The Relationship between Moral Sensitivity and Professional Behaviour and Its Comparison in First- and Last-Year Undergraduate Nursing Students

Background Nursing students should be equipped with ethical sensitivity and professional behaviour because they will face challenging ethical issues in their future work environment. This study aimed to determine the relationship between moral sensitivity and professional behaviour and compare it in first- and last-year undergraduate nursing students. Methods This study was a cross-sectional, correlational study that was conducted at Isfahan University of Medical Sciences in 2019. The sample size of this study was 238 nursing students. The tools used in this study were the Persian versions of the moral sensitivity questionnaire and the professional behaviour questionnaire. The data were analyzed using SPSS 18 software. Results Linear regression showed that the total score of moral sensitivity of nursing students had a significant relationship with their professional behaviour (p  <  0.05). The result of the univariate analysis showed that the mean total score of moral sensitivity and professional behaviour was significantly higher in the last year than in first-year students (p  <  0.05). Conclusion Considering the relationship between moral sensitivity and the professional behaviour of nursing students, the promotion of moral sensitivity can become the basis for the development of the professional behaviour of nursing students. Therefore, it is suggested to focus on teaching the principles of nursing ethics to develop the moral sensitivity of undergraduate nursing students.


Introduction
Nurses have an essential role in upgrading the care and health of patients which depends on the quality of performance and professional behaviour of nurses [1].In this regard, promoting the quality of the nursing services provided to patients requires nurses to employ scientifc care and moral principles in their professional practice [2,3].Ethics is a pillar in nursing practice, and a critical part of the nursing profession is to achieve moral competency in parallel with clinical competency [4].Nurses are responsible for making the best professional and ethical care decisions, which necessitates moral sensitivity and professional behaviour [3,5,6].
Moral sensitivity is a crucial component of ethical decision-making, which refers to the ability that involves recognizing the ethical dilemmas and their efects, the vulnerability of patients, and comprehending the implications of ethical decision-making [7,8].Te lack of moral sensitivity makes it impossible for a person to recognize nursing ethical problems [9].Nursing students, as future healthcare providers, should be equipped with advanced degrees of moral sensitivity because they will face challenging ethical issues in their future work environment [10,11].Nonetheless, most studies show that nursing students possess diferent levels of moral sensitivity [12][13][14].In a study by Akca et al. [14], it was specifed that nursing students had moderate levels of moral sensitivity [14].Nevertheless, a study by Ozcetin and Hicdurmaz showed that the moral sensitivity score decreased with increasing age and educational level, and the students who passed ethics courses obtained lower scores in some subscales of moral sensitivity, as well as regarding the total score [15].In addition to paying attention to ethical issues in the structure of nursing education curricula, attention should be paid to the development of innovative content and educational methods at the undergraduate level [11,13].However, the efectiveness of ethics courses and proper educational strategies in nursing is controversial [16][17][18][19].
Professional behaviour is among the fundamental concepts of the nursing profession; so, inappropriate professional performance can lead to job burnout, reduction or loss of motivation, and demotion of job satisfaction among nurses [20].Similarly, nursing students' professional values are determined by their professional behaviours and performance [21].However, there has been debate regarding professionalism and the acquisition of skills in nursing, so that in some studies asserting that newly graduated nurses lack the readiness required for fulflling complex and professional nursing practices, including clinical skills, logical thinking, time management, communication skills, and teamwork skills [22,23].In a study by Nabavi et al. [24], it was reported that although nursing students attained desirable levels of professionalism during their frst years of academic education, they not only failed to progress in this area but also experienced a downturn during the fnal years of education [24].
Higher levels of moral sensitivity in nursing students can be related to their greater professional commitments [25].Chen et al. [8] showed that there was a positive correlation between moral sensitivity and professional values, and professional values played a mediating role in the relationship between moral sensitivity and ethical decisionmaking [8].Baykara et al. [26] study found that moral sensitivity has a positive efect on professionalism; therefore, it can be said that while moral sensitivity is a prerequisite for the development of professionalism, professionalism also accelerates the development of moral sensitivity [26].
Undergraduate nursing educational program in Iran for teaching ethical principles includes a course called "nursing ethics and professional communication" (1.5 credits and a total of 34 hours) [27].
Even though nursing students should recognize ethical challenges and overcome them by showing professional behaviour and making ethical decisions, very limited studies have been conducted in the feld of evaluating the relationship between ethical sensitivity and the professional behaviour of nursing students.Also, there are inconsistencies and uncertainties regarding the efectiveness of ethics education in terms of moral sensitivity and professional behaviour during the undergraduate nursing course.In this regard, the investigation of moral sensitivity and professional behaviour, as essential components of the development of professional ethics, can elucidate the effectiveness of ethics education during the undergraduate nursing course.Terefore, the present study aimed to determine the relationship between moral sensitivity and professional behaviour and compare them between frst-and last-year nursing students.

