Development and psychometric properties of the Ethics Environment Questionnaire

Determinants of burnout in Canadian health care workers during the COVID-19 pandemic

Background: Health care workers (HCWs) are among the most vulnerable groups to experience burnout during the coronavirus (COVID-19) pandemic. Understanding the risk and protective factors of burnout is crucial in guiding the development of interventions; however, the understanding of burnout determinants in the Canadian HCW population remains limited.Objective: Identify risk and protective factors associated with burnout in Canadian HCWs during the COVID-19 pandemic and evaluate organizational factors as moderators in the relationship between COVID-19 contact and burnout.Methods: Data were drawn from an online longitudinal survey of Canadian HCWs collected between 26 June 2020 and 31 December 2020. Participants completed questions pertaining to their well-being, burnout, workplace support and concerns relating to the COVID-19 pandemic. Baseline data from 1029 HCWs were included in the analysis. Independent samples t-tests and multiple linear regression were used to evaluate factors associated with burnout scores.Results: HCWs in contact with COVID-19 patients showed significantly higher likelihood of probable burnout than HCWs not directly providing care to COVID-19 patients. Fewer years of work experience was associated with a higher likelihood of probable burnout, whereas stronger workplace support, organizational leadership, supervisory leadership, and a favourable ethical climate were associated with a decreased likelihood of probable burnout. Workplace support, organizational leadership, supervisory leadership, and ethical climate did not moderate the associations between contact with COVID-19 patients and burnout.Conclusions: Our findings suggest that HCWs who worked directly with COVID-19 patients, had fewer years of work experience, and perceived poor workplace support, organizational leadership, supervisory leadership and ethical climate were at higher risk of burnout. Ensuring reasonable work hours, adequate support from management, and fostering an ethical work environment are potential organizational-level strategies to maintain HCWs' well-being.

Ethical climate in healthcare: A systematic review and meta-analysis

BACKGROUND

Ethical climate refers to the shared perception of ethical norms and sets the scope for what is ethical and acceptable behaviour within teams.

AIM

This paper sought to explore perceptions of ethical climate amongst healthcare workers as measured by the Ethical Climate Questionnaire (ECQ), the Hospital Ethical Climate Survey (HECS) and the Ethics Environment Questionnaire (EEQ).

METHODS

A systematic review and meta-analysis was utilised. PSYCINFO, CINAHL, WEB OF SCIENCE, MEDLINE and EMBASE were searched, and papers were included if they sampled healthcare workers and used the ECQ, HECS or EEQ.

ETHICAL CONSIDERATION

Ethical approval was not required.

RESULTS

The search returned 1020 results. After screening, 61 papers were included (n = 43 HECS, n = 15 ECQ, n = 3 EEQ). The overall sample size was over 17,000. The pooled mean score for the HECS was 3.60. Mean scores of individual studies ranged from 2.97 to 4.5. For the HECS studies, meta-regression was carried out. No relationship was found between the country of the studies, the study setting (ICU v non-ICU settings) or the mean years of experience that the sample had. For the ECQ, sub-scales had mean scores ranging from 3.41 (instrumental) to 4.34 (law) and were all observed to have significant and substantial heterogeneity. Three studies utilised the EEQ so further analysis was not carried out.

CONCLUSIONS

The above results provide insight into the variability of scores as measured by the HECS, ECQ and EEQ. To some extent, this variability is not surprising with studies carried out across 21 countries and in a range of healthcare systems. Results also suggest that it may be that more local and context specific factors are more important when it comes to predicting ethical climate.

Exploring the Well-being of Health Care Workers During the COVID-19 Pandemic: Protocol for a Prospective Longitudinal Study

BACKGROUND

Health care workers (HCWs) have experienced several stressors associated with the COVID-19 pandemic. Structural stressors, including extended work hours, redeployment, and changes in organizational mandates, often intersect with interpersonal and personal stressors, such as caring for those with COVID-19 infections; worrying about infection of self, family, and loved ones; working despite shortages of personal protective equipment; and encountering various difficult moral-ethical dilemmas.

OBJECTIVE

The paper describes the protocol for a longitudinal study seeking to capture the unique experiences, challenges, and changes faced by HCWs during the COVID-19 pandemic. The study seeks to explore the impact of COVID-19 on the mental well-being of HCWs with a particular focus on moral distress, perceptions of and satisfaction with delivery of care, and how changes in work structure are tolerated among HCWs providing clinical services.

METHODS

A prospective longitudinal design is employed to assess HCWs' experiences across domains of mental health (depression, anxiety, posttraumatic stress, and well-being), moral distress and moral reasoning, work-related changes and telehealth, organizational responses to COVID-19 concerns, and experiences with COVID-19 infections to self and to others. We recruited HCWs from across Canada through convenience snowball sampling to participate in either a short-form or long-form web-based survey at baseline. Respondents to the baseline survey are invited to complete a follow-up survey every 3 months, for a total of 18 months.

