| Abstract|| |
Background: The conscience is an essential value in healthcare and has a central position in ethics education. In clinical practice, healthcare professionals including students can be involved in challenging situations when they had to make difficult choices between following rules and their conscience.
Aim: The purposes of this study were to determine and to compare the views of healthcare (dental and nursing) students on conscience.
Materials and Methods: This descriptive study was carried out at a dental school and a nursing school in Turkey. A sample of 564 students (264 were from a dental school and 300 were from a nursing school) completed a self-reported questionnaire consisted of Likert-6 type 16 items concerning conscience. Descriptive statistics and independent t-tests were used for data analysis (SPSS 20.0) with statistical significance set at P < 0.05. Spearman's rank-order correlation coefficients were employed to determine the correlation between the items and the age of responders.
Results: While dental students were more likely to agree with the items of “our conscience can give us the wrong signals” and “our conscience expresses our social values;” nursing students were more likely to agree with the strong items “we cannot avoid the voice of conscience” and “when I follow my conscience, I develop as a human being,” and there were statistically significant differences between the groups (P < 0.001). Both groups tended to disagree with the statement, “I have to deaden my conscience to keep working in health care.”
Conclusion: According to the results of this study, it can be concluded that conscience is important for both professional groups. However, there are statistically significant differences between the dental and nursing students' views on conscience. Since the dental students' lower level of conscience is unacceptable from an ethical point of view and nursing students' high levels of conscience may cause moral stress for themselves, dental and nursing ethics curriculum should be updated by adding lectures concerning conscience.
Keywords: Conscience, dental ethics education, dental students, nursing students
|How to cite this article:|
Kadioglu FG, Yalçın SÖ, Selim K. Professional differences between dental and nursing students' views on conscience. J Educ Ethics Dent 2016;6:8-13
|How to cite this URL:|
Kadioglu FG, Yalçın SÖ, Selim K. Professional differences between dental and nursing students' views on conscience. J Educ Ethics Dent [serial online] 2016 [cited 2017 Dec 17];6:8-13. Available from: http://www.jeed.in/text.asp?2016/6/1/8/216519
| Introduction|| |
The term conscience covers two main aspects. The first is conscientia, which refers to the inner knowledge of what is right and wrong. The second synderesis means applying our moral principles to actual situations. Therefore, conscience has been defined as a person's moral values system, standards of behavior, and generally regarded as an inner state linked to an awareness of moral limits in our actions. It consists of a sense of accountability, including both responsibilities for past actions and feelings and obligation regarding future ones., Since it is one of the elements of professionalism, it also has a significant place in healthcare. For instance, according to American Dental Education Association (ADEA) Statement on Professionalism in Dental Education, integrity is an important value which requires the dentist to behave with honor and decency. In expanded definition, it means that the dentist should practice with a sense of integrity affirms the core values and recognizes when words, actions, or intentions are against one's values and conscience (ADEA, 2014).
In clinical practice, healthcare professionals,,,,,,,,, and students,,,,, can be actively involved in challenging ethical situations and they may be experience conscientious feelings. Because of these situations, nurses, physicians, and dentists may be involved in an ethical conflict and encounter moral distress, emotional pain, bad consciences, and feelings of shame and guilt.
In cases of moral dilemmas arising from conflict of ethical principles, healthcare professionals adopt conscience as a guide that enables them to differentiate right from wrong and directs them to act in the right way., According to Pellegrino, they try to preserve their moral integrity by acting in line with their conscience.