Materials and Methods
2.1.Study Design.Tis was a cross-sectional, correlational study to investigate the relationship between ethical sensitivity and professional behaviour, and also, this study compares moral sensitivity and professional behaviour between the frst-and last-year nursing students of Isfahan University of Medical Sciences in 2019.

Participants and Sampling.
In the second semester of 2019, 289 students were registered in the frst year and the last year.Te inclusion criteria for this study included being frst-year and last-year nursing students, not having a critical incident in the last 6 months, and not sufering from mental disorders.Te exclusion criteria from this study included unwillingness to continue participating in the study and incomplete questionnaires.Sampling was conducted by census method.Of 289 students who were registered in the semester, 238 nursing students, including 158 frst-year students and 80 fnal-year students, completed questionnaires.

Instruments.
A three-part questionnaire was used to collect the data.Te frst part of the questionnaire addressed demographic characteristics.Te second part of the questionnaire included the Persian version of Lutzen's moral sensitivity (1994) scale in determining the subjects' moral sensitivity, whose validity and reliability were confrmed by Hasanpoor et al. [28].Te original version of this questionnaire was made by Lutzen and Nordin [29].Tis questionnaire contained 25 queries organized into six subdomains, including respecting the patient's autonomy, knowing how to communicate with the patient, professional knowledge, ethical conficts experienced, applying moral concepts during ethical decision-making, and honesty and benevolence.Tese queries were scored on a 5-point Likert scale from totally disagree to totally agree.Te minimum and maximum of the total score were 0 and 100, respectively.Hasanpoor et al. assessed the reliability of the questionnaire using Cronbach's alpha method, reporting a coefcient of 81% [28].
Te third part of the data collection tool included the Persian version of the Goz professional behaviour (2010) questionnaire, which is in the study by Nabavi et al. [24]; Te original version of this questionnaire was made by Goz and Geckil [30].Te validity of this questionnaire was approved by experts in the feld, and its reliability using Cronbach's alpha method was reported as above 0.70 [24].Tis scale includes 27 items that were scored between 1 and 5, delivering a total score ranging from 27 to 135 [24].

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Nursing Research and Practice

Data Collection.
All the data were collected by only one of the researchers during 1 month (15 May to 15 June) in the second semester of 2019.Data collection was carried out from frst-year students in the nursing faculty and last-year students in the hospital in the morning (the questionnaires were completed during students' break).After stating the objectives of the research and obtaining informed consent from the students, the questionnaires were given to the students and the students completed them in a self-report form.Te duration of completing the questionnaires by the participants was between 15 and 20 minutes.