RESULTS

A total of 1926 participants completed baseline surveys between June 26 and December 31, 2020, and 1859 participants provided their emails to contact them to participate in follow-up surveys. As of July 2021, data collection is ongoing, with participants nearing the 6- or 9-month follow-up periods depending on their initial time of self-enrollment.

CONCLUSIONS

This protocol describes a study that will provide unique insights into the immediate and longitudinal impact of the COVID-19 pandemic on the dimensions of mental health, moral distress, health care delivery, and workplace environment of HCWs. The feasibility and acceptability of implementing a short-form and long-form survey on participant engagement and data retention will also be discussed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32663.

Burnout and intent-to-leave in physical therapists: a preliminary analysis of factors under organizational control

METHODS

Twelve hundred PTs were sent a survey packet including the 20-item Ethics Environment Questionnaire (EEQ) and additional items inquiring about contemporary practice factors. Returned packets (n = 340) were analyzed utilizing correlational and regression analyses to determine relationships between ethical environment, burnout, intent-to-leave, productivity standards, billing and coding requirements and ability to provide pro-bono services.

RESULTS

There was a strong correlation between PTs' view of organizational ethics and burnout (T_{b =} -0.55), and a moderate correlation between organizational ethics and intent-to-leave (T_b = -0.43). There was also a strong relationship between burnout/intent-to-leave and practice factors such as productivity standards, billing/coding policy, and organizational provision of pro-bono services (p ≤ 0.01). Finally, there was a moderate correlation between PTs' view of organizational ethics and practice factors such as productivity standards (T_b = 0.46) and billing and coding policy (T_b = -0.45).

CONCLUSIONS

Contemporary practice factors such as productivity standards and billing/coding practices are related PT's perception of ethical workplace environment and both are related to PT burnout and intent-to-leave. Factors identified in this study related to burnout are all under organizational control.

Impacts of morally distressing experiences on the mental health of Canadian health care workers during the COVID-19 pandemic

BACKGROUND

Research is urgently needed to understand health care workers' (HCWs') experiences of moral-ethical dilemmas encountered throughout the COVID-19 pandemic, and their associations with organizational perceptions and personal well-being. This research is important to prevent long-term moral and psychological distress and to ensure that workers can optimally provide health services.

OBJECTIVE

Evaluate associations between workplace experiences during COVID-19, moral distress, and the psychological well-being of Canadian HCWs.

METHOD

A total of 1362 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in an online survey. Participants completed measures reflecting moral distress, perceptions of organizational response to the pandemic, burnout, and symptoms of psychological disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD).

RESULTS

Structural equation modelling showed that when organizational predictors were considered together, resource adequacy, positive work life impact, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress also significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout.

CONCLUSIONS

Our findings highlight an urgent need for HCW organizations to implement strategies designed to prevent long-term moral and psychological distress within the workplace. Ensuring availability of adequate resources, reducing HCW risk of contracting COVID-19, providing organizational support regarding individual priorities, and upholding ethical considerations are crucial to reducing severity of moral distress in HCWs.

Impact of ethics, trust, and optimism on performance

Purpose

The purpose of this paper is to empirically assess the combined impact of the ethical environment, organizational trust and workplace optimism on individual performance.

Design/methodology/approach

A structural model is theorized and data from 250 individuals working for private organizations were analyzed using partial-least-squares structural equation modeling.

Findings

Both the ethical environment and organizational trust positively impact workplace optimism. Of the ethical environment, organizational trust and workplace optimism, only workplace optimism directly impacts individual performance. The impact of the ethical environment and organizational trust on individual performance is indirect through workplace optimism.

Research limitations/implications

To the authors’ knowledge, this is the first empirical study to assess the combined impact of the ethical environment, organizational trust and workplace optimism on individual performance. It is important to conduct similar studies to verify these findings.

Practical implications

An ethical environment and organizational trust foster high levels of workplace optimism that in turn lead to improved employee performance.

Originality/value

The important role that workplace optimism plays within the ethical climate of organizations is theorized and assessed. This is the first empirical assessment of the mediational role of workplace optimism on the established relationships between ethical environment and individual performance, and organizational trust and individual performance.

Validation of the Iranian Version of the Hospital Ethical Climate Survey

BACKGROUND AND PURPOSE

The aim of this study was to determine validation of the Iranian version of the Hospital Ethical Climate Survey (HECS).

METHODS

This is a methodological study with a cross-sectional design that was conducted in 2016. A forward-backward translation method was used to translate the questionnaire from English to Persian and face, content, and construct validity as well as reliability were assessed.

RESULTS

The factor structure of the HECS through explorative Principal Component Analysis (PCA) confirmed five factors that explained 64.7% of total variance. The overall Cronbach's alpha coefficient was .86 and the Cronbach's alphas for five of the subscales were between .63 and .92.

CONCLUSIONS

The Iranian version of HECS has adequate validity and reliability for measuring the hospital ethical climate in the Iraniansociety.

