Introduction

An attitude is a combination of beliefs and emotions, and a mental and nervous preparation which is organised through experience and which prepares the individual to perceive different people, objects, and groups in either a positive or negative light (1). An ethical attitude denotes motivation and commitment in practice and the capacity to respond to others. It is considered a significant aspect of human communication. Although it entails following the formal codes of professional ethics, an ethical attitude is more complicated than merely abiding by rules and ethical codes. An ethical attitude is important because rules and regulations alone cannot respond to challenging ethical predicaments. An ethical attitude can help find solutions to such predicaments and enable students to support patients under critical conditions (2, 3, 4, 5).

The concept of patient care extends far beyond performing a series of procedures and following repetitive routine instructions to satisfy a set of needs. The patients and community expect nurses to display ethical and emotional attitudes, such as moral values, intimacy, empathy and connectedness, and ultimately, ethical performance (5, 6).

As a symbol that indicates health sciences students’ and health personnel’s manner of dealing with the ethical aspect of patient care, an ethical attitude plays a significant role in creating a sense of accountability, altruism, respect and commitment towards the patient, and ultimately dictates ethical performance and the quality of patient care (5, 7, 8).

Problems such as an insufficient salary and benefits, a heavy workload and a lack of support from the authorities occasionally affect the performance of healthcare personnel (9, 10). A favourable ethical attitude can contribute to their enthusiasm about patients and to their passion for care and treatment (11). Values guide human beings in their efforts to help those in need; an ethical attitude helps revive these values and turns them into action. As a result, an ethical attitude and a sense of responsibility have direct effects on ethical action and ultimately, on the outcome of patient care (8).

Human beings are not ethical beings from birth. Their attitudes are constantly changing, and they also tend to develop and evolve their attitudes by observation and training (12, 13). An ethical attitude is, therefore, not created by accident and in fragments; rather, as suggested by evidence, a large part of the development of professional ethics and an ethical attitude takes place during the school years (11, 13).

The teaching of ethics contributes greatly to professionalism and the development of a person’s attitude, ethical behaviour and judgement. It also helps one gain a better understanding of the students’ personal values, which can be used to form their professional values (11, 14, 15). Universities should, therefore, develop their curricula in such a way that students end up with a balance of knowledge, attitude and skills (3).

Mebrouk revealed that in the nursing profession, values and the perception of the care of patients are largely influenced by religious and Islamic values (16). Mokhtari Lakeh et al (17) reported that nursing students have a positive attitude towards the nursing code of ethics and a strong commitment to ethical care. The authors argued that a positive attitude towards the code of ethics is the strongest predictor of commitment to ethical care (17). Ruth Elder also described the ethical attitude of nurses as positive, and showed that they differ significantly from medical students in a number of ethical domains. For example, nurses were better able to adopt their patients’ perspective, while medical students identified more strongly with their profession (6).

The results of another study conducted on the ethical attitude of nurses in a research institute showed that nurses consider ethical issues very important. According to the study, if the majority of the members of this research institute were nurses, greater attention would be paid to ethical issues (18). Another study compared the ethical attitudes of nurses and physicians in teaching hospitals in Saudi Arabia and showed that nurses had a more positive ethical attitude than physicians. Also, an ethical attitude was more strongly tied to the type of profession than to gender (19). Educational institutions are responsible for emphasising students’ emotional attributes and fostering positive emotions in them. It is important to do this because emotional attributes contribute greatly both to personality development and to job performance. While emotional attributes such as attitude are important educational objectives in and by themselves, they also provide the means to attain other educational objectives (20). These attributes act like a filter through which students can observe, understand, and react to the activities and incidents taking place at their university and workplace. Creating a favourable ethical attitude in nursing students is, therefore, crucial to their learning and their manner of performing their duties as future nurses. Universities should develop their curricula in such a way that ethical intentions and actions can come together (20). Since nursing students are the nurses and care-providers of the future, exploring their present status and their ethical attitudes and vision is of the utmost importance. A review of the literature showed that the studies conducted in Iran have not focused much on exploring ethical attitudes, particularly among students. Our study aimed to fill this gap.