Ethical Considerations. Tis study was approved by the Ethics Committee of Isfahan University of Medical Sciences
(the code of IR.MUI.RESEARCH.REC.1398.200).Sample recruitment was started after the study approval, getting the scientifc code, and necessary coordination was made with the research deputy of the university after elaborating the objectives and procedures of the study.Eligible students have explained the objectives of the study and the instructions for completing the questionnaire.Written informed consent was obtained from all participants.Participation in the study was completely voluntary, and the individuals' data remained entirely confdential.
2.6.Analytical Methods.Te data were analyzed using SPSS 18 software.Te results of qualitative variables were reported as numbers (percentage), and quantitative variables were reported as mean ± standard deviation.To compare the subscales of moral sensitivity based on demographic variables, multivariate analysis was used, and to compare the total score of moral sensitivity and professional behaviour, independent univariate analyses and one-way analysis of variance were used.To investigate the efect of subscales of moral sensitivity (on the feeling of standard score) and its total score taking into account the side variables on students' professional behaviour, multiple and simple regressions were used.Te results were reported at a signifcance level of 0.05.

Results
Te results showed that out of the participants, 158 were frst-year students.Te mean age was 20.34 ± 3.01 years, and the mean GPA was 16.93 ± 2.11.Most of the participants were single and lived with their families.Tere were 80 lastyear students.Teir mean age was 23.31 ± 1.87 years, and their mean GPA was 16.30 ± 1.06.Most of the last-year students were single and lived in the dormitory (Table 1).Te results of univariate and multivariate analyses showed that there was no signifcant diference between the total score of moral sensitivity and the score of its subscales and the score of students' professional behaviour based on marital status, housing, apprenticeship, working, and having another degree (p > 0.05).
Te results of multivariate analysis showed that there was not a signifcant diference between the mean score of the moral sensitivity subscales of men and women (p = 0.357), but the mean total score of moral sensitivity and professional behaviour of women was signifcantly higher than men (p < 0.05).
Te signifcance of the results of multivariate analysis showed that there was a signifcant diference in at least one of the subscales of moral sensitivity in frst-and last-year nursing students (p � 0.002) so, based on univariate analysis, it was found that the mean of all subscales of moral sensitivity and professional behaviour in last-year students was signifcantly higher than frst-year students (p < 0.05).
Pearson's linear correlation between grade point average and age of students with professional behaviour scores was equal to (r � −0.03, p � 0.718) and (r � 0.02, p � 0.815), respectively, and with moral sensitivity score was equal to (r � −0.11, p � 0.167) and (r � 0.20, p � 0.003), respectively, which indicated a weak positive linear correlation between age and the total score of moral sensitivity that was signifcant.In other cases, this correlation was not signifcant, and the correlation between professional behaviour and the total score of moral sensitivity was p < 0.001, r � 0.39, which indicated a positive (moderate) and signifcant correlation between the two variables (Table 2).
To investigate the efect of moral sensitivity subscales on students' professional behaviour scores by using multiple regression and observing their standardized coefcients, it was determined that the "Professional Knowledge" subscale had the most signifcant positive efect on the mean score of students' professional behaviour (p < 0.001).Te subscale of "Honesty and Benevolence" also had an insignifcant efect but considerable (p = 0.055).Te efect of other subscales on professional behaviour was not signifcant.A similar result was obtained after adjusting for the group efect (Table 3).
For assessing the efect of students' moral sensitivity on their professional behaviour with regard to students' academic year, frst, a separate simple linear regression was ftted in the group of frst-year and last-year students.Te results showed that in the frst-year students, this relationship was not signifcant, and in the last-year students, this relationship was signifcant, which indicated the interaction efect between academic year and moral sensitivity.For this purpose, the scatter plot of the score of moral sensitivity against the professional behaviour of students was drawn simultaneously for frst-and last-year students, which is shown in Figure 1.As it can be seen, this point of intersection occurred almost at the score of 75 moral sensitivity, which showed that the score of moral sensitivity can be divided into two intervals (<75 and ≥75) (it showed the same pattern in the score below 75), and this is the cut point indicates high moral sensitivity [28,29] (Figure 1).
Te regression model of the efect of the academic year (frst-and last-year) and moral sensitivity score (<75 and ≥75) and their simultaneous efect were ftted once in a simple way and once by adjusting the efect of gender on the professional behaviour score of students (Table 4).Te results showed that in both models, the interaction efect of the academic year on moral sensitivity was signifcant.Assuming that the efect of gender is constant, the results of the modifed model showed that the professional behaviour Nursing Research and Practice score of last-year students with a moral sensitivity score above 75 was 5.91 points lower on average compared to frstyear students.Also, the score of professional behaviour in last-year students with a sensitivity score of 75> was higher by 6.94 points on average compared to frst-year students.

