Factors of hospital ethical climate among hospital nurses in Korea: a protocol for systematic review and meta-analysis

INTRODUCTION

The hospital ethical climate refers to the ethical work environment within a hospital, which may positively or negatively impact individual nurses, nursing organisations and patient care. Most of studies investigating the hospital ethical climate among Korean nurses have been published in Korean. However, papers addressing the hospital ethical climate in Korean were excluded from the systematic review. To enhance our comprehension of the hospital ethical climate, a systematic review specifically focusing on Korean nurses is imperative. Additionally, it is crucial to ascertain the factors associated with the hospital ethical climate and their respective effect sizes through meta-analyses.

METHODS AND ANALYSIS

The systematic search will be conducted for papers published in both Korean and English, encompassing the hospital ethics climate of Korean nurses from 10 database inception to May 2023. Two reviewers will independently review each article based on the inclusion and exclusion criteria, and any differences in opinion will be resolved through discussion and consensus. The study selection process will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. Quality assessment will be conducted using the Checklist for Analytical Cross-Sectional Studies provided by Joanna Briggs Institute. Effect size will be analysed using Comprehensive Meta-Analysis software V.2.0. The results of this study will identify factors related to the hospital ethical climate and the effect size of these factors among nurses in Korea.

ETHICS AND DISSEMINATION

Ethical approval is not required, as the data will be collected from existing literature. Findings will be disseminated through peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022379812.

Descriptions of long-term impact from inter-professional ethics communication in groups

BACKGROUND

On a daily basis, healthcare professionals deal with various ethical issues and it can be difficult to determine how to act best. Clinical ethics support (CES) has been developed to provide support for healthcare professionals dealing with complex ethical issues. A long-term perspective of participating in inter-professional dialogue and reflective-based CES sessions is seemingly sparse in the literature.

RESEARCH AIM

The aim was to describe experiences of impact of Inter-professional Ethics Communication in groups (IEC) based on Habermas' theory of communicative actions, after 6 months from the perspective of an inter-professional team.

RESEARCH DESIGN

A qualitative inductive approach was chosen, and individual interviews (n = 13) were conducted. Interview data were analysed using qualitative content analysis.

PARTICIPANTS

The participants, 10 females and two males, represented assistant nurses, registered nurses, physicians, occupational therapists, physiotherapists, welfare officers and psychologists. Each had attended at least four IEC sessions.

ETHICAL CONSIDERATIONS

The study was approved by the Regional Ethical Review Board in Umeå, Sweden, and it has been undertaken in accordance with the Helsinki Declaration.

FINDINGS

Overall, the descriptions expressed a perceived achievement of a deepened and integrated ethical awareness that increased the participants' awareness of ethically difficult situations as well as their own ethical thinking, actions and approaches in daily work. Perspectives were shared and the team become more welded. They carried the memories of the reflections within them, which was perceived as supportive when encountered new ethically situations.

DISCUSSION

Putting words to unarticulated thoughts may stimulate repeated reflections, leading to new insights and alternative thoughts.

CONCLUSION

The outcome of IEC sessions 6 months following the last session can be described as an incorporated knowledge that enables actions in ethically difficult situations based on an ethical awareness both at a 'We-level' and an 'I-level'.

Well-Being and Professional Efficacy Among Health Care Professionals: The Role of Resilience Through the Mediation of Ethical Vision of Patient Care and the Moderation of Managerial Support

Drawing on the Conservation of Resources theory, this study analyzes whether resilience could be related to healthcare providers' wellbeing and professional self-efficacy, both directly and indirectly, as mediated by ethical vision of patient care and moderated by managerial support in dealing with ethical issues. Overall, 315 Italian healthcare professionals employed in neuro-rehabilitation medicine or palliative care specialties participated in this multi-centered cross-sectional study. The following variables were investigated: resilience (Connor-Davidson Resilience Scale), wellbeing (Maugeri Stress Index-Reduced), professional self-efficacy (Maslach Burnout Inventory-General Survey), ethical vision of patient care and managerial support in dealing with ethical issues (Italian version of the Hospital Ethical Climate Survey). Overall, resilience was positively associated with healthcare providers' wellbeing and professional self-efficacy, directly and indirectly, as mediated by ethical vision of patient care. Highly resilient healthcare professionals who perceived the presence of a positive ethical vision of patient care in their workplace were more likely to experience greater wellbeing when managerial support in dealing with ethical issues was high (vs. low). Thus, these findings provide suggestions for tailored interventions sustaining healthcare professionals along their daily activity characterized by high-demanding and challenging situations.