Materials and methods

This descriptive cross-sectional study was conducted over a four-month period in 2014. The study population consisted of all the third-year and senior students of nursing at Shahid Beheshti University of Medical Sciences. A total of 257 nursing students were selected through census sampling. The researcher visited the School of Nursing at Shahid Beheshti University of Medical Sciences and invited the selected students to fill out a questionnaire. The data were collected using Ruth Elder’s ethical attitude questionnaire (6). This questionnaire contains 22 items and is scored on the basis of a 5-point Likert scale (totally agree=+2, agree=+1, neutral=0, disagree=-1 and totally disagree=-2). The mean score obtained for all the items ranges from -2 to +2. The items fall under six dimensions, which are beneficence, autonomy, justice, morality, doctors’ rights/interests/obligations and unacceptable or reprehensible medical conduct. The mean score of each dimension is calculated by the mean score of its items. The items under the dimension of beneficence are the refusal of treatment, requests by the patient and family, and the best interest of the patient. The dimension of justice addresses the unbiased allocation of public resources to patients, contributions towards patients’ medical costs and the rights of older adults. The dimension of morality consists of items on respect for life, avoiding reproach or punishment by the medical team, and the protection of patients against impostors and non-professionals. The dimension of autonomy deals with informed consent, patients’ rights, confidentiality, learning about treatment processes, learning about procedures, refusing treatment, and hearing the truth. The dimension of the medical team’s commitments and obligations is concerned with the medical team’s knowledge of legal professional issues, liberty in clinical decisionmaking, steering clear of political bias and the utilisation of all means available for the patient’s recovery. The dimension of unacceptable or reprehensible medical conduct addresses the patient’s full right to accept or refuse treatments proposed by the medical team without blame.

Using the backward–forward method, the questionnaire was first translated into Persian and then back into English. It was then reviewed by an individual fluent in both Persian and English to examine the consistency of the two English versions. To determine the compliance of the questionnaire with Iranian culture, 10 experts in the field of bioethics, in particular, medical ethics, commented on it. The validity of the content of the questionnaire was measured using the Content Validity Index (CVI), which yielded a mean of 0.89. The items did not have to be modified. The reliability of the questionnaire was measured through its distribution among 20 nursing students who were asked to complete it, and was subsequently calculated as 0.86, using the internal consistency and Cronbach’s alpha value.

The study proposal was approved at the 155^th meeting of the ethics committee, held on August 31, 2014 under the code 12014. The study complied with all the ethical considerations of research, including optional participation in and withdrawal from the study, assuring the research subjects of the confidentiality of the information given by them and the anonymity of the questionnaires, and obtaining verbal consent from the research subjects.

The data were analysed in SPSS-18. Descriptive statistics (frequency, percentage frequency, standard deviation and mean) were used to measure the descriptive parameters, while the multivariate linear regression analysis and the independent t-test were used to measure the analytical parameters.

Results

Of the 257 students who participated in the study, 106 (41.2%) were third-year students and 151 (58.8%) were senior students of nursing. The study had a response rate of 100%, with all the questionnaires being returned successfully by the students. Before the questionnaires were distributed among them, they were briefed on the importance of responding to all items. The researchers were available to respond to any questions the students may have had while filling out the questionnaires and the returned questionnaires were examined at the end to ensure that they were fully completed. The mean and standard deviation of the students’ ethical attitude was 0.95±0.45. The mean and standard deviation of their age was 21.51±1.33. The youngest and the oldest students were 20 and 29 years of age, respectively. The majority were female (59.5% and n=153) and the males were in a minority (40.5% and n=104). Eightyfour per cent (216) of the students were single and 16% (41) married. In addition, 47.9% (123) of the students had previously participated in ethics seminars and 32.3% (83) had passed courses in ethics before. In the dimension of ethics, the female students had a more positive attitude than did their male counterparts, making for a significant difference (Table 1).

In the multivariate linear regression analysis (the enter method) for examining the variables of age, gender, previous participation in ethics seminars and having passed courses in ethics, only gender was found to have a significant role in the prediction of the nursing students’ ethical attitude (B coefficients=-0.18; p<0.05; male code=1; and female code=0).

The favourable mean ethical attitude of the nursing students attracted the attention of the researchers, who wanted to learn of the items that influenced the students’ ethical attitude. The items in which more than 50% of the students had selected the “totally agree” option were, therefore, interpreted separately.