Dahlqvistet al. showed that perceptions of conscience varied considerably among Swedish health-care professionals and that conscience can be perceived as an authority, a warning signal, demanding sensitivity, an asset, and a burden. If health-care professionals facing a moral dilemma and acting according to what they presume is morally right would not create bad conscience. Sometimes, nurses and physicians conflict with their own conscience when they cannot help as they want and according to their conscience and experience a moral stress. Jensen and Lidell indicate that the behaviors disturbing their actors' conscience cause healthcare professionals to feel guilt even years later. Within the traditions of healthcare ethics, having a good character, being honest, and “being a conscientious person” are all accepted as positive virtues., Healthcare professionals acting according to their personal conscience during daily practice are deemed to be proper in terms of personal moral integrity. However, nurses and physicians often should suppress their own conscience to meet patient expectations and adapt to the healthcare system regulations. These suppressed conscientious feelings turn into heavy burdens over time and form the causes of exhaustion for individuals. Furthermore, healthcare professionals perceive the concept of conscience as important in terms of understanding their attitudes and behaviors in ethical decision-making processes. The conscience has a moral voice role reminding healthcare providers of their responsibility for the patients' well-being, treatment, and quality of care.
In healthcare literature, there are a lot of studies,,,,,,,,, show us that nurses tend to suffer guilty conscience more than physicians do. Furthermore, according to our clinical experiences, while nursing students pay more attention to the notion of conscience, medical and dental students scarcely take into consideration. Moreover, as dentistry is a rather technical field, students sometimes completely ignore the notion of conscience.
Neither nursing and dental international, and national, ethical codes nor the national nursing and dental curriculum involve information concerning conscience.
We assumed that dental students are quite different on this issue compared to other healthcare students, but there was no study found within dental literature on conscience. Consequently, we decided to compare dental and nursing students, namely, two particular groups of students from both ends of the spectrum, and to find out whether the conscience perception is being shaped during students' education life or not.
In consideration of this point, the present study was planned to determine the views of dental and nursing students on conscience and to compare the differences between the groups.
| Materials and Methods|| |
Sample and procedure
This descriptive study was carried out between April and May 2014 and a convenience sample of dental and nursing students was recruited from Cukurova University Dental and Nursing Schools, in Adana, Turkey. Sample size was calculated by Epi-Infoversion 7 software package (Epi Info™ Downloads from: https://www.cdc.gov/epiinfo/support/downloads.html) using data from an earlier study we conducted to validate the scale by considering the following assumptions: 80% power of the study, 95% confidence interval, and 10% nonresponse rate. Since this study focused on a regional population of limited size, the finite population correction is applied. These parameters required a sample size of 640 (320 dental and 320 nursing students).
Considering the possibility of response rate, the self-administered questionnaire was distributed to 660 healthcare students; a total of 564 participants replied to the questionnaire and the response rate was 79.7% (264/330) for dental and 90.9% for nursing students (300/330). The ethics committee approval was granted from the regional ethics committee (Clinical Research Ethics Committee). All participants were selected on a voluntary basis and informed consent was obtained.
Participants completed a self-reported questionnaire consisted of two parts: demographic information (age, gender and school) and Likert-6 type items concerning the views on conscience. The questionnaire was adapted from questions of a study conducted by Dahlqvist et al. with the permission of the original authors (Dahlqvist and Norberg). The items were translated by experts from English to Turkish, then back to English. This was done to prevent loss of meaning during the adaptation. Following the adaptation, a pilot study was performed with a group of volunteers (five dental and five nursing students). Feedback from the pilot showed that the 16 items in the questionnaire were comprehensible.
Descriptive statistics and independent t-tests were used for data analysis (IBM SPSS Statistics 20 software) with statistical significance set at P <0.05. Spearman rank-order correlation coefficients were employed to determine the correlation between the items and the age of responders.
A descriptive statistical analysis was performed. The correlation between theoretical knowledge and practical application and between theoretical knowledge and self-assessment were estimated using Pearson's correlation coefficient (r), and the significance was tested using Student's t-test. The level of significance was set at 5%.
Reliability and validity
The reliability analysis of the questionnaire was determined by testing internal consistency. The internal consistency shows the homogeneity of items, how strongly answers to the logical construction of statements correlate. We estimated internal consistency of the questionnaire Cronbach's alpha r = 0.736. As the normal range of values is 0.0 and +1.00; the higher values reflect more internal consistency. The validity was performed by testing content validity and it was estimated by Cronbach's alpha if item deleted confirmed relevant data.