Physical Therapists' Ethical Dilemmas in Treatment, Coding, and Billing for Rehabilitation Services in Skilled Nursing Facilities: A Mixed-Method Pilot Study

OBJECTIVES

Reimbursement in skilled nursing facilities (SNFs) is driven by the number of minutes a patient receives rehabilitation. Physical therapists' (PTs) clinical decisions in evaluation and appropriate treatment of patients drive the dosing of rehabilitation services. Many times these 2 dynamics clash. The purpose of this study was to determine how PTs in SNFs viewed their ethical work environment, what primary issues drove their views, and what potential solutions were identified for the issues.

DESIGN

This was a mixed-methods, cross-sectional survey study.

SETTING AND PARTICIPANTS

An organizational ethics survey along with 2 open-ended questions were sent to a random sample of 1200 PTs in the state of Georgia; 340 surveys were returned, and the respondents were categorized into 9 typical PT work settings. Twenty eight participants (8.2%) reported they worked in SNFs.

MEASURES

The Ethics Environment Questionnaire was the quantitative measurement tool used for the study. In addition, 2 open-ended questions were asked regarding ethical concerns and possible solutions to those concerns.

RESULTS

Of the 9 workplace settings, therapists working in SNFs had the lowest perceptions of ethical work environment. They were also the only group that scored below the survey cut-off point for positive ethical work environment. Their primary concerns were overutilization issues, productivity standards, and billing and coding issues. The 2 primary themes regarding solutions were allowing PTs to be autonomous in their decision making and decreasing productivity standards.

CONCLUSIONS/IMPLICATIONS

The current Medicare reimbursement system rewards quantity of rehabilitation over quality. PTs are trained to deliver quality care that is dosed appropriately, and this may conflict with organizational objectives. The primary implication in this study is that clinicians and administrators should engage more in open, honest dialogue on how to share responsibility and balance organizational goals with clinical ethics.

What is 'moral distress'? A narrative synthesis of the literature

AIMS

The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress.

BACKGROUND

Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon.

DESIGN

Systematic literature review and narrative synthesis (November 2015-March 2016).

DATA SOURCES

Ovid MEDLINE® In-Process & Other Non-Indexed Citations 1946-Present, PsycINFO® 1967-Present, CINAHL® Plus 1937-Present, EMBASE 1974-24 February 2016, British Nursing Index 1994-Present, Social Care Online, Social Policy and Practice Database (1890-Present), ERIC (EBSCO) 1966-Present and Education Abstracts.

REVIEW METHODS

Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis.

RESULTS

In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity.

CONCLUSION

We suggest the combination of (1) the experience of a moral event, (2) the experience of 'psychological distress' and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.

Moral distress and moral competences in midwifery: A latent variable approach

Like other health professionals, midwives need moral competences in order to cope effectively with ethical issues and to prevent moral distress and negative consequences such as fatigue or impaired quality of care. In this study, we developed and conducted a survey with 280 midwives or midwifery students assessing the burden associated with ethical issues, moral competences, and negative consequences of moral distress. Results show that ethical issues associated with asymmetries of power and authority most often lead to the experience of distress. The results are critically discussed in the context of the conceptualization and operationalization of moral distress.

A Typology of Social Workers in Long-Term Care Facilities in Israel

This article explores moral distress among long-term care facility (LTCF) social workers by examining the relationships between moral distress and environmental and personal features. Based on these features, authors identified a typology of LTCF social workers and how they handle moral distress. Such a typology can assist in the identification of social workers who are in a particular need for assistance. Overall, 216 LTCF social workers took part in the study. A two-step cluster analysis was conducted to identify a typology of LTCF social workers based on features such as ethical environment, support in workplace, mastery, and resilience. The variance of the identified clusters and their associations with moral distress were examined, and four clusters of LTCF social workers were identified. The clusters varied from each other in relation to their personal and environmental features and in relation to their experience of moral distress. The article concludes with a discussion of the importance of developing programs for LTCF social workers that provide support and enhancement of personal resources and an adequate and ethical environment for practice.

Physical therapists' perception of workplace ethics in an evolving health-care delivery environment: a cross-sectional survey

Physical therapists are trained and obligated to deliver optimal health care and put patients first above all else. In the changing health-care environment, health-care organizations are grappling with controlling cost and increasing revenues. Moral distress may be created when physical therapists' desire to provide optimal care conflicts with their organization's goals to remain financially viable or profitable. Moral distress has been associated with low perception of ethical environment, professional burnout, and high turnover in organizations. This study identified groups who may be vulnerable to low perception of organizational ethical environment and identified self-reported strategies to remedy these perceptions. An ethics environment questionnaire was mailed to a random sample of 1200 physical therapists in Georgia. Respondents (n = 340) were analyzed by age, workplace setting, and position in organization. Therapists working in skilled nursing/assisted living environments scored the lowest on the questionnaire and voiced concerns regarding their ethical work environments. Owners and executives perceived their organizations to be more ethical than front-line clinicians. Respondent concerns included high productivity standards, aggressive coding/billing policies, decreased reimbursement, and increased insurance regulation. Possible solutions included more frequent communication between management and clinicians about ethics, greater professional autonomy, and increased training in business ethics and finance.

