Investigating the relationship between the ethical atmosphere of the hospital and the ethical behavior of Iranian nurses.

BACKGROUND: The ethical guidelines and ethical atmosphere of the hospital affect the quality of nursing care. Improving the health of patients in most cases depends on the observance of ethical points and ethical behaviors by nurses. The aim of this study was to determine the effect of hospital ethics and ethical training guidelines on improving the quality of nursing care and nurses' professional ethics.
MATERIALS AND METHODS: This is a descriptive-analytical study. This study was performed by multi-stage relative cluster sampling on 260 qualified nurses in 2014. Data were collected using the Hospital Ethical Climate Questionnaire and the Judgments about Nursing Decisions Questionnaire and analyzed using SPSS software version 19.
RESULTS: The results showed that nurses' perceptions of the ethical climate of hospitals were relatively positive. The ethical behavior of nurses was moderate and good. Nurses' perception of the ethical climate scores was not related to the ideal ethical behavior of nurses (r = 0.11, P = 0.86). The ethical climate perceptions of nurses were related to real workplace ethical behavior score (r = 0.188, P = 0.002). The results also showed that ethical guidelines can improve the quality of nursing care.
CONCLUSION: Considering the results of this study, it seems that holding nursing ethics training programs can be a big step toward promoting the professional behavior of nurses and the observance of professional ethics by nurses. Copyright:

Introduction

Organizational climate is a phenomenon that has always existed in the organization and, as a hidden force beyond the tangible, surrounds the mental, emotional, and attitudinal space of people. Atmosphere is neither a work environment nor a way for people to react to it but a perceptual channel through which the effects of the environment on attitudes and behaviors are identified. Proper organizational climate can be considered as an important resource in ensuring the mental health of employees. Therefore, change in any part of the organizational climate leads to immediate and profound changes in the way employees work and perform.[1234] As a result, the ethical climate is important for organizations and affects the ethical behavior of employees.[1] Ethical climate is an organization's value system, which is associated with its ethical performance. Positive ethical climate creates a willingness to do ethical work for employees.[5] The more ethical the organization feels, the more ethical the climate is. The ethical climate within an organization is the perception of the organization's members of the ethical values and behaviors that are supported by the organization. The factors affecting the ethical climate within the organization are personal interests, company profits, productivity, team interests, friendships, social responsibility, personal morality, rules, and professional guidelines.[6] Moral climate inspires the organization's ethical behavior and duties. Ethical climate is the spiritual face and personality on the organization. Relationships, behaviors, criteria, values, beliefs, and general behaviors within the organization derive from its ethical climate. Employees have a general perception of the organizational ethical climate in which they work. This perception largely reflects the desired ethical values and behaviors.[7] Researches showed that ethical work environment is one of the most important components of an organization that influences organizational decision-making and behaviors. As unethical climate is related to immoral behaviors,[8] ethical climate can promote moral behavior among employees through influence on the organizational values.[9] Therefore, managers and supervisors can affect the ethical climate of an organization and change unethical behaviors.[10] Hospital ethics is a type of organizational climate that consists of interpersonal relationships of treatment staff and staff communication with patients and their families. Work climate affects nurses’ willingness to continue serving. Existence of a negative moral atmosphere leads to job dissatisfaction of nurses and other problems.[1] Nursing is a profession that is mixed with moral behavior to perform its practice, and its nature is moral effort. Ethical behavior is one of the basic characteristics of professional nursing, and one of the vital aspects of nursing care and adherence to it is considered as an essential part of nurses’ job duties. Attention to the ethical behavior of nurses in the current era has become very important due to the increasing advances in the field of health care and related technologies and increasing concerns about unethical behaviors and its underlying factors.[11] Moral behavior is a set of social acceptance practices and behaviors that are learned through reward and punishment.[1213] Ethical behavior is influenced by the four components of the cognitive process. These four components include moral sensitivity, moral judgment, moral motivation, and moral character.[14] Moral sensitivity is the response to the ethical dilemma that is the essence of moral decision-making. The moral judgment is the degree of wisdom a person makes about the ethical pathways in different situations. A combination of ethical motivation and individual responsibility will help to fulfill the commitment to good and helpful care. Moral character is the key to the implementation of the moral decision.[15] Moral character is characterized by attributes such as insisting on a moral duty, courage, and tediousness.[16]