Discussion
Te study aimed to investigate the relationship between moral sensitivity and professional behaviour of nursing students and compare them between frst-year and last-year students.Te 4 Nursing Research and Practice results of our study indicated the existence of a positive and direct relationship between the level of moral sensitivity and professional behaviour of nursing students.Some studies showed that promoting moral sensitivity in nursing students may lead to their professional values or attitudes development [8,25,26].Compliance with ethical principles is one of the criteria required for professionalism in nursing [31].Te results of Chen et al. [8] also indicated the existence of a positive correlation between moral sensitivity, professional values, and moral decision-making of nursing students [8].According to previous studies, professional behaviour is a fundamental concept in the nursing profession [20] that can play an important role in clarifying the impact of ethics education on becoming professional and acquiring moral qualifcations in the course of students' studies [8,26,32].In this regard, education can be an important element in acquiring professional attitudes and developing the moral sensitivity of nursing students [26].
Te results of the present study showed that women students attained signifcantly higher total scores of moral sensitivity and professional behaviour compared to men.In previous studies, diferent results were presented on the efect of gender on the level of moral sensitivity [14,15,[33][34][35].In some other studies, the level of moral sensitivity of female nursing students was higher than that of males [33,34].In contrast with the present study, some studies have found no signifcant relationship between the moral sensitivity score and nursing students' gender [14,15,35].
According to several studies, age can also afect moral sensitivity, and some studies have noted a positive correlation between age and the moral sensitivity score [36,37].However, in other studies such as the study of Borhani et al. [33], no signifcant relationship between age and moral sensitivity was reported among nurses [33].In the present study, since lastyear students had signifcantly higher mean age and mean score of moral sensitivity compared to their frst-year counterparts, it can be argued that increasing age and, therefore, achieving more mental maturity can gradually improve students' moral sensitivity [36].
Te results indicated that last-year nursing students had signifcantly higher levels of moral sensitivity compared to frstyear students.Considering that undergraduate nursing students pass a theory course on nursing ethics and attend longer times in clinical environments in their last educational year, last-year students are expected to have higher moral sensitivity than frst-year students.In addition, during the last year, nursing students integrate their clinical reasoning skills with ethics at the highest level, and they have maximum maturity [11].Kohansal et al. [38] reported that the mean score of moral sensitivity was higher in students studying in the eighth academic semester compared to those in the third semester, indicating a signifcant link between moral sensitivity and the academic semester [38] which is aligned with the results of our study regarding the efect of the academic year on moral sensitivity.However, Baykara et al. [26] declared that students' moral sensitivity decreased with elevating educational years [15,26].In another study, Tuvesson et al. [34] also identifed no evidence indicating the improvement of moral sensitivity by passing academic years [34].Te inconsistency between these results may be related to the factors afecting training, such as the classroom environment, educational traits, level of preparedness, and the research tools used in studies [6].

