Hrev_master Healthcare in Low-resource Settings 2023; volume 11(s1):11176 The ethical principles and caring behavior of Indonesian nurses Ilkafah Ilkafah,1 Anestasia Pangestu Mei Tyas,1 Rini Rachmawaty2 1Nursing Study Program, Faculty of Vocational Studies, Universitas Airlangga, Surabaya, Indonesia;2Faculty of Nursing, Universitas Hasanuddin, Makassar, Indonesia Abstract Introduction: The caring behavior of nurses affects their work- ing performance and the health care quality received by patients. The adherence to ethical principles by nurses is also known to increase this factor. However, no previous studies have been con- ducted on how ethical principles affect the caring behaviors of nurses. Hence, this study aims to investigate the association between nursing ethics and other demographic characteristics and their caring behavior in Indonesian hospitals. Design and Methods: A cross-sectional descriptive-analytical study was conducted with 389 nurses working in Indonesian hos- pitals. Furthermore, data were collected using questionnaires, which included demographic characteristics, ethical principles- based attitudes, and caring behavior. The analysis of the data was performed using descriptive (M, SD) and inferential statistics (Chi-square, Spearman’s rank correlation, Fisher’s exact test, and multiple logistic regression) with α= 0.05. Results: According to this study, the caring behavior of nurses was associated with gender (p=0.030) and nursing ethical princi- ples, such as veracity (p=0.025), non-maleficence (p=0.007), beneficence (p<0.000), and fidelity (p<0.000). Fidelity was also revealed as the most influential ethical principle on nurses’ caring behavior, with a value of Exp(B)= 3.446. This indicates that nurs- es, who had demonstrated good fidelity, cared three times more than those who lacked this quality. Conclusions: Nurses with good ethical principles deliver suit- able caring behavior. Hence, applying the right ethics to a patient would result in a great caring attitude, as the principle of ethical behavior is compassion and respectful conduct towards patients. Introduction A caring attitude is an essential function that nurses must per- form, as this approach aids in their development into more profes- sional individuals, who prioritize patients’ interests and their fam- ilies.1,2 However, limited studies have been conducted on caring behavior among Indonesian nurses, with some reports showing a lack of this quality.3–6 A previous study also revealed that having a caring nurse while implementing a treatment or therapy plan was beneficial to patients. This approach helped patients adapt to their health problems, independently fulfilled their basic needs, pre- vented suffering from diseases, and improved their health, as well as body function.7 The caring attitude of nurses also increases their job satisfac- tion and quality of care.8 Although several nurses may have a com- passionate nature from childhood, this behavior must be learned and developed through education.9 Caring is a nurse’s attitude towards patients’ needs, which is provided with sincerity and affection, either through communication, support, or direct care. The ethics of this approach is essential and involves caring for both humans and nurses. Furthermore, this quality is related to the ontological basis of humanity, where an individual’s identity is defined by a set of relationships with other humans. This is also a universal attribute that is ethically fundamental to people. Therefore, it can be concluded that the application of ethical behavior by every human will result in the possession of a well- caring attitude.10 In Indonesia, limited studies have been conduct- ed to examine the correlation between nurses’ ethical and caring behavior. The majority of these studies only analyzed caring from a communication, personality, emotional intelligence, and organi- zational aspect.3,11 Also, previous studies using qualitative meth- ods were typically focused on patients’ perception towards nurses’ caring,12 and only a few examined nurses’ perceptions of their car- ing behavior.13,14 In addition to caring behavior, professional nurses must be able to apply ethical principles to all patients.15 Particularly, nurses who apply beneficence do the best for their patients by showing respect for their autonomy, which automatically confirms that a well-caring behavior has been demonstrated.16 Other studies dis- covered the attitude of nurses influences their ethical behavior while implementing care.17 In Watson’s caring theory, there are 10 carative factors,9 of which are nearly identical to the seven ethical principles. Therefore, this study aimed at examining the associa- tion between nurses’ ethical and their caring behavior. Design and Methods This study used a correlational with a cross-sectional descrip- tive-analytical design.18 Also, stratified random sampling was per- Significance for public health Nurses are required to have caring behavior, which is