The staff of health organizations and hospitals are heavily influenced by the ethical climate of the organization. Nurses are effective in creating the ethical climate due to their continuous and human interaction with patients. Ethical behavior of nurses is very effective on the general viewpoint of the society about health organizations and the people trust and participation. People expect nurses to be one of the leading groups in moral behavior. The improvement of employees’ ethical behavior has become a common goal for organizations today.[17] This goal is particularly important in hospitals, and among hospital staff, nurses are at the center of attention for improving ethical behavior.[15] In order to improve ethical behavior, the factors affecting it should be recognized. Different studies have suggested diverse factors on the improvement of employees’ ethical behavior. The corporate culture and organizational structure have a tremendous effect on employees’ ethical conditions. The relationship between some organizational factors with improving ethical behavior has been studied in several researches. The number of studies available about the relationship of the ethical climate and ethical behavior of nurses is enough. The results of some studies in this regard are also controversial.[1819202122] The aim of this study was to determine the effect of hospital ethics and ethical training guidelines on improving the quality of nursing care and nurses’ professional ethics.

Materials and Methods

This research is a descriptive-analytical cross-sectional study that was conducted in 2014 with the aim of investigating the relationship between nurses’ ethical behavior and the ethical climate prevailing in teaching hospitals in Yazd (a city in Central Iran and the capital of Yazd Province) in 2014. To make sure the ethical obligations are considered, an official letter of introduction to hospital authorities was presented for visiting different sections and distributing questionnaires. The aim of doing this research was explained, and the hospital staff were told that they can choose whether they want to cooperate or not. They were also ensured that their personal information would be kept confidential. Considering the 95% confidence level and 90% power and considering the correlation coefficient of 0.2, the sample size required for this study was 259 samples. Due to the dispersion and proportional to the size of the hospitals, sampling was performed by multi-stage relative cluster sampling method, and in each ward, sampling was performed according to the number of nurses in each ward, based on the sample size. Thus, 280 questionnaires were distributed in the mentioned hospitals and 260 questionnaires were returned.

r = Correlation coefficient of moral behavior and moral climate.

c = 0/5 − ln ([1 − r]/[1 + r]).

N= [(Z1 − α/2 + Z1 − β) × C]2 + 3.

The number of samples selected in each hospital was proportional to the number of nurses working in that hospital.

Data gathering tools were Hospital Ethical Climate Scale and Judgments about Nursing Decisions (JAND). To assess the hospital's ethics, Olson proposed the 1995 HECS questionnaire. He designed this tool to adapt to the conditions of the hospital based on the Victor and Cullen questionnaire so that it can measure the impact of the workplace and the organization on the ability of nurses and social workers to solve ethical problems. The questionnaire includes 26 items in 5 effective dimensions in creating the atmosphere of the hospital. Its dimensions are: patients’ dimension (items 19-11-6-2), colleagues’ dimension (items 23-18-10-1), nursing managers’ dimension (head nurse, supervisor, and metron) (items 5-9-14-17-22-26), and dimension of organization (hospital) (items 25-21-16-13-8-4). Questions from 1 to 5 are scored on a Likert scale (1 = almost never and 5 = almost always). Therefore, the higher the score obtained in this questionnaire, the more ethical the atmosphere in the hospital. In the study of Borhani et al., this questionnaire was first translated into Persian and then from Persian to English, and the degree of coordination between the two English versions was matched and the final questionnaire was obtained. Its validity was confirmed by content validity method based on the opinion of 10 faculty members. Reliability was determined by determining the internal correlation coefficient and calculating Cronbach's alpha coefficient of 0.78.[119] In the present study, reliability was confirmed by retest and alpha test of 0.80.