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.

Ethics interventions for healthcare professionals and students: A systematic review

Background:

The ethics and value bases in healthcare are widely acknowledged. There is a need to improve and raise awareness of ethics in complex systems and in line with competing needs, different stakeholders and patients’ rights. Evidence-based strategies and interventions for the development of procedures and practice have been used to improve care and services. However, it is not known whether and to what extent ethics can be developed using interventions.

Objectives:

To examine ethics interventions conducted on healthcare professionals and healthcare students to achieve ethics-related outcomes.

Research design:

A systematic review.

Methods:

Five electronic databases were searched: CINAHL, the Cochrane Library, Philosopher’s Index, PubMed and PsycINFO. We searched for published articles written in English without a time limit using the keywords: ethic* OR moral* AND intervention OR program OR pre-post OR quasi-experimental OR rct OR experimental AND nurse OR nursing OR health care. In the four-phased retrieval process, 23 full texts out of 4675 citations were included in the review. Data were analysed using conventional content analysis.

Ethical consideration:

This systematic review was conducted following good scientific practice in every phase.

Findings:

It is possible to affect the ethics of healthcare practices through professionals and students. All the interventions were educational in type. Many of the interventions were related to the ethical or moral sensitivity of the professionals, such as moral courage and empowerment. A few of the interventions focused on identifying ethical problems or research ethics.

Conclusion:

Patient-related outcomes followed by organisational outcomes can be improved by ethics interventions targeting professionals. Such outcomes are promising in developing ethical safety for healthcare patients and professionals.

Development and validation of a questionnaire to measure moral distress in community pharmacists

Background Pharmacists work within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment creates the potential for moral distress to occur due to the limitations it places on acting in congruence with moral judgements. Very little research regarding this phenomenon has been undertaken in pharmacy: thus, prominent research gaps have arisen for the development of a robust tool to measure and quantify moral distress experienced in the profession. Objective The aim of this study was to develop an instrument to measure moral distress in community pharmacists. Setting Community pharmacies in the United Kingdom. Method This study adopted a three-phase exploratory sequential mixed-method design. Three semi-structured focus groups were then conducted to allow pharmacists to identify and explore scenarios that cause moral distress. Each of the identified scenarios were developed into a statement, which was paired with twin seven-point Likert scales to measure the frequency and intensity of the distress, respectively. Content validity, reliability, and construct validity were all tested, and the questionnaire was refined. Main outcome measure The successful development of the valid instrument for use in the United Kingdom. Results This research has led to the development of a valid and reliable instrument to measure moral distress in community pharmacists in the UK. The questionnaire has already been distributed to a large sample of community pharmacists. Conclusion Results from this distribution will be used to inform the formulation of coping strategies for dealing with moral distress.

Nurse Moral Distress and Ethical Work Environment

This study examined the relationship between moral distress intensity, moral distress frequency and the ethical work environment, and explored the relationship of demographic characteristics to moral distress intensity and frequency. A group of 106 nurses from two large medical centers reported moderate levels of moral distress intensity, low levels of moral distress frequency, and a moderately positive ethical work environment. Moral distress intensity and ethical work environment were correlated with moral distress frequency. Age was negatively correlated with moral distress intensity, whereas being African American was related to higher levels of moral distress intensity. The ethical work environment predicted moral distress intensity. These results reveal a difference between moral distress intensity and frequency and the importance of the environment to moral distress intensity.

A Path Analytic Model of Ethical Conflict in Practice and Autonomy in a Sample of Nurse Practitioners

The purpose of this study was to test a causal model of ethical conflict in practice and autonomy in a sample of 254 nurse practitioners working in the primary care areas of family health, pediatrics, adult health and obstetrics/gynecology in the state of Maryland. A test of the model was conducted using a path analytic approach with LISREL 8.30 hypothesizing individual, organizational and societal/market factors influencing ethical conflict in practice and autonomy. Maximum likelihood estimation was used to estimate the parameters most likely to have generated the data. Forty-five percent of the total variance in ethical conflict was explained by the variables of ethical environment and ethical concern. Ethical concern, idealistic philosophy, ethics education in continuing education, percentage of client population enrolled in managed care, and market penetration explained 15% of the total variance in autonomy. The findings of this study indicate that the causal model of ethical conflict in practice and autonomy is consistent with the data and contributed to a fuller understanding of clinical decision making associated with practicing in a managed care environment. The final model supported a conceptual framework that is inclusive of three domains: individual, organizational and societal/market variables.

