ETHICAL SENSITIVITY AND RELATED FACTORS OF NURSES WORKING IN THE HOSPITAL SETTINGS

The purpose of the study is to determine the level of ethical sensitivity and related factors of nurses working in the hospital settings. This descriptive study was conducted at a public hospital and a university hospital in Ankara, Turkey between April–July 2012. A total of 111 nurses participated in the study. The data were collected using a data collection tool consisting of two parts. The first part consisted of questions that determined the nurses’ personal and socio-demographic characteristics. The second part comprised of “Byrd’s Nurses Ethical Sensitivity Test”. The data were evaluated by using frequency, percentage, t-test and one-way ANOVA. Of the 111 nurses, 39,7% had a work experience of 1–3 years, 51,4% was married and 38,7% did not have ethics education. Education levels of most of the nurses (62,2%) were bachelor’s degree. The mean ethical sensitivity score of nurses was 21,12±2,85. “It was determined that ethical sensitivity of nurses was found to be higher in those that had ethics education, older age group, and had bachelor’s degree than others (p<0,05)”. The mean ethical sensitivity score of nurses was of medium level. It is concluded that ethical sensitivity was influenced by ethics education, age groups, and educational background.

the nurse is clinically competent, but ethically insensitive or oblivious, then this provision will not have a part in the decision making and actions that are needed to deal with the whole patient situation (14).The nurses with ethical sensitivity can interpret a situation from other points of view and show sensitivity to the feelings and reactions of patients.Nurses who are ethically sensitive seeks information and listens carefully (15).
There is little research studies in Turkey about nurses' ethical sensitivity.The aim of this study is to determine the level of ethical sensitivity of nurses and the factors affecting their ethical sensitivity.This study will therefore make a significant contribution towards ethical sensitivity of nurses.

Methods
A descriptive design was used to determine the level of ethical sensitivity and related factors of nurses.This study was conducted at a public hospital and a university hospital in Turkey between April-July 2012.The study population of the nurses working at these hospitals was created and a sample selection was made.The total number of nurses in these two hospitals was 320 of which 111 (34.68%) agreed to participate in this study.
The relevant data were collected using a data collection tool, which consisted of two parts.The first part consisted of questions that determined the nurses' personal and socio-demographic characteristics.The second part comprised of "Byrd's Nurses Ethical Sensitivity Test" that was developed by Byrd (10) in 2006 in order to determine nurses' ethical sensitivity.Turkish validity and reliability of the test was carried out by Orgun (11) and it was accepted as valid and reliable.Byrd's nurses ethical sensitivity test (Byrd's NEST) is a 3-point Likert-type scale consisting of 10 items.It consists of 10 different scenarios that cover the ethical dilemmas encountered during everyday nursing practices.Each scenario has three possible multiple-choice answers.The answers are rated between 1 -3 points, and the level of ethical sensitivity is classified as low, medium, or high based on the scores.In this scale, the lowest and highest scores are 10 and 30, respectively.According to this test, the degree of ethical sensitivity is considered to be lower between 10-16 points,