The JAND was designed by Shake Ketefian in 1981, and it was revised in 2007. The questionnaire consists of six stories and two short scenarios. The questionnaire has 48 questions. Subjects respond to each question in two separate columns according to the five-point Likert scale (completely agree = 5, agree = 4, neutral = 3, disagree = 2, and completely disagree = 1). The first column is related to the ethical belief of the individual, and the second column specifies his performance scores in the actual workplace. The sum of scores for each column can range from 48 to 240. For the Nursing Decisions Judgment Questionnaire, the validity of the instrument was re-evaluated. Thus, the main questionnaire in English was translated into Persian by two people with a master's degree in English translation. The Persian translations were changed to English again, and finally, the translations were reviewed by fluent English speakers. After preparing the tools, the questionnaire was given to 10 faculty members of Razi School of Nursing and Midwifery in Kerman and Shahid Sadoughi School of Nursing and Midwifery in Yazd. Content validity index was calculated in three areas of simplicity, comprehensibility, and relevance, which was set in the range of 1–4. Using the opinions and guidance of professors, the questions of the questionnaire were examined in terms of content and its ambiguities were removed to confirm its validity. After collecting the suggestions and making the necessary corrections, the final questionnaire was modified and prepared. For the questions of this questionnaire, the average validity coefficient of 0.89 was obtained from a score of 1. In this study, the internal correlation method was used to determine the scientific reliability of data collection tools (questionnaire of JAND). For this purpose, the questionnaire was given to 30 nurses, and after completing it using the internal correlation method, their Cronbach's alpha coefficient for the Nursing Judgment Decision Questionnaire for column A was 0.72 and column B was 0.78.[20]

Ethical considerations

In this research, the researcher did the following by observing the following ethical points:

The plan was approved by the Ethics Committee of the Kerman University of Medical Sciences

The researcher received a letter of introduction from the esteemed dean of the faculty of his place of study in order to refer to the teaching hospitals of Shahid Sadoughi University

The researcher referred to the hospitals and, while presenting a letter of introduction from the university of his place of study, obtained the necessary permission from the head of the hospitals, respected matrons, and clinical and educational supervisors to conduct the research and submit a questionnaire

The purpose of conducting the research and keeping the information confidential was communicated to the research units. All research units completed written consent to participate in the study

It was explained to the research units that they are free to participate in the research, and if they wish, they can participate in the project.

The collected data were analyzed using SPSS software version 19 (IBM Company, Armonk, NY, USA). The Pearson correlation coefficient test was used to determine the relationship between ethical behavior and ethical climate. To determine the relationship between ethical behavior and ethical climate with demographic characteristics, one-way ANOVA and independent t-test were used. For all analyses, P < 0.05 was considered statistically significant.

Results

In this study, 260 were examined. The demographic characteristics of the shirts are listed in Table 1.

Table 1

Demographic characteristics of the participants

Variable	Frequency (%)
Gender
Female	161 (61.9)
Male	99 (38.1)
Marital status
Single	39 (15.0)
Married	221 (0.85)
Level of education
Bachelor	251 (96.5)
Master’s degree	9 (3.5)
Job title
Nurse	215 (82.7)
Matron	37 (14.2)
Supervisor	8 (31.0)
History of participating in ethics workshop
Yes	61 (23.5)
No	199 (76.5)
Work experience (years)
<5	32 (12.3)
10-6	64 (24.6)
15-11	61 (23.5)
>15	53 (20.4)

Table 2 shows the mean, standard deviation, and response rank of nurses to each of the items in the hospital nurses’ perceptions of the ethical climate of their work setting. The “My manager is someone I can respect” score was the highest 4.26 (±0.65) and the “Physicians ask nurses for their opinions about treatment decisions” score was the lowest 2.60 (±1.09). The average score of the hospital's ethical atmosphere was 3.6 (in the range of 1–6) with a standard deviation of 0.6.