Content Validation of the Organizational Climate for Research Integrity (OCRI) Survey

The purpose of this study was to develop and establish content validity of an instrument designed to measure the organizational climate for research integrity in academic health centers. Twenty-seven research integrity scholars and administrators evaluated 64 survey items for relevance and clarity, as well as overall comprehensiveness of the constructs that are measured (organizational inputs, structures, processes and outcomes). Both quantitative and qualitative methods were used, particularly content validity indices (CVI) and analyses of respondents' comments. The content validity index for the overall survey was initially high (CVI = .83) and improved (CVI = .90) when 17 marginal-to-poor items were removed. This study resulted in the Organizational Climate for Research Integrity (OCRI) survey, a 43-item fixed-response survey with established content validity.

When healthcare professionals cannot do the right thing: A systematic review of moral distress and its correlates

Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions. This review describes the publication trend on moral distress and explores its relationships with other constructs. A bibliometric analysis revealed that since 1984, 239 articles were published, with an increase after 2011. Most of them (71%) focused on nursing. Of the 239 articles, 17 empirical studies were systematically analyzed. Moral distress correlated with organizational environment (poor ethical climate and collaboration), professional attitudes (low work satisfaction and engagement), and psychological characteristics (low psychological empowerment and autonomy). Findings revealed that moral distress negatively affects clinicians' wellbeing and job retention. Further studies should investigate protective psychological factors to develop preventive interventions.

Validation of the Hospital Ethical Climate Survey for older people care

Background:

The exploration of the ethical climate in the care settings for older people is highlighted in the literature, and it has been associated with various aspects of clinical practice and nurses’ jobs. However, ethical climate is seldom studied in the older people care context. Valid, reliable, feasible measures are needed for the measurement of ethical climate.

Objectives:

This study aimed to test the reliability, validity, and sensitivity of the Hospital Ethical Climate Survey in healthcare settings for older people.

Design:

A non-experimental cross-sectional study design was employed, and a survey using questionnaires, including the Hospital Ethical Climate Survey was used for data collection. Data were analyzed using descriptive statistics, inferential statistics, and multivariable methods.

Participants and research context:

Survey data were collected from a sample of nurses working in the care settings for older people in Finland (N = 1513, n = 874, response rate = 58%) in 2011.

Ethical considerations:

This study was conducted according to good scientific inquiry guidelines, and ethical approval was obtained from the university ethics committee.

Results:

The mean score for the Hospital Ethical Climate Survey total was 3.85 (standard deviation = 0.56). Cronbach’s alpha was 0.92. Principal component analysis provided evidence for factorial validity. LISREL provided evidence for construct validity based on goodness-of-fit statistics. Pearson’s correlations of 0.68–0.90 were found between the sub-scales and the Hospital Ethical Climate Survey.

Discussion:

The Hospital Ethical Climate Survey was found able to reveal discrimination across care settings and proved to be a valid and reliable tool for measuring ethical climate in care settings for older people and sensitive enough to reveal variations across various clinical settings.

Conclusion:

The Finnish version of the Hospital Ethical Climate Survey, used mainly in the hospital settings previously, proved to be a valid instrument to be used in the care settings for older people. Further studies are due to analyze the factor structure and some items of the Hospital Ethical Climate Survey.

Perceptions of the hospital ethical environment among hospital social workers in the United States

Hospital social workers are in a unique context of practice, and one where the ethical environment has a profound influence on the ethical behavior. This study determined the ratings of ethical environment by hospital social workers in large nationwide sample. Correlates suggest by and compared to studies of ethical environment with nurses are explored. Positive ratings of the ethical environment are primarily associated with job satisfaction, as well as working in a centralized social work department and for a non-profit hospital. Religiosity and MSW education were not predictive. Implications and suggestions for managing the hospital ethical environment are provided.

Ethical climate and nurse competence – newly graduated nurses' perceptions

Background:

Nursing practice takes place in a social framework, in which environmental elements and interpersonal relations interact. Ethical climate of the work unit is an important element affecting nurses’ professional and ethical practice. Nevertheless, whatever the environmental circumstances, nurses are expected to be professionally competent providing high-quality care ethically and clinically.

Aim:

This study examined newly graduated nurses’ perception of the ethical climate of their work environment and its association with their self-assessed professional competence, turnover intentions and job satisfaction.

Method:

Descriptive, cross-sectional, correlational research design was applied. Participants consisted of 318 newly graduated nurses. Data were collected electronically and analysed statistically.

Ethical considerations:

Ethical approval and permissions to use instruments and conduct the study were obtained according to required procedures. Data were rendered anonymous to protect participant confidentiality. Completing the questionnaire was interpreted as consent to participate.

Findings:

Nurses’ overall perception of the ethical climate was positive. More positive perceptions related to peers, patients and physicians, and less positive to hospitals and managers. Strong associations were found between perceived ethical climate and self-assessed competence, turnover intentions in terms of changing job, and job satisfaction in terms of quality of care. Nurses at a higher competence level with positive views of job satisfaction and low turnover intentions perceived the climate significantly more positively.