More than 50% of the students opted for the “totally agree” option in a number of items within the dimensions of autonomy, justice, morality and doctors’ obligations. In the autonomy dimension, 75.5% of the students chose this option for the “Patients have an absolute right to confidentiality” item and 58% chose it for the “Consent must always be obtained before an intervention” item. In the social justice dimension, 68.9% of the students chose the “totally agree” option for the “Public resources should be used fairly and without biases” item. Of the four items pertaining to the social justice dimension, three were considered crucial by the students, indicating how they viewed the role of justice in care. As for the “Elderly patients have a right to full and proper healthcare” item, 65.4% of the students chose the “totally agree” option. In the justice dimension, 52.5% of the students chose the “totally disagree” option in response to the “Public resources should never be used for self-inflicted injury or illness” item. As for the dimensions of morality and doctors’ rights/interests/obligations, 63.4% of the students chose the “totally agree” option for the items “Respect for life is an absolute principle that is paramount in medical decisions”, “Doctors should never chastise or punish or be influenced by moral viewpoints in their interactions with a patient” and “Doctors must safeguard themselves against potential litigation”

Discussion

The study showed that the nursing students’ mean ethical attitude was higher than average and was, therefore, deemed favourable. According to Karimi et al (2015) and Moosavi et al (2015), ethical sensitivity, too, was higher than average among the students and nurses (21, 22). A study conducted in 2010 by Tamim suggested that the attitude of nurses was moderate, but asserted that awareness and the preservation of ethics was greater among them than physicians (19). Ruth Elder also found that nurses had a more ethical attitude than did medical students (6). The nurses who participated in a study conducted by Nåden considered ethical values and attitudes central to care, and believed that they comprised the artistic dimension of nursing (8). In our study, the moderately positive ethical attitude of the participants may have been affected by the fact that more of the students were female (60%) than male (40%). According to Gilligan, women assess ethical situations on the basis of the ethics of care, which tends to emphasise communication and accountability, whereas men act on the basis of the ethics of equity, which is based on individualism, autonomy and rights (23). Since the mid-1990s, a new paradigm has emerged that considers the ethics of care and of equity imperative in the ethical development of nurses (24). In the 19^th century, Florence Nightingale wrote: “You cannot be a good nurse unless you are a good woman.” (25) Moreover, studies have shown that clinical experience and contact with clinical personnel affect the understanding of nursing students and their attitude towards the profession. An ethical attitude is not related to what people do, but to the way in which they do what they do. Senior nursing students have a better attitude because of greater clinical experience and their position as role models. In his study, Kim explains that ethical development and judgement are more desirable among senior nursing students than among students of other levels (26).

Our study showed that only gender plays a significant role in predicting the ethical attitude of nursing students, as the mean level of ethical attitude was higher among the female than male students. While the results of some studies have suggested the absence of a definitive distinction between the ethical attitudes of men and women (6, 27, 28), some studies do show that women are more ethics-oriented (29, 30). Over the past two decades, the subject of ethics and gender has attracted a significant amount of attention. Moral philosophers believe that men have a higher sense of rational morality, while women have a higher sense of emotional morality (24). The issue involved in nursing is the ethics of care. Gilligan believes that women are sensitive to their own and to others’ sense of security, and are more interested in establishing relationships involving care. They are, therefore, likely to have a more ethical attitude than men (23).

More than half of the participants chose the “totally agree” option in a number of items related to the dimensions of autonomy, justice, morality and doctors’ obligations. According to the American Association of Colleges of Nursing, five values are essential to the profession of nursing: (i) altruism; (ii) autonomy; (iii) respect for others; (iv) honesty and conduct in compliance with the established ethical standards and codes; and (v) social justice. The students’ responses in this study are consistent with these values (31). In Ruth Elder’s study, the choices made by the nurses were similar to those made by the participants in our study. She believes that the nurses’ choices might be influenced by the fact that they are in close contact with patients, and see their patients and themselves as being in a position of relative powerlessness within the health pyramid (6).

“Autonomy” is based on the principle that human beings are unique and able to make decisions. Informed consent is a legal doctrine designed to protect patients. Respect for human dignity requires the recognition of other’ rights, in particular the right to choose for themselves, which is the rational basis of informed consent in care. In legal and moral terms, patients have the right to receive accurate, thorough and comprehensible information, and nurses are responsible for assessing the information given by patients, as well as honouring and maintaining their autonomy (32).