Factors influencing public health nurses' ethical sensitivity during the pandemic

BACKGROUND

Ethical sensitivity is a prerequisite for ethical nursing practices. Efforts to improve nurses' ethical sensitivity are required to correctly recognise ethical conflicts and for sound decision-making. Because an emerging infectious disease response involves complex ethical issues, it is important to understand the factors that influence public health nurses' ethical sensitivity while caring for patients with COVID-19, an emerging infectious disease.

OBJECTIVES

This study aims to identify the relationship between nursing professionalism, the organisation's ethical climate, and the ethical sensitivity of nurses who care for emerging infectious disease patients in Korean public health centres. Further, it sought to identify factors influencing ethical sensitivity and the mediating effect of the organisational ethical climate to inform guidelines and improve ethical sensitivity.

RESEARCH DESIGN

This was a cross-sectional descriptive study.

PARTICIPANTS AND RESEARCH CONTEXT

Data were collected from February 3 to 8 March 2021. Participants included 167 nurses caring for patients with COVID-19 in public health centres in South Korea.

ETHICAL CONSIDERATION

This study was approved by the Institutional Review Board of the Chung-Ang University and followed the principles of research ethics.

RESULTS

The factors influencing ethical sensitivity were working at a COVID-19 disease direct response department, nursing professionalism, and organisation's ethical climate. The organisation's ethical climate showed a partial mediating effect on the influence of nursing professionalism on ethical sensitivity.

CONCLUSION

Our findings show that nurses' ethical sensitivity can be improved by refining the organisation's ethical climate and nursing professionalism.

'No other alternative than to compromise': Experiences of midwives/nurses providing care in the context of scarce resources

Midwives and nurses play a critical role in safeguarding the lives of women in resource-constrained African countries. Working within the context of scarce resources may undermine their moral agency and hinder their ability to care. The purpose of this paper is to understand the influence of resource scarcity on midwifery and nursing care and practice. A critical ethnography was conducted in the obstetric department of three tertiary-level facilities in Ghana. Purposive sampling was used to recruit 30 midwives and nurses and semistructured interviews, field notes and documentary materials were used to generate in-depth understanding. Ethical approval was granted from Canada and Ghana and written, and ongoing informed consent was obtained from the participants. Five conceptual themes depicting the impact of scarce resources on midwifery and nursing care were discovered: compromised care, constrained care, dehumanized care, missed care and disengaged care. Improving the maternal health of women and averting avoidable maternal morbidity and mortality require governments and institutions to invest in health infrastructure that will support the delivery of ethical and safe midwifery care for women in their most vulnerable period.

[Occupational safety and health promotion in the context of nurse staffing: A scoping review]

Occupational safety and health promotion in the context of nurse staffing: A scoping review Abstract. Background: Increasing workload has led to a rise in mental and physical burden among nurses. In order to prevent this, it should be investigated, whether and to what extent aspects of occupational safety and health promotion can be integrated into nurse-staffing ratios. Aims: The objective of this scoping review was to identify ways and approaches of including occupational safety and health promotion into existing nurse-staffing ratios. Methods: A scoping review was conducted. The literature search took place in relevant professional databases. Articles in English and German language published between January 2015 and April 2020 with a focus on (care) organisations, staffing, occupational safety and/or health promotion, and person-related services were included. Results: Fifteen articles met the inclusion criteria. Three main topics were identified: staffing methods, leadership and control, and work organisation and design. No evidence was found regarding the inclusion of occupational health and safety and health promotion in staffing procedures. However, there is a demand for consideration of aspects "beyond numbers". Conclusions: In the further development of staffing-ratios, factors should be included that go beyond quantifiable measures and, by doing so, also address occupational safety and health promotion.

