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Almaraz-Castruita D, Alonso-Castillo B. Sensibilidad ética y su relación con el consumo de alcohol en el personal de enfermería. Rev Enferm Inst Mex Seguro Soc. 2016;24(2):123-8.

Ethics sensitivity and its relation with alcohol consumption in nurses

Diana Almaraz-Castruita,¹ Bertha Alonso-Castillo²

¹Maestría en Ciencias de Enfermería, Facultad de Enfermería; ²Facultad de Enfermería. Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México

Correspondence: Bertha Alonso-Castillo

Email.: betty.alonso@gmail.com

Received: June 1^st 2015

Judged: January 15^th 2016

Accepted: March 9^th 2016

Abstract

Introduction: Alcohol consumption is a social phenomenon that affects general population, regardless of gender, cultures and professions. It is noteworthy that the health professions are also affected by this phenomenon, despite the importance to them of preventing risky behaviors. Among the health professionals nurses highlight, since they have a leading role in promoting health and are not exempt from this behavior motivated by multiple factors, such as coping with various problems generated by their professional practice.

Objective: To know the relationship of ethical sensitivity and alcohol use in nursing staff.
Methods: Descriptive correlational design, in a sample of 214 nurses from a public hospital in the metropolitan area of Monterrey, Nuevo Leon.

Results: The age of the participants was positively related to moral strength. It was also observed that the dimension of moral burden was significantly related to alcohol consumption of participants. Likewise, the moral burden and moral responsibility were positively and significantly related with harmful alcohol consumption.

Conclusions: The age of participants is positively related to the moral strength. Also it was observed that the dimension of moral burden was significantly related to participants’ alcohol consumption. Similarly, the moral burden and moral responsibility were positively and significantly related to harmful alcohol consumption.

Keywords: Nursing ethics; Nursing staff; Alcohol drinking; Alcohol abuse

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Introduction

According to the Pan American Health Organization (PAHO), close to 80,000 deaths a year could now be avoided in the Americas if alcohol were not consumed. Mexico is among the top five countries with the highest mortality rate from alcohol consumption in the Americas, with an average of 17.8 per 100,000 deaths a year and a loss of more than 310,000 years of healthy life for the country’s population.¹ This social phenomenon affects the general population, regardless of gender, cultures, or professions. It is noteworthy that the health professions are also affected by this phenomenon, despite the importance for them to prevent risky behaviors. Nursing staff stand out among health professionals, having a major role in health promotion and not being exempt from this behavior, which is motivated by multiple factors, such as facing various problems generated by professional practice.²

Recent studies show that nurses present drinking behavior and that more than half of the populations analyzed have consumed alcohol sometime in their lives.Those who did it frequently present dependent and harmful consumption.^3,4 This situation represents a health problem, given that nursing professionals are currently regarded as role models for healthy lifestyles for the population. This duality in theory positively or negatively affects nurses’ decisions about health care for their patients.

Professional decisions are framed in cognitive aspects that are reasoned under a framework of ethics and morality. Recently one of the factors that has demonstrated influence is ethical sensitivity, a concept built from qualitative studies with nurses specializing in psychiatry.

Professionals make decisions about essential care needs and those under their care, using cognitive ability based on intuition and feelings, in addition to the ability to perceive the patient's vulnerability; thus ethical sensitivity is defined.⁵

Studies show that ethical sensitivity is an essential component in practice,⁶ which has been associated with occupational moral stress. Findings show that two elements of ethical sensitivity are predictors of professionals’ stress, a situation that has been associated with alcohol consumption,3 so ethical sensitivity can be a risk factor for alcohol use in nursing staff as a way of coping with feelings that can happen when providing care within an ethical framework. The literature review shows research on alcohol consumption by nursing staff regarding decision-making, attitudes towards the patient who consumes alcohol, and moral stress; however, despite the high prevalence of alcohol consumption, studies in which this habit is related to ethical sensitivity have not been located until now. The purpose of this study therefore is to determine the relationship between alcohol consumption by nurses and ethical sensitivity.