Conclusion:

Nursing management responsible for and having the power to implement changes should understand their contribution in ethical leadership, as well as the multidimensional nature of nurses’ work environment and the interaction between work-related factors in planning developmental measures. Future research should focus on issues in nurse managers’ ethical leadership in creating ethical work environments. There is also a need for knowledge of newly graduated nurses’ views of factors which act as enhancers or barriers to positive ethical climates to develop. Interventions, continuing education courses, and discussions designed to promote positive ethical climates should be developed for managers, nurses, and multi-professional teams.

Take me to my leader: the importance of ethical leadership among formal nurse leaders

Although ethical leadership by formal nurse leaders is critical to enhancing ethical health-care practice, research has shown that many nurses feel unsupported by their leaders. In this article, we consider the limited attention directed toward ethical leadership of formal nurse leaders and how our own research on ethical nurse leadership compares to other research in this field. In searching Nursing Ethics since its inception 20 years ago, we found only a dozen articles that directly addressed this topic. We then reviewed nurses' professional codes of ethics in Canada and found significant retractions of ethical guidelines for formal nurse leaders' ethical responsibilities over the past decade. We began to seek explanations of why this is so and offer some recommendations for the study and enhancement of ethics for formal nurse leadership.

What actions promote a positive ethical climate? A critical incident study of nurses' perceptions

Few qualitative studies explore the phenomenon of positive ethical climate and what actions are perceived as promoting it. Therefore, the aim of this study was to explore and describe actions that acute care ward nurses perceive as promoting a positive ethical climate. The critical incident technique was used. Interviews were conducted with 20 nurses at wards where the ethical climate was considered positive, according to a previous study. Meeting the needs of patients and next of kin in a considerate way, as well as receiving and giving support and information within the work group, promoted a positive ethical climate. Likewise, working as a team with a standard for behaviour within the work group promoted a positive ethical climate. Future research should investigate other conditions that might also promote a positive ethical climate.

Framing the issues: moral distress in health care

Moral distress in health care has been identified as a growing concern and a focus of research in nursing and health care for almost three decades. Researchers and theorists have argued that moral distress has both short and long-term consequences. Moral distress has implications for satisfaction, recruitment and retention of health care providers and implications for the delivery of safe and competent quality patient care. In over a decade of research on ethical practice, registered nurses and other health care practitioners have repeatedly identified moral distress as a concern and called for action. However, research and action on moral distress has been constrained by lack of conceptual clarity and theoretical confusion as to the meaning and underpinnings of moral distress. To further examine these issues and foster action on moral distress, three members of the University of Victoria/University of British Columbia (UVIC/UVIC) nursing ethics research team initiated the development and delivery of a multi-faceted and interdisciplinary symposium on Moral Distress with international experts, researchers, and practitioners. The goal of the symposium was to develop an agenda for action on moral distress in health care. We sought to develop a plan of action that would encompass recommendations for education, practice, research and policy. The papers in this special issue of HEC Forum arose from that symposium. In this first paper, we provide an introduction to moral distress; make explicit some of the challenges associated with theoretical and conceptual constructions of moral distress; and discuss the barriers to the development of research, education, and policy that could, if addressed, foster action on moral distress in health care practice. The following three papers were written by key international experts on moral distress, who explore in-depth the issues in three arenas: education, practice, research. In the fifth and last paper in the series, we highlight key insights from the symposium and the papers in the series, propose to redefine moral distress, and outline directions for an agenda for action on moral distress in health care.

Ethical issues in practice: a survey of public health nurses in Japan

OBJECTIVES

The purposes of this study were to identify specific components and frequencies of ethical issues that public health nurses (PHNs) encountered in their practice, relationships between ethical issues and demographic data, and ethics education and workplace environment.

DESIGN AND SAMPLE

Cross-sectional survey for PHNs at local governmental agencies in Japan. Usable data were 3,409.

MEASURES

Public health nurses completed the frequency of ethical issues, experience of ethics education, workplace environment, and demographics.

RESULTS

Item and exploratory factor analysis for the frequency of encountering ethical issues revealed: (1) discrepancy of intention between client and his/her family on treatment or care; (2) differences in views between PHNs and their organization's administrators regarding providing services; and (3) discrepancy of caretaking views between PHNs and various professionals. All factors were related to work experience and one factor was specifically related to the type of local government employing PHNs. Only 11.1% of PHNs received ethics education via continuing education programs. PHNs reported that programmed continuing education systems were not sufficiently available.

CONCLUSIONS

Systematic continuing ethics education programs for PHNs need developing, tailored to the specific characteristics associated with PHNs' ethical concerns, such as nurses' working experience and the type of employing local government.