Values and self-perception of behaviour among critical care nurses

BACKGROUND

Moral distress has various adverse effects on nurses working in critical care. Differences in personal values, and between values and self-perception of behaviour are factors that may cause moral distress.

RESEARCH AIMS

The aims of this study were (1) to identify ethical values and self-perception of behaviour of critical care nurses in Japan and (2) to determine the items with a large difference between value and behaviour and the items with a large difference in value from others.

RESEARCH DESIGN

A nationwide, cross-sectional study was conducted.

PARTICIPANTS AND RESEARCH CONTEXT

We developed a self-administered questionnaire with 28 items, which was completed by 1014 critical care nurses in Japan. The difference between value and self-perception of behaviour was calculated from the score of each value item minus the score of each self-perception of behaviour item. The size of the difference in value from the others was judged by the standard deviation of each item.

ETHICAL CONSIDERATIONS

The study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214, M2019-045).

RESULTS

The items with a large difference between value and behaviour sources were related to the working environment and decision-making support. The items with a large difference in value from others were related to hospital management and disclosure of information to patients.

DISCUSSION

Improving the working environment for nurses is important for reducing moral distress. Nurses are faced with a variety of choices, including advocating for patients and protecting the fair distribution of medical resources, and each nurse's priorities might diverge from those of other team members, which can lead to conflict within the team.

CONCLUSION

This study revealed items with particularly high risks of moral distress for nurses. The results provide foundational information that can guide the development of strategies to mitigate moral distress.

An examination of the moral habitability of resource-constrained obstetrical settings

BACKGROUND

While there have been studies exploring moral habitability and its impact on the work environments of nurses in Western countries, little is known about the moral habitability of the work environments of nurses and midwives in resource-constrained settings.

RESEARCH OBJECTIVE

The purpose of this research was to examine the moral habitability of the work environment of nurses and midwives in Ghana and its influence on their moral agency using the philosophical works of Margaret Urban Walker.

RESEARCH DESIGN AND PARTICIPANTS

A critical moral ethnography was conducted through the analysis of interviews with 30 nurses and midwives, along with observation, and documentary materials.

ETHICAL CONSIDERATIONS

After receiving ethics approval, signed informed consent was obtained from participants before data collection.

RESULTS

Five themes were identified: (1) holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) scarcity of resources as limiting capacity to meet caring responsibilities; (3) gender and socio-economic inequities shaping the moral-social context of practice; (4) working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) surviving through adversity with renewed commitment and courage.

DISCUSSION

The nurses and midwives were found to work in an environment that was morally uninhabitable and dominated by the scarcity of resources, overwhelming and incoherent moral responsibilities, oppressive conditions, and workplace violence. These situations constrained their moral agency and provoked suffering and distress. The nurses and midwives negotiated their practice and navigated through morally uninhabitable work environment by holding onto their moral values and commitments to childbearing women.

CONCLUSION

Creating morally habitable workplaces through the provision of adequate resources and instituting interprofessional practice guidelines and workplace violence prevention policies may promote safe and ethical nursing and midwifery practice.

Does incivility impact the quality of work-life and ethical climate of nurses?

Purpose

The purpose of this study is to assess the relationship between incivility and two organizational and personal attitudes, namely, perceived ethical climate and perceived quality of work-life of nurses, in the framework of organizational climate.

Design/methodology/approach

Quantitative data of 148 nurses working in a medium-sized hospital in Israel were collected. Furthermore, qualitative data were collected through semi-structured interviews with 12 nurses and 14 doctors from the same hospital, constructing a mixed-method approach.

Findings

Findings revealed that witnessing or experiencing incivility affected the nurses' perception of the ethical climate of their work unit and their perceived quality of their work-life. Additionally, we found that the relationship between incivility and nurses' perceived quality of work-life was partially mediated through their perceived ethical climate. The qualitative data supported some of the findings.

Originality/value

The article stretches the incivility theory beyond its dyadic boundaries, prominently showing the spillover effect of incivility as an organizational problem. Additionally, it offers some evidence-based support for the multidimensionality of incivility, strengthening the need for a construct cleanup.

Moral distress revisited: the viewpoints and responses of nurses

AIM

To present and discuss the main themes that were revealed following an analysis of the qualitative research findings that were extracted from a national survey regarding the causes and effects of moral distress amongst New Zealand nurses.

