Development, reliability, and validity of the nurses’ conscientious objection attitude scale (COAS-N) | BMC Medical Ethics
There is no tool for measuring nurses’ attitudes toward CO, and upon evaluating the literature reviewed in this study, it becomes clear that a measurement tool is needed in nursing. To our knowledge, this is the first study to develop a scale to measure nurses’ attitudes toward CO and establish its validity.
Factor analysis is essential to test the construct validity of the scale [35]. To proceed with the exploratory factor analysis in our scale development study, KMO was first applied to test the suitability of the data structure in terms of sample size and was found to be 0.84. The result of Barlett’s test, which tested the validity of the factor analysis, was p < 0.001 and showed that the data came from a multivariate normal distribution. The result is a desirable condition to indicate that the data have a factorable structure. This finding shows that the sample size is quite suitable for factor analysis, and the correlation matrix of the items included in the questionnaire is suitable for factor analysis [36, 37]. As a result of the factor analysis performed with varimax rotation, a four-factor structure emerged. The four factors explain 56.3% of the total variance. It is generally desirable that the explained variance ratios are above 40% [38]. This shows that the scale explains the existing structure.
In addition, when the item-total correlations were examined in our study, only the 23rd item was less than 0.25. Values above 0.25 are often suggested for factor loads that sufficiently explain the items’ correlation with the factors (subscale) [27].
Several model fit indices, including Cmin/df value (χ2 /df), RMSEA, RMR, and GFI, were used to assess the proposed model’s fit. The RMSEA value was found to be close to the limit of perfect fit and the χ2/df value indicated excellent fit. Acceptable values of other fit indices confirmed the goodness of model fit, and construct validity of COAS-N [33, 34].
Reliability means the consistency and stability of test results. The reliability of a measurement tool is the degree to which the tool consistently measures the variable it is intended to measure or the degree to which the measurement results are free from errors [35].
Cronbach’s alpha coefficient measures the internal consistency of the items in the scale. When the alpha coefficient is less than 0.40, the measurement tool is not reliable; 0.40–0.59 is not very reliable; 0.60–0.79 is reasonable reliability; 0.80-1.00 is highly reliable [39]. The overall Cronbach’s alpha value of the scale was found to be highly reliable (0.81). This is evidence that COAS-N measures nurses’ attitudes towards CO with the items that make up the scale. In addition, Cronbach’s alpha value was 0.797 for the “prioritizing professional values” dimension, 0.776 for the “prioritizing personal values” dimension, and 0.889 for the “requesting the right to conscientious objection dimension”. A very high Cronbach’s alpha coefficient indicates a high level of agreement between the items in the measurement tool [40]. In addition, the test-retest reliability was evaluated with ICC, and the result (ICC = 0.780) shows that the reliability of the scale is at a sufficient level [27]. In the Bland Altman graph created based on the test-retest data, it was observed that the errors were randomly distributed, and the mean of the differences was close to zero, so it is said that the results of both measurements are consistent. The Spearman-Brown coefficient rSB obtained with the split-half method was 0.930, and according to this value, this scale shows high reliability [27].
The analyses obtained in this study showed that the scale have a three-factor structure: “Prioritizing Professional Values”, “Prioritizing Personal Values” and “Requesting the Right to Conscientious Objection”. These factors provide an essential framework for understanding the different attitudes and reasons behind nurses’ decisions to CO. Notably, while the literature presents both supporting and opposing views on CO, this three-factor structure aligns with critical aspects identified in previous studies, demonstrating its relevance and applicability in real-world scenarios.
The sub-dimension “prioritizing professional values” reflects the recognition of patient rights and professional responsibilities, even in situations where personal beliefs may conflict with professional duties. For example, Ko et al. found that 68.7% of participants believed that patient rights should take precedence over CO [23]. This finding highlights the importance of ensuring that professional standards guide decision-making processes. Nurses who adhere to professional values are likely to prioritize patient welfare and ensure equitable and ethical care. This factor highlights the role of institutional policies and ethical guidelines in balancing professional responsibilities with personal beliefs.
The sub-dimension “Prioritizing personal values” highlights the prevalence of nurses who are inclined to CO because of personal or moral beliefs. For example, a study of American nurses found that CO was acceptable if alternative care providers were available and the patient’s life was not at risk [41]. This finding points to a critical area where personal values intersect with professional responsibilities. In some specific cases, such as abortion, CO is common, with individuals refusing to participate in procedures on the basis of personal or moral beliefs. In this sense, it is important to recognize that attitudes to CO may be both country and profession specific, depending on cultural norms and professional regulations [15].
The sub-dimension “Requesting the Right to Conscientious Objection” is based on revealing the desire or tendency on this issue in our country. For example, in the study by Ko et al. only 21.1% of nurses stated that CO was a priority. However, when it came to refusing to provide abortion care, 42.5% of nurses indicated that they would be willing to refuse to participate in an abortion case if allowed [23]. This suggests considerable variability in attitudes depending on the specific context and nature of the procedure. At this point, it should not be overlooked that the recognition of the right to CO may have implications for patients and the provision of health services [2]. The establishment of clear policies that define the scope and limits of CO is essential to ensure that patient care is uninterrupted while respecting the ethical boundaries of healthcare providers.
The implications of these findings are important. First, recognition of these three factors provides a nuanced understanding of the ethical dilemmas nurses face in practice. Healthcare organizations can use this scale to identify areas where additional training or ethical guidance is needed. For example, interventions that focus on strengthening nurses’ understanding of professional values while respecting their personal beliefs may improve the quality and consistency of care.
Limitations
This study has several limitations. Firstly, because of the limited knowledge and lack of common language about CO in our country, some nurses had difficulty understanding its meaning. Sample questions in the scale were helpful in clarifying this concept and guiding participants. Second, as this scale is the first and only one of its kind, comparisons with other existing instruments could not be made. Third, the study was conducted within a specific cultural and health care context, which may limit the generalizability of the scale to other cultures or health care systems. In addition, the inclusion of a specific group of nurses raises concerns about the generalizability of the results to all nurses or other health professionals. Further research is needed to assess the applicability of the scale in different cultural contexts and healthcare settings, and to test its validity and reliability with a wider range of healthcare professionals.
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