“Social justice” has two dimensions. One is the dimension of direct action, which is associated with ensuring good care. The other is an action and protection dimension, which is associated with rules and policies and is aimed at the removal of obstacles against access to services. Nursing is among the pioneering professions in the establishment of justice. The importance of protecting patients and establishing justice, as illustrated in Florence Nightingale’s writings (1859), the efforts of nursing leaders to change laws to further the promotion of health, and the act of providing for the common needs of mankind – regarded by theorists in the field as the ultimate end of nursing – all demonstrate the value of social justice and its association with professional nursing (33, 34). Justice is a basic human need, and signifies respect for oneself and for others and should be reflected in the decision of a nurse when providing care for a patient, while considering the family, the community and also other members of the medical team (35). When social justice is tied to the profession of nursing in a society, the health indicators become more stable (36).

An extremely important group receiving health services across the world is the group of elderly people. This population has been increasing due to scientific and technological advances and reduced mortality and birth rates. Governments, policymakers and health service providers should, therefore, focus on ensuring justice and access to services to this group. The quality of care for the elderly depends directly on the attitudes of the physicians, nurses and nursing students caring for them (37, 38). Fostering a positive attitude in today’s students, who will be tomorrow’s nurses, is essential for enhancing the quality of the care of these patients (39, 40, 41). Factors found favorably linked with a positive attitude towards the care of the elderly are age (over 25 years), gender (female), environment, positive clinical experience and previous experience of looking after grandparents, which is customary in Iranian culture (29).

The Nursing students’ positive attitudes to the use of public resources for self-inflicted injury or illness, falling under the dimension of justice, were in line with the results of some studies (29, 41), that note a positive change in the attitude of the nurses and nursing students towards caring for these patients Although the participants in our study were all Muslims, and although self-inflicted injury and suicide are forbidden in Islam, given the philanthropic and altruistic nature of the profession of nursing, the students believed that these people are also entitled to health services.

Respect for human beings and the preservation of human dignity are at the core of nursing care. All Abrahamic religions share the doctrine that the murder or revival of one man is equal to the murder or revival of all men. Thus, nothing compares to preserving human dignity. In medical ethics, human dignity must be the basis of decision-making on the human body and mind, and no instructions of medical ethics can be contradictory to this principle. Moreover, liberty, usefulness, non-harmfulness and justice, must find their meaning in the light of this principle (42). In an annual survey conducted in the USA, nursing was chosen as the most ethical profession for eight years, and the participants reported high levels of honesty, altruism and ethical standards among nurses (43). A knowledge of the ethical codes and legal issues related to the profession improves the quality of care, which is the ultimate end of the profession of nursing. This knowledge helps in the development of an ethical attitude and motivation, and ultimately, ethical judgement and behaviour.

Conclusion

The participants in our study had a favourable ethical attitude, and female students had a more positive attitude than male students in the dimension of ethics. In Iran, one single ministry is responsible for health and medical education. The ministry should, therefore, promote an appropriate relationship between the dimensions of health and medical education. Fostering a positive ethical attitude among nursing students is a valuable and influential input into this system, as such an attitude is an essential part of professional nursing performance and it is the nurse’s attitude that makes for a committed performance. The participants also emphasised the dimensions of autonomy, knowledge of duties and obligations, and social equity. These findings can be used to improve education, management of patients and education management, clinical conditions and nursing research. In the dimension of education, the students’ attitude to important ethical principles can aid in proper, constructive planning, so that in an appropriate setting, they can acquire professional values by modelling themselves after their professors and experienced nurses, and even improve the ethical environment of clinical settings through their own positive ethical attitudes.

Limitations of the study

The sample selected for the study consisted only of nursing students at Shahid Beheshti University of Medical Sciences, which might have affected the generalisability of the results. The researchers recommend that this topic be explored by further studies which have larger sample sizes and the participants of which are selected from other medical universities in the country. The bias introduced by wishing to give a socially desirable response is one of the problems that affect the validity of a variety of studies, especially those dealing with socially sensitive issues. The bias is greater in studies in which the participants are likely to be recognised during the process of sampling. The ethical attitude of students who have participated in ethics seminars may be different from the attitude of those who have participated in this type of study and may have been affected by such a bias. This bias must have been reduced in our study due to the fact that the students were assured of their anonymity when filling out the questionnaire and of the confidentiality of the data pertaining to them,. Nevertheless, one must exercise caution when trying to generalise the results.