Keywords

Ethical work climate; Moral courage; Moral distress; Organizational citizenship behavior

Introduction

Now-a-days, the amount of unethical activity has increased and it has caused a major loss of organizational integrity and competitive advantage. These cases emphasize the value of an ethical climate at workplace in describing how and why unethical attitude occurs [1]. In fact, the structure of organizational climate plays an essential role in the organizational perceptions and behaviors, such as ethical climate [2].

Ethical climate represents nurses' perception regarding regulations, practices and procedures which an organization awards and expects in relation to ethics [2]. The presence of ethical climate influences the organizations and nurses; it improves the productivity and efficiency of the organization’s performance, increases nurses satisfaction and commitment, improves job performance and encourages ethical decision making [3].

Climate of the work in unit is associated with moral courage, that it is an important factor affecting nurses’ behavior and practice [3]. Moral courage is known as continuous truth, defense of rights and commitment to moral principles in defending patients’ rights, even in potential danger to their job position [4].

Nurses who have moral courage; prefer commitment to organization, care for patients with diverse cases and find their own interests to help others; follow the consequences of correct moral performance to achieve desirable results. While those have low level of moral courage; lose their motivation for moral work and their willingness to serve patients [3].

The effect of moral courage occurs through formal culture, which includes leadership, structure, policy, reward system, socializing mechanism and decision-making process. When behaving ethically and morally; high-quality care delivered, modern healthcare systems, struggling with issues of nurses’ turnover and decrease their moral distress toward organization [4]. Moral distress defined as an emotion that is explicated when the ethical complexity of a situation is not driving to solution [5]. Increased levels of moral distress can cause medical faults, exhaustion, burnout, and patient avoidance. In contrast to decreased levels, which lead to increase nurses' satisfaction, commitment and their citizenship behavior towards the organization [1]. Organizational citizenship behavior is a conscious and discretional individual behavior. It influences nurses’ attitudes and behaviors and guides their activities towards the hospital objectives' accomplishment and it can affect quality of the care delivered to the patients [6].

Significance

Ethical climate in hospitals is very important key to create a suitable environment for the nursing care which can be affected by various working issues and conditions such as management policy, relation with (manager, physician, peers and patients). The efforts made by nurses to make changes in the organization, depend upon presence of ethical climate and moral courage. They help nurses to turn challenge into opportunity, improve their performance, increase productivity, decrease moral distress and increase organizational citizenship behavior among nurses. So the aim of this study was to explore the relationships among ethical work climate, moral courage, moral distress and organizational citizenship behavior among nurses at Zagazig university hospitals.

Aim

To explore relationships among ethical work climate, moral courage, moral distress and organizational citizenship behavior among nurses.

Research questions

What is the nurses' perception towards ethical work climate?

What are the levels of nurses' moral courage, moral distress and organizational citizenship behavior?

Are there relations among ethical work climate, moral courage, moral distress and organizational citizenship behavior?

Material and Methods

Design

A descriptive correlational design was utilized for this study.

Setting

This study was performed at all Zagazig University Hospitals, Egypt, which includes two sectors, involving 8 teaching hospitals and providing free treatment.

Subjects

Staff nurses working in the aforementioned setting with one year of experience at the least.

Sample size

It was estimated at confidence interval 95%, a margin of errors 5.0%, a total population size of 2246 staff nurses, by using this formula [n= N/ 1+ N (e)²] [7]; the required sample size was 384 staff nurses. A stratified random sample was used.

Instruments

Tool 1: Ethical work climate questionnaire: Divided into two parts; First: personal characteristics of staff nurses. Second: Ethical work climate questionnaire: developed by Victor & Cullen [8] to measure nurses’ perception regarding ethical work climate (26 items); grouped under five domains. Answers were measured along a continuum of five-point Likert scale ranged from 1 (almost never true) to 5 (almost always true). When score≥ 60% reflects positive perception and when it was < 60% reflects a negative perception. Cronbach’s alpha coefficient ranged 0.81-0.92.

Tool 2: Professional moral courage scale: It was developed by Sekerka et al. [9] to assess and quantify the construct of moral courage among nurses. It consists of 15 items, grouped under five dimensions. Answers were measured on five point Likert scale ranged from 1 (never) to 5 (always). Scores from 0 to ≥ 39 demonstrate low level and scores ≥ 40 demonstrate high level. The Cronbach’s alpha coefficient was 0.85.