Ethics Environment in Long-Term Care

This study assesses three hypotheses regarding a long-term care facility’s ethics environment and the relationships between ethics environment, employees’ work features, and residents’ outcomes. Validated questionnaires measure ethics environment, work satisfaction, managing disagreement, goal attainment, care and work opinion including retention, and mental health status among full-time employees ( N = 110; 53%) and residents ( N = 139; 57%) who volunteered for this cross-sectional cohort analysis. Ethics environment is rated above average (> 3.0, 1-5 scale) by employees and residents, with statistically significant ( p = .001) Spearman correlations between ethics environment and employees’ attainment of goals, opinion of care, and work satisfaction; between residents’ ethics environment and care opinion and mental status (MCS, SF-36). Among others, ethics environment is revealed as a robust correlate to two critical factors for quality care: employees’ care opinion including retention and residents’ mental health. It is possible to develop and sustain ethics environments, thus these findings are applicable to clinical practice.

Registered nurses' perceptions of moral distress and ethical climate

Moral distress is a phenomenon of increasing concern in nursing practice, education and research. Previous research has suggested that moral distress is associated with perceptions of ethical climate, which has implications for nursing practice and patient outcomes. In this study, a randomly selected sample of registered nurses was surveyed using Corley's Moral Distress Scale and Olson's Hospital Ethical Climate Survey (HECS). The registered nurses reported moderate levels of moral distress intensity. Moral distress intensity and frequency were found to be inversely correlated with perceptions of ethical climate. Each of the HECS factors (peers, patients, managers, hospitals and physicians) was found to be significantly correlated with moral distress. Based on these findings, we highlight insights for practice and future research that are needed to enhance the development of strategies aimed at improving the ethical climate of nurses' workplaces for the benefit of both nurses and patients.

Primary care nurse practitioners' integrity when faced with moral conflict

Primary care presents distressful moral problems for nurse practitioners (NPs) who report frustration, powerlessness, changing jobs and leaving advanced practice. The purpose of this grounded theory study was to describe the process NPs use to manage moral problems common to primary care. Twenty-three NPs were interviewed, commenting on hypothetical situations depicting ethical issues common to primary care. Coding was conducted using a constant comparative method. A theory of maintaining moral integrity emerged consisting of the phases of encountering conflict, drawing a line, finding a way without crossing the line, and evaluating actions. The NPs varied in their awareness and the discord encountered in conflict, and in clarity, flexibility and justification of the line drawn. A critical juncture occurred when NPs evaluated how well integrity had been maintained. Some experienced no distress while others experienced self-doubt, regret, outrage and frustration at external constraints, and attempted to reconcile through avoiding, convincing themselves, and compensating.

Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States

Nurses and social workers are fundamental to the delivery of quality health care across the continuum of care. As health care becomes increasingly complex, these providers encounter difficult ethical issues in patient care, perceive limited respect in their work, and are increasingly dissatisfied. However, the link between ethics-related work factors and job satisfaction and intent-to-leave one's job has rarely been considered. In this paper, we describe how nurses and social workers in the US view the ethical climate in which they work, including the degree of ethics stress they feel, and the adequacy of organizational resources to address their ethical concerns. Controlling for socio-demographics, we examined the extent to which these factors affect nurses and social workers' job satisfaction and their interest in leaving their current position. Data were from self-administered mail questionnaires of 1215 randomly selected nurses and social workers in four census regions of the US. Respondents reported feeling powerless (32.5%) and overwhelmed (34.7%) with ethical issues in the workplace and frustration (52.8%) and fatigue (40%) when they cannot resolve ethical issues. In multivariate models, a positive ethical climate and job satisfaction protected against respondents' intentions to leave as did perceptions of adequate or extensive institutional support for dealing with ethical issues. Black nurses were 3.21 times more likely than white nurses to want to leave their position. We suggest several strategies to reduce ethics stress and improve the ethical climate of the workplace for nurses and social workers.

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate

OBJECTIVE

To explore registered nurses' and attending physicians' perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.

DESIGN

Descriptive pilot study using a survey design.

SETTING

Fourteen ICUs in two institutions in different regions of Virginia.

SUBJECTS

Twenty-nine attending physicians who admitted patients to the ICUs and 196 registered nurses engaged in direct patient care.

INTERVENTIONS

Survey questionnaire.

MEASUREMENTS AND MAIN RESULTS

At the first site, registered nurses reported lower collaboration (p<.001), higher moral distress (p<.001), a more negative ethical environment (p<.001), and less satisfaction with quality of care (p=.005) than did attending physicians. The highest moral distress situations for both registered nurses and physicians involved those situations in which caregivers felt pressured to continue unwarranted aggressive treatment. Nurses perceived distressing situations occurring more frequently than did physicians. At the second site, 45% of the registered nurses surveyed reported having left or considered leaving a position because of moral distress. For physicians, collaboration related to satisfaction with quality of care (p<.001) and ethical environment (p=.004); for nurses, collaboration was related to satisfaction (p<.001) and ethical climate (p<.001) at both sites and negatively related to moral distress at site 2 (p=.05). Overall, registered nurses with higher moral distress scores had lower satisfaction with quality of care (p<.001), lower perception of ethical environment (p<.001), and lower perception of collaboration (p<.001).