Introduction
Improved patient care and global advancements in healthcare technologies is reflected in the health care practices.This has given rise to new ethical dilemmas, particularly for nurses.Previous research studies pointed out that physicians and nurses were confronted with ethical dilemmas when making decisions regarding provision/ withdrawal of life-sustaining treatment, resuscitation orders, artificial hydration and nutrition, organ transplantation, brain death, euthanasia and end of life, lack of adequate resources for care and treatment, lack of respect for the individual, and lack of informed consent(1-7).
Nurses as an advocate for the patient play an important role in solving ethical problems.Nurses who are in constant contact with the patient can quickly realize any ethical issue.The importance of ethics in nursing and understanding the need for education about ethical values are crucial for the development of professional nursing practices (7)(8)(9)(10).
Ethical problems should be identified in order to solve ethical dilemmas.Determining and adopting the existence of an ethical problem requires ethical sensitivity.Ethical sensitivity is defined as the ability to be aware of the existing ethical issues and to determine the importance of this situation in terms of individuals (7,11).It includes caring for the ethical dimension of the events, identifying ethical issues, and making ethical decisions competently.Ethical sensitivity not only solves problems ethically or justifies the actions, but is also able to prevent ethical dilemmas or conflicts (7,12).
Ethical sensitivity requires that nurses should be able to interpret and be aware of verbal or nonverbal clues and behaviors of patients in order to determine the needs of the patient.They should be sensitive to the patients' physical and emotional needs, and should take this into account when caring for them (13).
Sometimes, nurses define a problem as a clinical one without seeing the ethical aspects existing.If the ethical issues that exist are missed, then part of the situation goes unattended by the nurse.If The mean ethical sensitivity score of nurses was found to be of medium level (21,12±2,85) (Table 2).Ethical sensitivity of nurses with ethics education was higher compared to nurses with no ethics education (p=0,009).Ethical sensitivity according to the educational background was also statistically significant (p=0,022).In post-hoc analyses, it was determined that such a difference was caused by the groups with high school and graduate degrees.The average ethical sensitivity score according to age groups was found to be statistically significant (p=0,006).The advanced statistical analysis (Bonferroni test) determined that this difference arose from 18-26 and 37-46 age groups.
The questionnaires were given to the nurses.An information sheet explaining the purpose of the study and a consent form were attached to the questionnaire.Head nurses were asked to grant nurses the time to complete the questionnaires.The nurses were reminded of the study 2, 4, and 6 weeks later.All completed questionnaires were collected from the head nurses' offices where the researcher retrieved them.
Independent variables in the study were age, marital status, educational background, ethics education, work experience, current hospital of employment, current department of employment, and income level.Suitability of the normal distribution of data was evaluated using the Kolmogorov-Smirnov test that showed normal distribution of the data set.The effect of taking ethics education on ethical sensitivity was evaluated using t-test, and other variables were evaluated using one-way analysis of variance (ANOVA) with Bonferroni correction.
Written permission was obtained from the institutions involved.The study was approved by an ethical committee of a university.The data were collected after the approval of the ethical committee.Prior to the data collection, informed consent of all nurses were obtained.The anonymity and confidentiality of participants were guaranteed.

Results
The socio-demographic characteristics of the sample are presented in Table 1.Of the 111 nurses, 44 (39,7%) had a work experience of 1-3 years.Approximately 57 (51,4%) were married.Education levels of 69 nurses (62,2%) were bachelor's (graduate) degree.Their average age was 28,43 years.A total of 43 (38,7%) nurses did not have ethics education.A vast majority (92,7%) of nurses who had ethics education had taken it up in the nursing school.In the study, 61 (55%) nurses worked in a public hospital.The nurses working in the two different hospitals were determined to be similar to each other in terms of socio-demographic characteristics (p>0,05).
case studies also can not be presented.Therefore, the importance of this issue should be emphasized in the in-service training after graduation.However, just 5,9% of the nurses in our study stated that they had in-service training to ethics education.In the studies carried out by other researchers about nurses' ethical sensitivity, it was found that nurses' in-service ethics training ranged from 20,51-48,3% (16,18,19).
The mean ethical sensitivity score of nurses in this study was 21,12±2,85, which comes medium level.A few other studies conducted by using different scales also found the ethical sensitivity of nurses to be medium level (16,18,19).These results strengthened our research findings.
A statistically significant difference was found between ethics education and ethical sensitivity of the nurses in this study.The ethical sensitivity of nurses with ethics education was found to be higher compared to those with no ethics education.This result emphasizes the importance of ethics education for increasing ethical sensitivity.Literature indicated that ethics education needs to be strengthened not only in nursing education, but also in medical education (7,20).
The average age of nurses in this study was 28,43 years (±6,252).The mean ethical sensitivity score according to age groups was found to be statistically significant.Advanced statistical analysis determined that this difference originated in the 18-26 and 37-46 age groups.Mean ethical sensitivity score of the youngest group was found to be lower compared to the elderly group.Ethical sensitivity increases with advancing age.The studies conducted by Kim et al. (19) and Tosun (7) indicated that nurses' ethical sensitivity increases with age.
Mean ethical sensitivity score of older nurses was higher than young nurses.This is because older nurses become more experienced and sensitive to face ethical problems over the years compared to younger nurses.
The nurses' mean ethical sensitivity scores were statistically significant (p=0,022) according to the educational background.High school was the lowest ethical sensitivity group and graduate de-

Table 2 .
The mean ethical sensitivity score of nurses in terms of some variables No statistically significant differences were observed between nurses' marital status, work experience, income level, current hospital of employment, current department of employment, and mean ethical sensitivity score in this study.As a result, the mean ethical sensitivity score of nurses was of medium level.Ethical sensitivity was influenced by ethics education, age groups, and educational background; and, it was not influenced by marital status, income level, work experience, current department or hospital of employment.In order to increase the ethical sensitivity of nurses, it is considered that ethics education in school/course programs should be reviewed.Moreover, the importance of this issue should be emphasized to students.It is recommended that ethics issue should be incorporated both during school education and in-service training programs after graduation.It is also recommended that nurses should be organized according to age groups and educational backgrounds while undergoing in-service training.