Nursing Research and Practice
Consequently, it is necessary to pay attention to the signifcant role of education and the use of efective ethical teaching strategies to upgrade students' moral sensitivity [38].
In the present study, both groups of students attained the highest score in the domain of "professional knowledge" and the lowest score in the domain of "honesty & benevolence."In contrast with this study, Mostafavian et al. [35] described that the highest score obtained by students was related to the domain of "knowing how to communicate with the patient" [35].In the study of Kohansal et al. [38], the highest mean score was related to the domain of "honesty & benevolence" while the lowest scores were obtained in the domains of "professional knowledge" and "applying moral principles when making ethical decisions" [38], which opposed the fndings of the present study.Tis inconsistency could be related to the diferent student populations, so that, in the present study, last-year students were compared with frstyear students who had limited clinical experience.Likewise, in the study of Borhani et al. [36], who enrolled undergraduate nursing students, the domains of "expressing benevolence" attained the highest mean scores, this domain refers to concepts such as honesty, trust between the nurse and the patient, considering patients' reactions to care, and patients' perception and knowledge about their disease [36].Establishing a suitable and sympathetic relationship with the patient along with honesty and benevolence can lay the ground for winning patients' trust [36,38].Te fact that both groups of frst-year and last-year students obtained the lowest scores in the "honesty and benevolence" dimension might refect the weakness of students in dealing with ethical dilemmas and applying the theoretical ethical concepts learned in the clinical setting.Tis issue highlights the need for nursing students to receive more training during their education on how to apply professional ethics principles, benefcence, and nonmalefcence.Moral sensitivity is created through education, but it is established through professional competency and showing ethically acceptable professional behaviours [14].
In the present study, both groups of students enrolled had the desired levels of professional behaviour.Some studies have indicated that students possess desirable levels of professional behaviour [32,39], and others, such as Taylan et al. [21], have reported moderate-level professional behaviour among nursing students [21].Te diferences observed in students' levels of professional behaviour in various studies may be related to features such as the place of studying, as well as value and cultural diferences among communities [39].In addition, some demographic characteristics of students can infuence their professional behaviour.In this regard, Nemati et al. [32] noticed that students' age and GPA were positively associated with their professional behaviour scores [32].However, in the present study, the student's professional behaviour scores had no signifcant relationship with their GPA.Te mean score of professional behaviour was signifcantly higher among last-year students compared to frst-year students.Nevertheless, Nemati et al. stated that none of the professional skills of students were related to their academic semester [32].
In this study, by adjusting for gender, it was found that the professional behaviour score of last-year's students with high moral sensitivity was lower compared to frst-year students.Because of some organizational and professional factors, nursing students may face problems in developing professional behaviours [21,40].Factors such as the existence of an inappropriate pattern in the clinical environment, confict with other members of the healthcare team, nonstandard performance of nurses, and the infuence of nurses and students on each other can be efective for this issue [21,37].Te professional socialization process of lastyear students may be destroyed during the process of transition to the clinical setting and becoming independent due to the gap between theory and practice [41].Terefore, nursing students may be infuenced by nurses' behavioural patterns or suppressive behaviours which lead to inappropriate professional behaviour, despite having high moral sensitivity.

. Conclusions
Our study showed that there is a positive relationship between the moral sensitivity of nursing students and their professional behaviour.In addition, the results indicated that last-year nursing students had signifcantly higher levels of moral sensitivity and professional behaviour compared to their frst-year students.Tis fnding may denote that the educational content of nursing undergraduate courses and the more encounter of students with ethical conficts in the clinical environment can infuence their perception of ethical challenges and how to handle them.Nursing students are believed to struggle to learn professional behaviours during educational courses [21].Terefore, it may be benefcial to use novel educational methods that acquaint students with real clinical situations, which may lead to achieving a correct understanding of the application of ethical concepts and conundrums in ethical decisions.Te relationship between the moral sensitivity of nursing students and their professional behaviour can suggest an important role in explaining the efect of ethics education on professionalization and the acquisition of moral qualifcations in the course.

Figure 1 :
Figure 1: Te scatter plot of the moral sensitivity score against professional behaviour for frst-and last-year nursing students.

Table 2 :
Comparison of the total and subscale scores of moral sensitivity and professional behaviour in nursing students based on demographic variables.

Table 1 :
Frequency distribution of demographic variables of nursing students.

Table 4 :
Regression model of the efect of academic year and moral sensitivity on professional behaviour of nursing students with adjustment of gender efect.

Table 3 :
Regression model of the efect of moral sensitivity subscales on the professional behaviour score of nursing students.