Methodology

The design was descriptive and correlational. The total sample was of 219 nurses from a public hospital in the metropolitan area of ​​Monterrey, Nuevo Leon, selected by random sampling, calculated using the statistical package nQuery Advisor®, version 4.0 (Elashoff, Dixon, Crede and Fothenringham, 1997). A ratio was estimated with a confidence interval (CI) of 95%, using a conservative approach (p = q = ½) with an estimation error limit of 0.05 (± 5%).

The study used the Cédula de Datos Personales, Laborales y de Prevalencia del Consumo de Alcohol (CDPLYPCA) (Survey of Personal and Labor Data and Prevalence of Alcohol Consumption) and two instruments: the Moral Sensitivity Questionnaire from Lützén, Dahlqvist, Eriksson, and Norberg (2006), which consists of nine items with six possible answers on the Likert scale, ranging from 1, which indicates total disagreement, to 6, which means total agreement, so the minimum score is 9 and the maximum is 54, with higher scores indicating higher ethical sensitivity.

For this moral sensitivity instrument (Lützén et al., 2006) a component analysis was done with varimax rotation, which resulted in three components: moral burden, which included items 4, 6, 7, and 8, which refers to the "negative" dimension of ethical sensitivity, i.e. that with which one cannot cope or what one is not "prepared" for, such as morally troubling situations; moral strength (items 2, 3 and 5) is current courage and the ability to argue to justify one’s actions on behalf of others; finally, moral responsibility, which includes items 1 and 9, is the moral obligation to work according to rules and regulations and vision of one’s purpose. This instrument was first used in Mexico by Alonso⁷ with students and teachers in clinical nursing practice; Alonso’s study reported a Cronbach's alpha of 0.70. For this study the Moral Sensitivity Questionnaire (MSQ) reported a Cronbach's alpha coefficient of 0.73, which is considered an acceptable internal consistency.

The Alcohol Use Disorders Identification Test (AUDIT) from De la Fuente and Kershenobich⁸ was also used, which was developed by the World Health Organization (WHO) and validated and adapted by De la Fuente and Kershenobich for the Mexican population (1992). The cutoffs are: 0 to 3 points is considered sensible consumption; 4 to 7 points starts to have problems with dependent consumption; and 8-40 is considered high-risk and harmful alcohol consumption. This instrument has been used by Hinojosa,⁹ Alonso,⁷ and Castillo for health workers in Mexico; it found a Cronbach's alpha of 0.85. For this study, AUDIT presented a Cronbach's alpha of 0.80, which is considered aceptable.¹⁰

Approval for data collection was granted by the Research Committee and the Research Ethics Committee of the Facultad de Enfermería of the Universidad Autónoma de Nuevo León, as was the authorization of the directors of the hospital where the study was held. With the list previously obtained from the randomization of participants, they were located and approached in their work areas in different shifts. The study's purpose and objectives were explained, and they were asked for their voluntary participation by signing the informed consent. Subsequently a sealed envelope was delivered containing the survey and instruments that were answered by participants. When staff reported not drinking alcohol in the past year, they were instructed not to answer the Alcohol Use Disorders Identification Test (AUDIT).

With regard to ethical considerations, the study followed the provisions of the Reglamento de la Ley General de Salud regarding health research (MoH [SS], 1987).

The Statistical Package for the Social Sciences [SPSS], version 21.0 for Windows, was used for data analysis. The internal consistency of the instruments was determined through Cronbach's alpha reliability coefficient. An alpha of 0.76 was reported for the MSQ and 0.78 for AUDIT. The Kolmogorov-Smirnov goodness-of-fit test with Lilliefors correction was used to determine normal. For purposes of this study the Spearman correlation coefficient was used.