BACKGROUND/INTRODUCTION

Moral distress continues to be a major concern amongst nurses around the world. In New Zealand, a country where nurses have just been on strike over their working conditions and the deteriorating state of their roles within the health services, it remains a major issue.

METHOD

In the original research project, large numbers of nurses supplied not only quantitative data that revealed the extent and impact of moral distress on their practices, but also extensive notes that more specifically explained the causes and effects of their moral distress. This material has since been thematically analysed and is now presented.

FINDINGS/RESULTS

The data strongly suggested that New Zealand nurses experienced and attempted to respond to several major issues; that is, they were not properly supported by 'the system', frequently experienced problems with managers and bullying, witnessing poor care practices and collegial incompetence, and suffered from ongoing problems caused by moral residue.

CONCLUSION

Under current working conditions, nurses are struggling under an increasing weight of moral residue to maintain their ethical standards within an increasingly difficult ethical climate.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This research suggests that although nurses clearly seek out and use various ways to cope with moral distress in their practices, there is a continuing need for moral courage and strengthening of moral resilience that involves greater input from not just nurses themselves, but nurse managers, educators and other health services representatives.

The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization

The present study was conducted to determine the relation between nurses’ moral distress and the ethical climate in selected hospitals of the Iranian Social Security Organization (ISSO). This descriptive-analytical correlational study was conducted in 6 hospitals under the coverage of the Iranian Social Security Organization in 2016. Three hundred nurses were selected by convenience sampling method. Data were gathered using Corley’s Standard Moral Distress and Olson’s Hospital Ethical Climate Scales. Data were analyzed using SPSS software version 19.

The mean score of the nurses’ moral distress was 1.94 ± 0.66, which is considered moderate. The mean score of ethical climate was 88.97, indicating desirable ethical climate in these hospitals. The frequency score of moral distress had a unilateral reverse correlation with the total score of ethical climate as well as its dimensions, including colleagues, patients, hospitals and physicians. The score of the intensity of nurses’ moral distress also had a unilateral reverse correlation with the total score of ethical climate and the scores of the hospital and physicians dimensions.

These results emphasized the importance of creating a positive ethical climate to decrease moral distress as well as the need for professional interventions to increase support in moral issues.

Relationships among Climate of Care, Nursing Family Care and Family Well-being in ICUs

BACKGROUND

Frequent exposure to ethical conflict and a perceived lack of organizational support to address ethical conflict may negatively influence nursing family care in the intensive care unit.

RESEARCH AIMS

The specific aims of this study were to determine: (1) if intensive care unit climate of care variables (ethical conflict, organizational resources for ethical conflict, and nurse burnout) were predictive of nursing family care and family wellbeing and (2) direct and indirect effects of the climate of care on the quality of nursing family care and family wellbeing.

RESEARCH DESIGN

A cross-sectional, correlational design was used.

PARTICIPANTS AND RESEARCH CONTEXT

Convenience sample of 111 nurses and 44 family members from five intensive care units at a Midwest hospital in the United States.

INSTRUMENTS

The Ethical Conflict Questionnaire-Critical Care Version, Maslach Burnout Inventory-Human Services Survey and Hospital Ethical Climate Scale were used to measure climate of care. The Family-Centered Care-Adult Version and Nurse Provided Family Social Support Scale were family measures of the quality of nursing family care. The Family Wellbeing Index was used to measure family wellbeing.

DATA ANALYSIS

Hierarchical regression and mediation analysis were used to answer the study aims.

ETHICAL CONSIDERATIONS

The study was approved by the Institutional Review Board at the study site.

FINDINGS

In separate regression models, organizational resources for ethical conflict (β = .401, p = .006) and depersonalization (β = -.511, p = .006), a component of burnout, were significant predictors of family-centered care. In simple mediation analysis the relationship between organizational resources for ethical conflict and family-centered care was mediated by depersonalization (β = .341, 95% confidence interval (.015, .707)).

DISCUSSION

Inadequate organizational resources and depersonalization may be related to family care delivery, and present obstacles to family-centered care in the intensive care unit.