Construct validity was also estimated before starting to use factor analysis and the data adequacy was tested. Two criteria show data adequacy Kaiser–“Meyer–“Olkin (KMO) and Bartlett's test of sphericity. In our study, KMO measure result was 0.806, considered adequate for the analysis. Bartlett's test of sphericity was 120 and rejected at P = 0.001, also supporting the construct validity.
| Results|| |
Our survey group consisted of 564 healthcare students' mean age was 21.1 ± 1.9 years with ranging between 17 and 32. Two hundred and sixty-four (46.8%) were dental students (from 1st year to 5th year) and 300 (53.2%) were nursing students (from 1st year to 4th year), and in total, 61% were female and 39% were male.
The findings obtained from the questionnaire are summarized in [Table 1], [Table 2], [Table 3], [Table 4]. [Table 1] shows the mean scores of all participants' agreement with the statements (1 = strongly disagree, 6 = strongly agree) about the conscience perceptions. According to the findings, three statements that all participants the most agreed were “the voice of conscience must be interpreted” (5.19), “God speaks to us through our conscience” (4.74), and “our conscience warns us against hurting others” (4.73) in the given order. The three statements that received the least agreement were, respectively, “our conscience weakens if we do not listen to it” (3.41), “I have to deaden my conscience in order to keep working in health care” (2.53), and “my conscience is far too strict” (2.27) [Table 1].
|Table 1: Total mean scores of participants' agreement with the items about the conscience perceptions (n=564)|
Click here to view
The comparative means of participants about the conscience perceptions by schools (dental and nursing) are shown in [Table 2]. The nursing students were more likely to agree than the dental students with the statements “you need inner peace to be able to hear the voice of conscience,” “we cannot avoid the voice of conscience,” “our conscience warns us against hurting ourselves,” “our conscience warns us against hurting others,” “we should follow our conscience, no matter what other people think,” “at my workplace I can express what my conscience tells me,” “god speaks to us through our conscience,” “when I follow my conscience, I develop as a human being.” For these items, there were statistically significant differences between the groups (P < 0.05 and P < 0.001) [Table 2].
The comparative means of participants about the conscience perceptions by gender (female and male) are shown in [Table 3]. While the female students were more likely to agree than the male students with these two statements: “The voice of conscience must be interpreted,” “we cannot avoid the voice of conscience,” male students were more likely to agree with the item “our conscience can give us the wrong signals.” There were statistically significant differences between the groups (P < 0.05 and P < 0.001) [Table 3].
[Table 4] shows the Spearman rank-order correlation coefficients between conscience expressions and age of the responders. Weak but statistically significant positive correlations were found between the age and the statements, “our conscience warns us against hurting others,” “we should follow our conscience, no matter what other people think,” “at my workplace I can express what my conscience tells me,” and “I follow my conscience in performing my work.” The statistically significant negative correlation was only found between the age and agreement with the statement “our conscience can give us the wrong signals” (P < 0.05) [Table 4].
| Discussion|| |
Based on this study results, nursing students showed more agreement than the dental students to strong expressions such as “we cannot avoid the voice of conscience,” “we should follow our conscience, no matter what other people think,” “at my workplace I can express what my conscience tells me,” “when I cannot meet my own demands on myself, I get a bad conscience,” “when I follow my conscience, I develop as a human being” and “God speaks to us through our conscience.”
It can be explained by nursing traditions. While medicine focuses curing the diseases, nursing focuses caring. Nurses may attach more importance to conscience because of their closer relations with patients during patients' daily vital activities (eating, drinking, physical exercise, pain, excretion, etc.), their patient rights defending roles, the traditional scope of nursing, and their inherent desire to show mercy. Furthermore, in our cultural context, being compassionate is accepted as a sign of having conscience by both nurses and patients. As a moral voice, conscience reminds the nurses of their responsibilities for the patients' well-being.