Results

The female sex predominated (70.3%). Also, most of the participants were single (68.5%). As for the level of education, the highest proportion had undergraduate education (50.3%); however, the predominant employment status was non-professional (63.5%). Regarding work experience, most had less than 10 years of work experience (80.9%), and in regard to shift most of the participants belonged to the evening shift (30.1%), followed by hourly weekend schedule (25.1%), morning shift (23.3%), and night shift (21.5%). As for the labor area, the largest concentration of participants was found in the area of ​​Maternal and Child Health (26.5%), followed by Internal Medicine / Neurology / Nephrology (22.8%), Emergency Medicine (19.2%), Surgery / Traumatology (17.4%), Intensive Care (8.2%) and finally, Operating Room (5.9%).

The average age of nurses was 28.2 years (standard deviation [SD] 9.7). Regarding the age of onset of alcohol consumption, the average was 18.9 years (SD 3.5), and average nursing staff consumed an average of 3.8 drinks per occasion (3.0).

Regarding the prevalence of drinking among nurses, 84.5% (with a 95% confidence interval [CI] of 79-89) of participants reported having consumed alcohol at some time in their lives, 70.3% (95% CI 64-76) reported drinking alcohol in the past year, 50.2% (95% CI 43-56) of participants reported having consumed alcohol in the last month, and 22.7% (95% CI 17- 28) reported having consumed alcohol in the last 7 days (Table I).

Table II shows Spearman's correlation coefficient for the nurses’ types of alcohol use and ethical sensitivity. It was identified that the age of the participants was positively and significantly correlated (rs = 0.144, p < 0.05) with moral strength (dimension of moral sensitivity), indicating that the older nurses had greater moral strength. Also, it can be seen that the dimension of moral burden was related positively and significantly with participants’ alcohol use (rs = .174, p < 0.05), indicating that greater moral burden had increased alcohol consumption. Similarly, moral burden (rs = 0.193, p < 0.05) and moral responsibility (rs = 0.159, p < 0.05) correlated positively and significantly with harmful alcohol consumption, indicating that the higher the moral burden and moral responsibility, the more harmful drinking.

Discussion

Regarding the participants’ socio-demographic profile, it is observed that most were female (70.3%), single (68.5%) with a mean age of 28.2 years. This profile of nurses who work in these institutions is consistent with that reported by the Instituto Nacional de Estadística Geografía e Informática (INEGI),¹¹ which shows that there are 302,000 nurses in the country; of that total, nine out of 10 are women with an average age of 30 years. In addition, according to Juarez,¹² studies are expected to generally report a greater number of female nurses, since traditionally in society, care is identified as an activity inherent to women.

Regarding employment data, it was recorded that the staff had an average work experience of 7.6 years. The majority of nurses had undergraduate-level education (50.3%). These data are similar to those reported by the Sistema de Información Administrativa de Recursos Humanos de Enfermería (SIHARE),¹³ which indicates that more than half of nursing staff have undergraduate degrees, followed by technical and auxiliary staff. However, it is noteworthy that the prevailing job category was non-professional (63.5%). According to the above, international organizations such as the WHO,¹⁴ have always recognized the importance of nursing work in the health field, and have spoken about their knowledge and functions. The WHO has also identified poor working conditions, increased workload, loss of job security, lack of supplies for service provision, low wages, lack of human resources in nursing, and increased legal proceedings, leading to work overload, fatigue, and physical and mental exhaustion, aspects that can lead nurses to have an increased moral burden.

As regards the work shift, most of the participants belonged to the evening shift (30.1%), followed by hourly weekend schedule (25.1%), morning shift (23.3%), and night shift (21.5%). This is similar to what is shown by De Melo and Ferraz,¹⁵ who found a uniform distribution of nurses in different shifts. Regarding the above, Sabaté¹⁶ states that working time is one of the aspects of working conditions that has a direct impact on everyday life. The number of hours worked and their distribution can affect not only the quality of life at work, but life outside of work for nurses, which causes damage to workers’ health and social life and thus is likely to increase their moral burden.