CONCLUSION

Further research to explicate the relationships among organizational resources, ethical conflict, burnout, and family-centered care is needed to guide the development of effective interventions that enhance the quality of nursing family care in the intensive care unit.

Cancer nurses' perceptions of ethical climate in Greece and Cyprus

BACKGROUND

In recent years, the interest in ethical climate has increased in the literature. However, there is limited understanding of the phenomenon within the cancer care context as well as between countries.

AIM

To evaluate cancer nurses' perceptions of hospital ethical climate in Greece and Cyprus.

RESEARCH DESIGN

This was a quantitative descriptive-correlational comparative study with cancer nurses. Data were collected with the Greek version of the Hospital Ethical Climate Survey questionnaire in addition to demographic data.

PARTICIPANTS AND RESEARCH CONTEXT

In total, n = 235 cancer nurses working in cancer care settings in Greece and Cyprus were recruited at two national oncology nursing conferences.

ETHICAL CONSIDERATIONS

The study conforms to the principles of the World Medical Association Declaration of Helsinki and the relevant ethical approvals were obtained according to national law.

RESULTS

The results showed that in terms of the "Managers" dimension, participants working in Greek hospitals (4.30 ± 0.73) had a higher score compared to the Cyprus participants (3.66 ± 0.93) (t = -5.777, p ≤ 0.001). The perceptions of nurses working in oncology units in Greece regarding the ethical climate were more positive compared to Cyprus (M = 3.67 for Greece and M = 3.53 for Cyprus, p ≤ 0.001). Nurses with a higher level of education had a lower average ethical climate score across all dimensions. All dimensions exhibit positive and moderate to high correlations between them (r = 0.414-0.728, p < 0.01).

CONCLUSION

It is imperative to evaluate and improve the hospital ethical climate that prevails in each cancer care department. This highlights the fact that nurses working in seemingly similar cultural and organizational contexts might still have different perceptions of the ethical climate. Despite these differences, it is necessary to create the right conditions to address ethical issues. A positive ethical climate requires good relationships between healthcare professionals and the presence of good teamwork in order to ensure better healthcare provision.

Phenomenon of moral distress through the aspect of interpretive interactionism

BACKGROUND

Most previous studies on moral distress focused on the factors that cause moral distress, paying inadequate attention to the moral conflict of nurses' values, the physician-nurse power hierarchy, and the influence of the culture.

RESEARCH OBJECTIVE

To analyze the main causes for moral distress with interpretive interactionism.

RESEARCH DESIGN

A qualitative study was adopted.

PARTICIPANTS

Through purposeful sampling, 32 nurses from 12 different departments were chosen as the samples.

ETHICAL CONSIDERATIONS

Approval from the Institutional Review Board of the Kaohsiung Medical University Hospital.

FINDINGS

Moral distress is likely to occur in the following clinical situations: patients have no idea about their diseases; the medical decisions fail to meet the optimum benefit of patients; and patients with terminal cancers are not given a proper death. The reason why nurses become trapped in moral distress is that they fail to achieve moral goodness. Inadequate confidence, the physician-nurse power hierarchy, and the Oriental culture affect nurses' goodness-based intention for patients, which deteriorates moral distress.

DISCUSSION

The main cause for moral distress is the moral goodness of nurses. If nurses' goodness-based intention for patients is inconsistent with the moral objective of achieving optimum benefit for patients, it leads to moral distress. Culture is an essential background factor of care for patients. In the Oriental culture, family members influence patients' right to know about their diseases, the choice of treatment, and patients' autonomy of not receiving cardio-pulmonary resuscitation. This results in moral distress in medical care.

CONCLUSION

The occurrence of moral distress demonstrates that nurses have moral characteristics such as goodness and caring. It is suggested that appropriate educational strategies can be adopted to weaken the power hierarchy between physicians and nurses and enhance nurses' confidence and cultural sensitivity, so as to reduce the moral distress of nurses.

The mediating effect of ethical climate on religious orientation and ethical behavior

Background:

Nurses’ behavior in Educational-Medical centers is very important for improving the condition of patients. Ethical climate represents the ethical values and behavioral expectations. Attitude of people toward religion is both intrinsic and extrinsic. Different ethical climates and attitude toward religion could be associated with nurses’ behavior.