Table 2

Mean, standard deviation, and response rank of nurses Olson’s questionnaire

Number	Item	Mean±SD	Rank
1	My colleagues listen to my concerns about patient care
2	Patients know what to expect from their caregivers	3.83±0.84	7
3	When I am unable to decide what is right or wrong in a patient care situation, my manager helps me	3.11±0.93	18
4	Hospital policies help me with difficult patient care issues	4.12±0.78	2
5	Nurses and physicians trust one another	3.31±1.04	15
6	Nurses have access to the information necessary to solve a patient care problem	3.46±0.83	13
7	My manager supports me in my decisions about patient care	3.86±0.79	6
8	A clear sense of the hospital’s mission is shared among nurses	3.29±0.98	16
9	Physicians ask nurses for their opinions about treatment decisions	2.60±1.09	20
10	My colleagues help me with difficult patient care issues	3.75±0.90	10
11	Nurses use the information necessary to solve a patient care issue/problem	3.78±0.76	9
12	My manager listens to me about patient care issues	3.89±0.82	4
13	The feelings and values of all parties involved in a patient care issue/problem are taken into account when choosing a course of action	3.26±0.96	17
14	I participate in treatment decisions for my patients	3.33±0.99	14
15	My manager is someone I can trust	3.92±0.87	3
16	Conflict is openly dealt with, not avoided	3.62±0.92	12
17	Nurses and physicians respect each other’s opinions	3.33±1.03	14
18	I work with competent colleagues	3.75±0.73	10
19	The patient’s wishes are respected	3.87±0.66	5
20	When my colleagues are unable to decide what is right or wrong in a patient care situation, I have observed that my manager helps them	3.79±0.83	8
21	There is a sense of questioning, learning, and seeking creative responses to patient care problems	3.75±0.71	10
22	Nurses and physicians respect one another	3.72±0.91	11
23	Safe patient care is provided in my unit	3.87±0.81	5
24	My manager is someone I can respect	4.26±0.65	1
25	I am able to practice nursing in my unit as I believe it should be practiced	3.79±0.83	8
26	Nurses are supported and respected in this hospital	2.80±1.25	19

SD=Standard deviation

The mean score of nurses’ perception of the ideal moral practice was 181.56 with a standard deviation of 17.6. They also earned ethical performance in real-world scores with a mean of 166.58 with a standard deviation of 17.77. The difference between the perception of the ideal ethical practice and the ethical practice in the real situation was 13.6 units, which was 7.2%. Table 3 shows the correlation between ethical climate and moral behavior. Ethical behavior A reflects knowledge of the ideal of moral action. Ethical behavior B is reflected as the real workplace moral action.

Table 3

Correlation between hospital ethical climate and ethical behavior of nurses

Ethical behavior	Mean	Ethical climate (r, P)
Ideal ethical behavior (A)	181.56±17.60	0.011, 0.86
Real ethical behavior (B)	168.5±17.77	0.188, 0.002

Among the demographic variables, gender was one of the factors affecting the ethical behavior and employees’ perception of the ethical climate of the hospital. Men had higher scores in ethical behavior (P < 0.001). The score of nurses’ perception of ethical climate was higher among women significantly (P < 0.001). Ideal ethical behavior and perception of ethical climate were different between single and married nurses (P < 0.05). However, the actual ethical behavior was not different between single and married nurses (P = 0.348). Education level was not a significant factor in ethical behavior and perception of nurses about ethical climate of hospitals (P > 0.05). Supervisors had a significantly higher ethical behavior score in comparison to head nurses and nurses. The correlations between age and work experience with ethical behavior and perception of ethical climate of hospital were not statistically significant (P > 0.05). Previous attendance to moral-related workshop was not related to ethical behavior (P > 0.05), but it was associated with nurses’ perception of ethical climate within the hospital (P = 0.02).