CONCLUSIONS

Registered nurses experienced more moral distress and lower collaboration than physicians, they perceived their ethical environment as more negative, and they were less satisfied with the quality of care provided on their units than were physicians. Provider assessments of quality of care were strongly related to perception of collaboration. Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.

Nursing advocacy in an Australian multidisciplinary context: findings on medico-centrism

As a follow-up to a recent study which highlighted the existence of medical dominance in multi-disciplinary team (MDT) meetings, this paper presents research findings from an Australian study which shows that medico-centrism is a key cause of tension within MDTs. The findings are from a 1-year qualitative study in a regional hospital that explored the ethical decision-making of health professionals within an acute care medical unit. This exploration was conducted through an iterative, phenomenological, qualitative research methodology that consisted of open-ended interviews with a multi-disciplinary representation of health professionals and a sample of consumers for whom they care. The paper situates the notion of nursing advocacy within the context of medico-centrism and examines how the nursing profession interfaces with other disciplines. The findings indicate that the professional framework of nursing includes the language of advocacy, whilst the framework of doctors centres around the medical decision-making process. All professional groups made reference to the MDT as the modus operandi for patient-centred care. All participants noted that time and familiarity with patients and their families is essential for patient-centred care and this could be achieved through MDT collaboration. However, doctors who have scant time to spend with patients saw it as their responsibility to direct the decisions of the MDT and viewed the MDT as adding confusion to the decision-making process. Nurses reported that the limited amount of time spent by doctors in patient consultation translated into the need for advocacy. Professional and clinical confidence and experience are noted as necessary to successfully engage in the process of advocacy. The findings of this article indicate that the adoption of an advocacy role by nurses represents an important means through which MDT operation can be enhanced, medico-centrism limited and patient-centred care improved.

Ethical climate in nursing practice: the leader's role

Clarity in an organization's mission, vision, and values is key to effective management in today's complex healthcare work environment. To clearly articulate mission, vision, and values, employees must experience consistency between what is espoused and what is lived. The purpose of this article is to discuss the nurse leader's role in ensuring congruence between caring missions and caring practices. Ethical principles are discussed as the foundation necessary for creating an ethical climate for nursing practice. Components of ethical climate are presented and strategies to create a positive ethical climate for nursing practice are provided.

Predictors of nurse practitioners' autonomy: effects of organizational, ethical, and market characteristics

PURPOSE

To identify the predictors of autonomy of nurse practitioners (NPs) affiliated directly and/or indirectly with managed-care systems (e.g., HMOs).

DATA SOURCES

A mailed survey sent to a stratified random sample of 254 NPs certified and licensed to practice in the state of Maryland. The measures consisted of selected organizational characteristics; market factors of HMO penetration and percentage of client population enrolled in managed care; and factors of ethical concern, such as ethical ideology, ethics education, and autonomy. The County Surveyor Database was used to assess market penetration in the state.

CONCLUSIONS

Although NPs were ethically concerned about their autonomy in a managed-care environment (70.2%), actual autonomy scores were high. The higher the percentage of HMO penetration, percentage of client population enrolled in managed care, and perceived ethical concern, the lower the perceived autonomy of NPs.

IMPLICATIONS FOR PRACTICE

Findings may be used for future research to address the complexity of variables that influence the autonomous practice of NPs.

Ethical conflict associated with managed care: views of nurse practitioners

BACKGROUND

Ethical conflict of nurse practitioners (NPs) practicing within a managed care environment has not been systematically examined, yet like physician practitioners, NPs are confronted with daily ethical conflicts.

OBJECTIVE

To determine perceptions toward ethical conflict in practice espoused by NPs affiliated with managed care systems and to identify the relationship between selected individual, organizational, and societal/market contextual factors and ethical conflict in practice.

METHOD

Descriptive, cross-sectional, correlational survey of a stratified random sample of 700 NPs licensed and certified to practice in the state of Maryland, conducted from November 2000 to January 2001.

RESULTS

A majority of respondents reported being moderately to extremely concerned with managed care. Eighty percent of the sample perceived that it was sometimes necessary to bend managed care guidelines with 61% agreeing that the practitioner must weigh the patient's interest against managed care organizations' interests. The NPs in a staff/group model health maintenance organization (a) were less ethically concerned (p <.001); (b) perceived the ethical environment more positively (p <.001); and (c) had lower ethical conflict scores (p <.001) than NPs in other types of practice settings.

DISCUSSION

Results from this study indicate that NPs are experiencing ethical conflict associated with practicing within a managed care environment; however, NPs in a staff/group model health maintenance organization report these concerns less. Ethical support through intervening strategies (i.e., ethics education and interdisciplinary ethics support systems) may help mitigate the conflict associated with this system of care.