essential in the interaction with humans and other nurses. This attitude may also assist nurses in becom- ing more professional while providing patient care. In addition, professional nurses are obligated to apply ethical principles in delivering care to all patients. In Watson's caring theory, there are 10 carative factors, and the core of these characteristics is nearly identical to the seven ethical principles. Therefore, this study describes the association between the ethical behavior and other demographic characteristics of nurses and their caring behavior towards hospitalized patients in Indonesian hospitals. Article [page 52] [Healthcare in Low-resource Settings 2023; 11(s1):11176] Non -co mmerc ial us e o nly Article [Healthcare in Low-resource Settings 2023; 11(s1):11176] [page 53] formed by selecting patients from all inpatient units in the hospital, based on the inclusion criteria to maintain the representativeness of the sample. The respondents included 389 nurses, who had been working for at least 2 years, in the inpatient room, the maximum age is 55 years, not in the period of study assignment or study per- mit, and is willing to be a respondent and interviewed if something is lacking in filling out the questionnaire. An ethical, demographic, and Watson’s 10 carative factors-based questionnaires were used.9,19 The latter instrument was developed based on the 2019 Code of Ethics Guidelines from the New Zealand Nurses Organization20 and the ethical recommendations from the Indonesian National Nurses Association. In addition, the Cronbach alpha value on tests 1 and 2 were 0.89 and 0.91, and Pearson’s cor- relation coefficient between the first and second surveys was =0.901 and 0.93. hence, the questionnaire was valid and reliable. Univariate analysis was presented in the form of a table containing frequency (n), percentage (%), Mean (M), and Standard Deviation (SD). Statistical tests, such as Chi-square, Spearman’s Rank Correlation, and Fisher’s exact were used to investigate the associ- ation between the respondents’ characteristics, ethical, and caring behavior. Bivariate analysis was also used as a multivariate test selection with a p-value<0.25. Multivariate logistic regression was selected to examine which independent variables (numeric or cat- egorical) had the greater influence on the dependent (categori- cal).18 The ethical clearance of this study was obtained from the Ethics Committee of the Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia (Number 2063-KEPK). Results and Discussions Table 1 shows that there is no relationship between gender and caring behavior (p > 0.135). A majority (59.7%) of the male nurses have good caring behavior, while the (51.2%) females were less Table 1. The characteristic of respondents in three hospitals in Indonesia. No Variable Caring behavior Total p-value Less (n=192) Good (n=197) (n=389) n % n % n % 1 Gender Male 27 40.3 40 59.7 67 100 0.135a* Female 165 51.2 157 48.8 322 100 2 Marital status Single 60 45.8 71 54.2 131 100 0.372a Married 132 51.2 126 48.8 258 100 3 Education Diploma nurses 76 49.7 77 50.3 153 100 0.053b* Undergraduate nurses 116 50.4 114 49.6 230 100 Post-graduate nurses 0 0 6 100 6 100 4 Role in the wards Associate nurse 160 48.5 170 51.5 330 100 0.501a Primary nurse 32 54.2 27 45.8 59 100 5 Career level Pre-clinical nurse 9 37.5 15 62.5 24 100 0.636b Clinical nurse I 107 49.1 111 50.9 218 100 Clinical nurse II 63 52.1 58 47.9 121 100 Clinical nurse III 12 48 13 52 25 100 Clinical nurse IV 1 100 0 0 1 100 6 Autonomy Less 116 68.6 53 31.4 169 100 0.000a* Good 76 34.5 144 65.5 220 100 7 Non-maleficence Less 132 68.4 61 31.6 193 100 0.000a* Good 60 30.6 136 69.4 196 100 8 Beneficence Less 126 72.4 48 27.6 174 100 0.000a* Good 66 30.7 149 69.3 215 100 9 Justice 0.000a* Less 115 75.2 38 24.8 153 100 Good 77 32.6 159 67.4 236 100 10 Veracity Less 117 76.5 36 23.5 153 100 0.000a* Good 75 31.8 161 68.2 236 100 11 Fidelity Less 125 77.6 36 22.4 161 100 0.000a* Good 67 29.4 161 70.6 228 100 12 Age (Mean ± SD) 31.57 ± 5.74 31.17 ± 5.71 389 100 0.240c* 13 Length of work (Mean ± SD) 7.35 ± 5.71 6.79 ± 5.33 389 100 0.252c a ) Chi-Square test. a*) Chi-Square test and candidate MLR (p<0,25). b )Fisher’s Exact test. c ) Spearman test . c*) Spearman test and candidate MLR (p<0,25). Non -co mmerc ial us e o nly compassionate. No relationship was observed with marital status (p > 0.372), with most (54.2%) unmarried nurses depicting this attitude, while their (51.2%) married counterparts were less caring. However, there was no relationship with education (p > 0.053). The majority of (100%) nurses with post-graduate degrees had bet- ter caring behavior than those (50.4%) with undergraduate, and (50.3%) diploma degrees. This study also shows that Diploma nurses cared 0.7% better than the undergraduates, due to their lengthier period of stay in the hospital. Several other studies illus- trated that length of work experience has a positive impact on nurse’s caring behavior and quality