The results of this study showed that by considering the variables, the relationship between moral behavior A and gender, marital status, and moral behavior B is significant [Table 4].

Table 4

Relationship between ethical behavior A and other variables based on general linear models

Variable	Degrees of freedom	Test statistics	P
Gender	1	8.004	0.005
Marital status	1	10.592	0.001
Education	1	0.066	0.936
Participate in an ethics workshop	1	2.011	0.157
Work experience	1	0.031	0.860
Age	1	0.005	0.945
Ethical climate	1	0.416	0.520
Ethical behavior B	1	105.21	<0.001

The results of statistical studies also showed that there is a significant relationship between moral behavior B with gender, position, moral climate, and moral behavior A [Table 5].

Table 5

Relationship between ethical behavior B and other variables based on general linear models

Variable	Degrees of freedom	Test statistics	P
Gender	1	6.921	0.009
Marital status	1	1.036	0.310
Education	1	3.081	0.036
Participate in an ethics workshop	1	0.012	0.914
Work experience	1	2.708	0.101
Age	1	1.370	0.243
Ethical climate	1	17.397	<0.001
Ethical behavior A	1	105.216	<0.001

It should be noted that the results showed that there is a significant relationship between ethical climate and gender, participation in ethics workshop, work experience, and ethical behavior B [Table 6].

Table 6

Relationship between ethical climate and other variables based on general linear models

Variable	Degrees of freedom	Test statistics	P
Gender	1	13.751	<0.001
Marital status	1	3.726	0.055
Education	1	0.156	0.856
Participate in an ethics workshop	1	4.707	0.031
Work experience	1	4.292	0.039
Age	1	3.703	0.055
Ethical behavior A	1	0.416	0.520
Ethical behavior B	1	17.397	<0.001

Discussion

The results of this study showed that nurses’ perception of the ethical climate of the hospital was at the moderate and higher level. Based on McDaniel categorization, the score above 3.5 indicates that the attitude of personnel toward ethical climate of hospital is positive. Several studies have been conducted in Iran that assessed ethical climate in the hospitals. In 2003, Mobasher et al. reported an ethical climate mean score of 3.5 in Kerman hospitals.[21] The ethical climate mean score in selected hospitals in Tehran reported 3.36 in the study conducted by Jalali et al. reported the mean score of ethical climate of 3.1 in Gorgan hospital.[23] A study conducted in Ahvaz Khazani et al. (2013) reported a positive mean ethical climate score of 3.66.[24] The mean score of perception of ethical climate was 3.33 in the United States.[25] Being a woman and single was related to more positive evaluation of ethical climate of hospitals. Previous history attendance to ethical workshops also was related to more positive evaluation of ethical climate. Based on these results, it can be recommended to more ethical workshop be held in hospitals. In the current study, managerial position was not related to perception of ethical climate and ethical behavior scores. This finding may indicate that having a managerial position has little effect on the ethical characteristics of nurses.

In fact, high levels of ethical behavior have been observed in organizations where ethical norms are adopted and implemented, and when these norms become part of the knowledge of the organization's employees, they will affect employees’ ethical decisions. The result of such decisions is to make the atmosphere of the organization more ethical. Organizational policies also affect individual opportunities to be ethical and the ethical atmosphere of the organization. The ethical or immoral nature of decisions stems directly from organizational goals and policies. In other words, the ethical atmosphere is important for organizations and affects the ethical behavior of employees.[1]

Based on the data and findings of this study, it can be claimed that belief in nurses is influenced by education during school and has a direct and significant relationship with performance and is not affected by the moral climate of the hospital. Nurses’ performance is also related to the hospital atmosphere, but this relationship is weak. In all the literature reviewed in this study, behavior has been studied in different environments of the hospital. The weak correlation found in this study may be due to the fact that nursing behavior is caring and is itself a moral value. Furthermore, the nurse's desire to perform moral behavior is influenced by his attitude and belief in that behavior and his feelings and perception about the way others think about the behavior he is doing and is less affected by the environment. The nurse always tries to perform ethical behavior based on existing codes or the moral, cultural, and social beliefs of the community. In health-care organizations, other things govern the professional behavior of the individual, such as patient rights, highly competitive needs, expensive technologies, increased health-care costs, and social values. In addition, accreditation commissions and health organizations have specific rules and regulations in hospitals that govern the professional conduct of nurses.