As for the work area, it was found that 66.7% worked in the hospital areas of Internal Medicine, Neurology, Nephrology, Maternal and Child Health, and Surgery and Traumatology, areas where the staff demand is higher due to the greater number of patients. The above data are similar to those reported by Zorrilla,³ according to whom 39.8% of participants worked in inpatient areas (Internal Medicine, Pediatrics, Hemodialysis, Chemotherapy, Hospital Admission, Nephrology, Isolation, Joint Assessment and Stay). This could be because both studies were performed in public hospitals with the basic specialties (Maternal and Child Health, Internal Medicine, and General Surgery).

Regarding the age of onset of participants’ alcohol use, the average of 18.9 years was found. This data is consistent with the 2011 Encuesta Nacional de Adicciones (ENA),¹⁷ which states that the age of onset of alcohol consumption is between 18 and 25 years. This also coincides with what was stated by Zorrilla,3 who notes that the age of onset of alcohol use was 18.2 years. Similarly, the results coincide with those reported by Castro,⁴ who reported age of onset of 21.4 years. This can be explained because this research was conducted in similar contexts and populations to Zorrilla’s and Castro’s studies.

Regarding the prevalence of alcohol use among nurses, it was found that 84.5% of participants had consumed alcohol at some time in their lives, 70.3% in the last year, 50.2% in the last month, and 22.7% in the last seven days. These data are similar to those reported in the ENA,¹⁷ in which it is mentioned that 73.3% of the population aged 12 to 65 years had consumed alcohol at some time in their lives, in the last year in 55.9%, and in the last month in 31.6%. Moreover, this coincides with the results found in a study conducted in a public hospital in Zacatecas,3 where it was reported that 81.1% of participants consumed alcohol at some time in their lives, 71.1% of nurses in the last year, 42.8% in the last month, and 12.4% in the last seven days.

With regard to the above, the prevalences of alcohol consumption reported in this study are relevant and represent a health problem, as nursing professionals are currently considered role models in terms of healthy lifestyles for the population. Vargas and Villar claim that one of nursing staff’s primary functions of is to act as promoters of health.¹⁸

In the main aim of this study, which was to identify the relationship of ethical sensitivity to alcohol use in nurses, it was identified that the dimension of moral burden is related positively and significantly with participants’ alcohol use (rs = 0.174, p < 0.05), indicating that greater moral burden increased alcohol consumption. Similarly, moral burden (rs = 0.193, p < 0.05) and moral responsibility (rs = 0.159, p < 0.05) correlated positively and significantly with harmful alcohol consumption, indicating that with greater moral burden and greater moral responsibility, there is more harmful drinking. The above results are relevant, since there are no studies linking ethical sensitivity to alcohol use.

It is important to note that some studies have indicated that the working conditions of nursing personnel pose a risk to their physical and mental health, because the exercise of care involves an ethical, professional, and emotional overload due to multiple problems arising from the care and health systems, as well as their own personal, professional, and family needs. In this vein, nurses see their occupational, professional, and personal satisfaction threatened. All these risk factors, coupled with conditions and lifestyles, cause profiles of discomfort, illnesses, physical and emotional exhaustion, and job disability and dissatisfaction, and can cause nurses to engage in alcohol use behaviors.

Conclusions

Based on the results found in this study it can be concluded that the average age of first alcohol use was 18 years with a consumption of three alcoholic drinks on a typical day. The overall prevalence (ever in life) of alcohol consumption in nurses was 84.5%, the interval prevalence (in the last year) was 70.3%, the current prevalence (in the last month) was 50.2%, and the instantaneous prevalence (in the last seven days) was 22.7%.

A positive and significant correlation was documented between moral strength and age; a significant positive correlation was also found between moral burden and alcohol use, and it was identified that with greater moral burden and greater moral responsibility, there was more harmful drinking.

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