Aim:

To study the mediating effect of ethical climate on religious orientation and ethical behaviors of nurses.

Research design:

In an exploratory analysis study, the path analysis method was used to identify the effective variables on ethical behavior.

Participants/context:

The participants consisted of 259 Iranian nurses from Hamadan University of Medical Sciences.

Ethical considerations:

This project with an ethical code and a unique ID IR.UMSHA.REC.1395.67 was approved in the Research Council of Hamadan University of Medical Sciences.

Findings:

The beta coefficients obtained by regression analysis of perception of ethical climate of individual egoism (B = −0.202, p < 0.001), individual ethical principles (B = −0.184, p = 0.001), local egoism (B = −0.136, p = 0.003), and extrinsic religious orientation (B = −0.266, p = 0.007) were significant that they could act as predictors of ethical behavior. The summary of regression model indicated that 0.27% of ethical behaviors of nurses are justified by two variables: ethical climate and religious orientation.

Discussion and conclusion:

Intrinsic religious orientation has the most direct impact and then, respectively, the variables of ethical climate of perceptions in the dimensions of individual egoism, individual ethical principles, local egoism, global ethical principle, and ethical behavior and extrinsic religious orientation follow. All the above, except global ethical principles and intrinsic orientation of religion have a negative effect on ethical behavior and can be predictors of ethical behavior. Therefore, applying strategies to promote theories of intrinsic religious orientation and global ethical principles in different situations of nursing is recommended.

Ethical climate in nursing environment: A scoping review

Background:

In the past two decades, interest in the concept of ethical climate and in its research has increased in healthcare. Ethical climate is viewed as a type of organizational work climate, and defined as the shared perception of ethically correct behavior, and how ethical issues should be handled in the organization. Ethical climate as an important element of nursing environment has been the focus of several studies. However, scoping reviews of ethical climate research in nursing have not been conducted to guide further research in this area.

Objective:

The purpose of this scoping review is to describe and analyze studies focusing on ethical climate in nursing environment to elicit an overall picture of the research in this field.

Methods:

A scoping review methodology guided by Arksey and O’Malley and Levac et al. was used. Studies were identified by conducting electronic searches on PubMed/MEDLINE, CINAHL, Web of Science Core Collection, PsycINFO, and Scopus and Philosophers’ Index databases. Of 1051 citations, 56 articles matched the inclusion criteria.

Ethical considerations:

This study was conducted according to good scientific guidelines.

Findings:

Ethical climate is a topical research area which has been explored with different methods and outcomes, in different environments, and has mainly been perceived positively. The focus of the studies was on finding associations between ethical climate and work-related factors such as job satisfaction, moral distress, and turnover intentions. Methodologically, research was rather homogeneous using quantitative, descriptive, and correlative research designs.

Conclusion:

Novel perspectives and more diverse methodological approaches paying attentions to issues affecting generalizability of the findings could expand our knowledge in this area.

How work setting and job experience affect professional nurses’ values

Background:

The development of professional values in nursing is directly related to quality and ethical clinical practise and may also increase practitioner and patients’ satisfaction. Some factors, such as work setting or work experience, can influence the importance granted to the professional values of nursing.

Objectives:

To compare in primary care nurses and hospital care nurses the importance granted to professional values and to contrast this perception as a function of professional experience.

Research design, participants and research context:

Descriptive cross-sectional study. Participants were 380 nursing professionals from the public health system (primary care and hospital care). Three dimensions were analysed: ethics, professional expertise and professional mastery. Data were collected from January to June 2015.

Ethical considerations:

We obtained permission from the Ethics Committee and participants’ informed consent.

Findings:

Hospital care professionals attached more importance to all the values analysed, regardless of their work experience. Ethical values, such as confidentiality and respect for the person, were considered to be very important in both systems. Values related to professional expertise obtained lower scores, especially in primary care. In general, professionals with more than 20 years’ experience granted less importance to the values.

Conclusion:

The professional setting influenced the importance assigned to professional nursing values, and clear differences were observed between primary and hospital care. The domain of ethics was considered the most important. It is necessary to reflect on the significance attributed to professional values, especially in more expert nursing staff.