Managers’ domain had the highest score among five domains of ethical climate survey. It was compatible with the results of Mobasher et al., Joolaee et al., Jalali et al., and Khazani.[21232426] It indicates the importance of nursing managers on the improvement of ethical climate of hospitals.

Nurses in this study identified the ideal ethical behaviors, and they were committed to do the ethical behavior in real work situations. Men had higher ethical behavior scores. In a study conducted in the West and Northwest of the United States, on 203 nurses, the results showed that gender is an effective factor in ethical behavior of nurses.[27] The results of another study in Malaysia showed that ethical behavior of pharmacists was not affected by gender.[28] Gender was not an effective factor in ethical behaviors of university personnel in Esfahan, Iran.[29]

While the relationship between perception of nurses of ethical climate and real ethical behavior of nurses was significantly positive, it has no relationship with ideal ethical behavior. This result indicates that ethical beliefs have not been influenced by the ethical climate of the hospital. Beliefs are the intention of behavior that can predict ethical or unethical behavior. They are based on ethnic, cultural, and religious beliefs[30] and form during nursing education.[26] Ethical beliefs are the source of behavior and will not be affected by the environmental conditions and the organization's climate.[31]

The results of this study showed that by considering the variables, the relationship between moral behavior A and gender, marital status, and moral behavior B is significant, also there is a significant relationship between moral behavior B with gender, position, moral climate, and moral behavior A, and that there is a significant relationship between ethical climate and gender, participation in ethics workshop, work experience, and ethical behavior B. In Borhani et al. study, age did not show a significant relationship with nurses’ views on moral climate, but in terms of gender, women's perception of moral climate was more favorable than men.[1] In the Joolaee et al. and Nakhae et al. (2007) study, none of the demographic characteristics of nurses had a significant relationship with their views on the moral climate.[3132] Borhani et al. (2012) in their study in Kerman stated that gender and perception of the atmosphere are not significantly related.[33] In the study of Pauly et al. and Ulrich et al., unlike our study, none of the demographic characteristics had a significant relationship with the moral climate.[3435]

Since the favorable moral climate affects the performance of nurses, any factor that disturbs the comfort of nurses while performing their duties leads to a decrease in the proper performance of nurses and dissatisfaction of patients and their companions with care services. Therefore, it is necessary to make coherent planning on each of the effective areas in creating the moral atmosphere. It is important for managers to be aware of the fact that the favorable ethical climate of nurses toward the organization is encouraging.[3637] It should also be noted that men and women are different in terms of personality, emotional and psychological, so this issue can be one of the reasons for the difference between the moral atmosphere and moral behavior in men and women. Therefore, the present result does not seem to be far from expected. Factors such as individual, environmental, organizational, and even the nature of work affect gender attitudes toward the moral climate.

One of the limitations of the study was the presence of stress in the hospital and work-related fatigue that may affect the responses. To eliminate this problem, the questionnaires were given to the nurses to complete them at home. Because the study was conducted only in one city, the generalization of its results can be minimized.

Conclusion

The results of the current study showed that nurses had a positive perception about hospital's ethical climate. This perception had a significant relationship with ethical behavior, and it was not influenced by most of the demographic variables. Nurses’ ethical beliefs were not correlated with their perception about hospital ethical climate. This result indicates that, while ethical behaviors of nurses may be influenced by the ethical climate of the hospital, their moral beliefs are less affected. In regard to promote ethical behaviors, all people who are influential in shaping the ethical climate of the hospital, including policymakers, managers, doctors, nurses, and other staff, should work to improve it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.