of care.21,22 There is no relationship between nurses’ role in the wards and their caring behavior (p > 0.501). A majority of (51.5%) associate nurses were seen to care more than most of their counterparts in the primary level (p > 0.636). The entire (100%) clinical nurses IV were less compassionate than most (62.5%) of those in the pre- clinical stage. According to previous studies, managers had lower scores than clinical nurse 1 in “assurance of human presence” and “respectful difference of others”. Additionally, they had lower scores on four dimensions of caring behavior than clinical nurses 2 and 3 in “respectful difference of others”.23 The workload of nurses also increased with their career levels, with managers taking on more assignments. This phenomenon was stated as the cause of stress, which affects their interactions with other people. Humanistic behavior has been established to fade over time, affect- ing the nursing practice. Consequently, patients are faced with poor caring attitudes and behaviors.24 There was also no relationship with age (p > 0.240). However, nurses aged 32 years and above were reported to have less caring behavior while those who were less than 31 years displayed more of this character. No relationship was observed between the length of work and the caring behavior of nurses, where those with an average working experience of 7.4 years cared less while individ- uals with 6.8 years were more compassionate. The demographics of nurses had no effect on caring behavior, hence, this variable is unique. Personality, emotional and organiza- tional factors in nurse’s workplace can affect this behavior.11,25 This study shows that a caring nature may be acquired from birth or learned in school. Furthermore, length of work does not affect car- ing, indicating that the study of this behavior prior to employment is essential. Respect and care for others can be formed in the fam- ily.26,27 Some people are easy to empathize with and care for others because their personalities easily empathize with others.28 Especially during the study period, students need to educate regarding caring behavior to become nurses who behave caring.29 Caring for students is also a topic that is discussed frequently because early education is very effective in creating nurses who are ready to work in the field and have good behavior.30,31 The respondent’s characteristics may not affect caring behav- ior because nurses with inadequate knowledge on this matter do not understand how to behave in compassionate situations. Therefore, education and training on caring should begin at an early age, through its implementation in nursing schools and work- places.30,32 When taking a degree as a nurse, caring for nurses must be given a separate and more specific topic and teachers have to know student personally.29,33 These educational institutions may also assist in the develop- ment of caring abilities, skills, social involvement, and emotional intelligence.34 According to the multiple logistic regression (MLR) analysis in Table 2, there is a correlation between gender and caring behav- ior (p=0.030). Consequently, a majority of male nurses were seen to be more compassionate than females. This was reinforced by another study, where male nurses were more caring in terms of knowledge, skills, and assurance of human presence. Also, the presence of male nurses results in a greater diversity as concerns this behavior.23 In Indonesia, despite experiencing several obsta- cles, this set of nurses had higher self-efficacy levels and were usu- ally just as caring as their female counterparts or even better.21,35 An imbalanced number was observed between the male and female respondents, with the females being higher. Due to the high level of studies in an East Java district and the culture of respect for patients and families, men were seen to be just as caring as women. Furthermore, culture is known to greatly influence the nursing practice, not only the customs of the patient but also that of the nurse.36 Based on the MLR test in Table 2, veracity (p=0.025), non- maleficence (p=0.007), beneficence (p =0.000), and fidelity (p=0.000) were discovered to be significant. Nurses with good non-maleficence and veracity principles were two times more car- ing compared to the less ethical individuals. Meanwhile, good beneficence was nearly three times more. The most influential principle was fidelity with a value of Exp(B) = 3.446, hence, nurs- es who have this character were three times more caring than those lacking. Furthermore, fidelity creates an environment for achiev- ing goals of care and services.37 The principle of fidelity that many nurses do in this study is keeping promises when educating patients, providing information about the patient’s condition to other health workers, and involving patients in developing nursing plans. This principle requires nurses to treat all patients with respect, which is not always easy, specifically when patients are