, the evaluated components and subcomponents in terms of the ethical behaviour of nurses with the medical team and based on the outcomes of interviews can be presented as follows:

One of the many types of evaluated ethical behaviour of nurses towards the medical team is deontology. Deontology is an effort for performing the right deed [34]. Therefore, many researchers believe that deontology has intertwined with ethics and is called deontological ethics [35]. In several studies, deontology has been mentioned as a moral behaviour that can improve the patient care process [36], improve the quality of hospital services [37], increase patient satisfaction with the treatment team [38], and improve the hospital atmosphere [39] and relationships between nurses and physicians [40]. In addition, it is considered as one of the pivotal values in nursing [41].  In the code of ethics in most countries, deontology has been noted as one of the moral codes that nurses should adhere to [42–44].

Attention and respect is another evaluated component that refers to a polite and respectful behaviour towards colleagues and physicians and fair treatment towards them. Attention and respect is not only considered a type of ethical behaviour [45], it can also improve relationships between nurses and the medical team. Also, it prevents problems and tensions that can adversely affect the performance of nurses and physicians [46]. This behaviour is also considered as one of the dimensions of organizational citizenship behaviour (OCB) [47]. Organizational citizenship behaviour refers to the positive behaviour that people demonstrate towards their colleagues and organizations without any financial compensation or reward; it has positive impact on organizational functions [48].

Emotional support means reassuring the members of the medical team and encouraging them in times of trouble so as to make them feel valued and to give them a sense of emotional well-being [49]. The researchers believe that emotional support is an aspect of social support [50]. Family members, co-workers, and even managers can provide emotional support [51]. Nursing is essentially a stressful profession, and the relationship between the members of a healthcare team is one of the most important sources of job stress among nurses. Hence, emotional support provided by managers and colleagues to nurses is one of the most important generators for improving the level of motivation among nurses [52]. On the other hand, establishing family relationships among nurses is not only one of the sub-components of emotional support that nurses provide to the medical team, but also is one of the behaviour types that helps family members to gain a better insight into the difficulties of this profession. This understanding can cause families to provide more emotional support to nurses.

Another abstracted component is benevolent monitoring, which refers to the benevolent surveillance of the performance of medical team members, is also an effort to improve the performance of the medical team and to provide on-the-job experience. Monitoring the performance of medical team member’s amounts to giving caution about mistakes to the team and to report it to superiors; it aims at controlling the performance of the medical team [53]. In contrast, the purpose of benevolent monitoring, in addition to control, is to establish positive interactions for promoting the members of the medical team. Since nurses work in stressful environments, acquiring communicative and social skills is necessary for them [54]. Several studies have indicated that none of the succession planning programmes for nurses in hospitals and healthcare systems will conclude without active participation of experienced nurses and their intrinsic motivation for sharing knowledge and skills with colleagues [55]. Another type of ethical behaviour is thee continuous effort of nurses for knowledge accumulation and sharing such knowledge with other colleagues. This behaviour not only improves the professional atmosphere among the members of the medical team, but also promotes the quality of services given to patients. This can increase the level of patient satisfaction with medical services and nursing cares.

The emergence of the subcomponents of benevolent training can be considered as a facilitator for the establishment of a knowledge management system in the organization. Knowledge management refers to the systematic accessibility and availability of scientific resources [56]; it can be considered as one of the requirements of the nursing profession [57] because every action of nurses reflects their knowledge that encompasses both practical experience and knowledge acquired from scientific research [58]. Dissemination of modern sciences relating to the nursing profession, transfer of Individual knowledge to improve hospital services, offering personal experiences voluntarily, training all nursing staff members who are eager to learn are the types of ethical behaviour that has been

Figure 1. components and sub-components of the ethical behaviour of nurses towards the medical team

noted in the knowledge management cycle of nurses [59].

Acknowledgment

The authors appreciate the nursing management of Khorasan Razavi province and all the virtuous. They gratefully acknowledge the contribution of the representative nurses who participated in this study and patiently answered the questions to assist the researcher to carry out this study. It should also be noted that this article is taken from the PhD thesis of the first author, which has been proposed in Letter No. 437743/92 and approved at 04.17.2013.

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