Since the national dental and nursing curriculum still lack conscience education, the reason behind nursing students giving higher scores to strong conscience statements may be explained by informal curriculum. As dental students' lower levels of conscience are deemed unacceptable in ethical and professional aspects, we believe that it would be useful to add lectures to dental ethics curriculum that are pointing out the importance of balanced conscience among healthcare professionals.
Jensen and Lidell's research shows that nurses perceive conscience as “the driving force behind boldly taken actions” and “an important element that enables us to see the vulnerability of human,” and that conscience provide them “confidence and guidance” in cases of hesitation. In the same research, it was reported that nurses feel more comfortable when the decisions they take as part of an ethical evaluation comply with their conscientious judgments. Glasberg's et al., Saarnio's et al., and Tuvesson's et al.,, studies show that the level of exhaustion is rather high in nurses who frequently find themselves struggling in conscience conflicts.
According to the findings of our research, dental students expressed more agreement with the expressions “our conscience can give us the wrong signals” and “our conscience expresses our social values” than the nursing students. Our study results were similar to those of other studies that conducted on physicians undertaking active roles on vital decisions concerning patients. It is possible for physicians to perceive conscience as an obstruction against medical interventions. Studies,, have shown that perceptions of conscience and stress of conscience are related to the risk of burnout and that moral sensitivity at work among health-care providers. Lawrence and Curlin studied 446 primary care physicians in the US the rate of the physicians agreeing with the statement “sometimes we may have to perform a medical treatment that does not conform to our conscience” was found out to be 22%.
Savulescu argues that since the rights provided to patients are established by law or by the rules of medicine, physicians' conscience should be excluded from medical practice. Savulescu emphasizes that in cases where the physician's conscience may prevent the treatment performance that is right according to the patient's condition. In fact, the Medical Student Section of the American Medical Association introduced a resolution to adopt a policy in support of exemptions for students with ethical or religious objections in 1996. Therefore, medical students can have conscience-based objections to participating in educational activities, which is still a controversial issue.
According to our results, the female students were more likely to agree than the male students with the strong statements such as “we cannot avoid the voice of conscience.” This result is similar to our nursing students' preferences and it is understandable because the majority of nursing students are female (69%).
Furthermore, the rates of agreement with the items “our conscience warns us against hurting others” and “I follow my conscience in performing my work” were observed to increase with increasing age of students. In other words, older students attach more importance to conscience and the possible answer may be found in the clinical years. In these years (4th and 5th years in dentistry; from the first to the last year in nursing), students can acquire knowledge and skills on their personal insights, value systems, and conscience in parallel with their growing professional experience.
Limitations of this study
There are several limitations to the study design that must be considered when interpreting the results. First, it is not possible to compare our research findings with those of previous studies performed on dental and nursing students because there are no other studies of this type. Second, the generalizability of the findings to other settings may be limited because the study was carried out on a small number of participants in a regional scale. In the future, prospective research with larger samples in other students in our country and elsewhere is required. In addition to, how conscience related to the ethical behaviors should be studied further.
| Conclusion|| |
According to the results of this study, although there are statistically significant differences between the dental and nursing students' views, it can be concluded that conscience is important for both professional groups. Therefore, it can be suggested that restructuring of ethics education concerning conscience would be beneficial. In this respect, health-care professionals'' listening, interpreting, knowing their own consciences, and defining its place in medical practice gain an importance. Neither the nursing nor the dental ethics curriculum involve information concerning conscience in our nursery and dental schools. However, through ethics courses, students maybe learn to be aware of conscience and to cope with the moral distress. We believe that it would be useful to add lectures to the both curriculum that are pointing out the importance of balanced conscience among health-care professionals.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cook ED. Always let your conscience be your guide. Am J Bioeth 2007;7:17-9.
Galdikiene N. Validity Study of a Questionnaire about the Perception of Conscienceamong Care Professionals in Primary Health Care in Lithuania. School of Health Science Blekinge Institute of Technology, Master Thesis, Sweden; 2005.
Staniuliene V. Conscience among Care Professionals in Hospital Setting. School of Health Science Blekinge Institute of Technology, Master Thesis, Sweden; 2005.