disagreeable, uncooperative, or rude.38 The notion of non-malefi- cence was performed to prevent physical and psychological harm or injury to patients. Therefore, nurses must always provide ser- vices with the intent of helping their patients overcome health problems. A caring behavior, specifically humanistic altruistic- value and providing a supportive and protective environment pre- vents physical, psychological, or social harm to patients.9 The presence of beneficence and fidelity is more likely to facil- itate a caring behavior. The principle of beneficence that many nurses do in this study is to provide nursing interventions that make patients comfortable, assist patients’ basic needs, and always Article Table 2. Analysis multivariate logistic regression (n=389). No Variable B Sig. Exp(B) 95% CI Lower Upper 1 Gender (1) -0.732 0.030 0.481 0.248 0.933 2 Non-maleficence (1) 0.726 0.007 2.067 1.225 3.486 3 Beneficence (1) 1.035 0.000 2.816 1.648 4.812 4 Veracity (1) 0.682 0.025 1.978 1.090 3.588 5 Fidelity (1) 1.237 0.000 3.446 1.989 5.969 6 Constant -1.476 0.000 0.229 [page 54] [Healthcare in Low-resource Settings 2023; 11(s1):11176] Non -co mmerc ial us e o nly re-assessments to identify nursing diagnoses that can arise. Beneficence is nurse’s obligation to defend the rights of others, prevent harm that may be experienced by patients,39 and provide beneficial care. This behavior also protects patients from anything that threatens their health or life. Nurse’s job is to provide educa- tion concerning the care offered to patients, assist in the decision- making process, and provide freedom for patients’ decisions.40 Fidelity is defined as the obligation to remain faithful to one’s commitments, particularly when information is given in confi- dence. Honoring commitments and providing a rationale for deci- sions also promotes this principle.20 Moreover, nurses and other health providers who make agreements with patients must respect and be committed to others,34 as these principles are part of caring behavior.9 Caring is also directly related to moral sensitivity and emotional intelligence.25 Hence, nurses who apply moral and ethi- cal principles will automatically behave in a caring manner. Applying these variables in all matters is also essential, specifical- ly in providing care to patients in order to improve the quality of nursing services.8,39,41 Because of the COVID-19 epidemic, inter- views for the questionnaire were completed over the phone. Further research should look into the barriers to nurses’ strengths in implementing ethical concepts to patients. Conclusions The essence of nursing is caring behavior. This is an inherent characteristic seen in nurses, which is influenced by their behavior through upholding ethical principles properly and correctly. Generally, caring and ethical behavior cannot be separated and will always be aligned to improve the quality of nursing and health ser- vices. References 1. Karlsson M, Pennbrant S. Ideas of caring in nursing practice. Nurs Philos 2020;21:1-5. 2. Ozan YD, Okumuş H, Lash AA. Implementation of Watson’s Theory of Human Caring: A Case Study. Int J Caring Sci 2015;8:25-35. 3. Karo M, Baua E. 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Nurses’ and Patients’ Perceptions on the Importance of Nurse-Caring Behaviors: A Study at the Surgical Wards of Kenyatta National Hospital, Nairobi. Int J Hum Caring 2015;19:55-61. Article Correspondence: Ilkafah Ilkafah, Faculty of Vocational Studies, Universitas Airlangga, Jl. Dharmawangsa Dalam Selatan No. 28-30, Surabaya, East Java, Indonesia, Tel.: +62315033869, Fax: +623199005114. E-mail: ilkafah@vokasi.unair.ac.id Key words: Caring behavior, ethical principles, Indonesian nurses, principle of ethics, quality of care. Acknowledgment: The authors are grateful to the Faculty of Vocational Studies, Universitas Airlangga, Surabaya, Indonesia, for their kind support and promotion during this study. Contributions: The authors contributed equally to this study. Conflict of interests: The authors declared no conflict of interests. Funding: This study was financially supported by the Faculty of Vocational Studies, Universitas Airlangga, Surabaya. Clinical trials: Ethical approval was obtained from the Health Research Ethics Committee of the Faculty of Nursing, Universitas Airlangga, Surabaya (Number 2063-KEPK). Availability of data and materials: The complete data are avaiable upon request. Informed consent: Written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be pub- lished in this article. Conference presentation: Part of this paper was presented at the 2nd International Nursing and Health Sciences Symposium that took place at the Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. Received for publication: 3 December 2021. Accepted for publication: 10 May 2022. 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AMA J Ethics 2017;19:80-90. Article [page 56] [Healthcare in Low-resource Settings 2023; 11(s1):1176] Non -co mmerc ial us e o nly