Hamilton N. Assessing Professionalism: Measuring Progress in the Formation of an Ethical Professional İdentity. Univ St Thomas Law Jo 2008;5:470-511.
Sørlie V, Jansson L, Norberg A. The meaning of being in ethically difficult care situations in paediatric care as narrated by female registered nurses. Scand J Caring Sci 2003;17:285-92.
Kälvemark S, Höglund AT, Hansson MG, Westerholm P, Arnetz B. Living with conflicts-ethical dilemmas and moral distress in the health care system. Soc Sci Med 2004;58:1075-84.
Glasberg AL, Eriksson S, Dahlqvist V, Lindahl E, Strandberg G, Söderberg A, et al.
Development and initial validation of the Stress of Conscience Questionnaire. Nurs Ethics 2006;13:633-48.
Torjuul K, Elstad I, Sørlie V. Compassion and responsibility in surgical care. Nurs Ethics 2007;14:522-34.
Jensen A, Lidell E. The influence of conscience in nursing. Nurs Ethics 2009;16:31-42.
Lawrence RE, Curlin FA. Physicians' beliefs about conscience in medicine: A national survey. Acad Med 2009;84:1276-82.
Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience, stress of conscience and burnout among nursing staff in residential elder care. J Adv Nurs 2010;66:1708-18.
Saarnio R, Sarvimäki A, Laukkala H, Isola A. Stress of conscience among staff caring for older persons in finland. Nurs Ethics 2012;19:104-15.
Tuvesson H, Eklund M, Wann-Hansson C. Stress of conscience among psychiatric nursing staff in relation to environmental and individual factors. Nurs Ethics 2012;19:208-19.
Kadioglu F, Yalçın S. Nurses'and physicians' views of conscience in Turkey. Rev Rom Bioet 2014;12:19-31.
Cantwell M, Clifford C. English nursing and medical students' attitudes towards organ donation. J Adv Nurs 2000;32:961-8.
Lemonidou C, Papathanassoglou E, Giannakopoulou M, Patiraki E, Papadatou D. Moral professional personhood: Ethical reflections during initial clinical encounters in nursing education. Nurs Ethics 2004;11:122-37.
Sharp HM, Kuthy RA, Heller KE. Ethical dilemmas reported by fourth-year dental students. J Dent Educ 2005;69:1116-22.
Christie C, Bowen D, Paarmann C. Effectiveness of faculty training to enhance clinical evaluation of student competence in ethical reasoning and professionalism. J Dent Educ 2007;71:1048-57.
Wiggleton C, Petrusa E, Loomis K, Tarpley J, Tarpley M, O'Gorman ML, et al.
Medical students' experiences of moral distress: Development of a web-based survey. Acad Med 2010;85:111-7.
Al-Zain SA, Al-Sadhan SA, Ahmedani MS. Perception of BDS students and fresh graduates about significance of professional ethics in dentistry. J Pak Med Assoc 2014;64:118-23.
Childress JF. Appeals to conscience. Chic J 1979;89:315-35.
Pellegrino ED. The physician's conscience, conscience clauses, and religious belief: A Catholic perspective. Cuad Bioet 2014;25:25-40.
Dahlqvist V, Eriksson S, Glasberg AL, Lindahl E, LÜtzén K, Strandberg G, et al.
Development of the perceptions of conscience questionnaire. Nurs Ethics 2007;14:181-93.
Gillon R. Conscience, good character, integrity, and to hell with philosophical medical ethics? Br Med J (Clin Res Ed) 1985;290:1497-8.
Savulescu J. Conscientious objection in medicine. BMJ 2006;332:294-7.
Conscience, virtue, integrity and medical ethics. J Med Ethics 1984;10:171-2, 190.
Wicclair MR. Conscience-based exemptions for medical students. Camb Q Healthc Ethics 2010;19:38-50.
Funda Gulay Kadioglu
Department of Medical Ethics, Faculty of Medicine, Cukurova University, Adana
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]