Tool 3: Moral distress scale of nurses: It was developed by Hamric et al. [10] to assess moral distress level of nurses. It included 21 items and divided into four dimensions. Answers were measured on five point Likert scale ranged from 0 (never) to 4 (always). The Score was considered high if it was ≥ 60% and low if it was < 60%. The Cronbach’s alpha coefficient was 0.94.

Tool 4: Organizational Citizenship Behavior (OCB): It is 24-items scale, developed by Organ in Podsakoff et al. [11]; grouped into five dimensions. Answers were measured on five point Likert scale; ranged from 1 (Strongly Disagree) to 5 (Strongly Agree). Scores ≥ 96 indicated a high level, from 72 to 95 indicated a moderate level and < 72 indicated a low level. The Cronbach’s ’s alpha coefficient was 0.96.

Fieldwork

Data collection started in March till end of June 2019. The researchers clarified study aim to nurses either individually or through groups. The questionnaire took about 25-35 minutes to be completed.

Pilot study

It was conducted on 38 staff nurses (10% of the study sample), selected randomly and not involved in the main research sample to ensure clarity and applicability of the tools, and to estimate required time for completing the questionnaire. The required adjustments were done.

Validity

The researchers translated the instruments into Arabic. After translation, they were tested for validity by a panel of experts in nursing administration (5 professors) at Zagazig University to ensure clarity, applicability and understanding. Accordingly, all necessary adjustments were done.

Statistical Analysis

Data were analyzed using computer software The Statistical Package for Social Science (SPSS), version 21. Qualitative data were represented by numbers and proportions while mean and standard deviation for quantitative data. Pearson correlation used for estimating interrelationships among variables.

Results

Table 1 clarifies that 43.5% of nurses aged from 30 to < 40 years, with a mean age of 35.27 ± 8.38. Additionally, the highest proportions of them were female, married, with experience less than 10 years and had a technical diploma in nursing (70.1%, 78.7%, 67.5%, and 55.5% respectively) (Figures 1-3).

Table 1: Distribution of personal characteristics of nurses (n=384).

Figure 1: Nurses’ perception as regards ethical work climate (n=384). Illustrates 89.1% of nurses had a positive perception of ethical work.

Figure 2: Levels of moral courage and moral distress among the studied nurses (n=384). Shows that more than three quarters of nurses had a high level of moral courage and moral distress (85.4% & 83.1% respectively).

Figure 3: Levels of organizational citizenship behavior among the studied nurses (n=384). Reveals that 47.7% of nurses had a moderate level of organizational citizenship behavior.

Table 2 Demonstrates total mean scores of ethical work climate, moral courage, moral distress and organizational citizenship behaviors as reported by nurses (77.33 ± 22.19, 53.48 ± 15.04, 69. 29 ± 10. 62 & 85.08 ± 12.09 respectively) of nurses had a high level of moral courage and moral distress (85.4% & 83.1% respectively).

Table 2: Distribution of different study variables’ total mean scores as reported by studied nurses (n=384).

Figure 3 Levels of organizational citizenship behavior among the studied nurses (n=384). Reveals that 47.7% of nurses had a moderate level of organizational citizenship behavior.

Table 3 Displays that ethical work climate was significantly and positively correlated to moral courage and organizational citizenship behavior (r=0.651, P=0.000 & r=0.493, P=0.000, respectively) and negatively with moral distress (r=-0.263, P=0.000).

Table 3: Correlations between study variables as reported by studied nurses (n=384).

Discussion

Ethical work climate in the organization is very important to increase its effectiveness and productivity and improve the quality of management and performance. Although personal and professional factors influence the moral courage of nurses, but in organization, it seems that the organization’s ethical climate can affect the ethical courage of employees, reduce moral distress and improve nurses' behaviors toward organization [12]. Therefore, this study aimed to explore the relationship among ethical work climate, moral courage, moral distress and organizational citizenship behavior among nurses at Zagazig university hospitals.

The findings of this research showed that the highest proportion of nurses had a positive ethical work climate perception. These findings could be due to the clear and shared sense of the hospital’s mission and vision and commitment toward organization. The previous study finding was supported by a study carried out in Turkey by Numminen et al. [13] and reported that nurses’ overall perception of the ethical climate was positive. However, these findings were inconsistent with a study done by Shafipour et al. [14] in Iran, who stated that the nurses' perception of the ethical work climate was negative. Concerning the moral courage level; more than three quarters of the studied nurses had a high level of the moral courage. These findings might be due to that nurses have good relationships with their supervisor. These findings are in agreement with a study carried out in Tehran by Moosavi et al. [15] and demonstrated that nurses reported high level of moral courage. However, these findings were incongruent with a study done by Day [16] who showed that nurses had a low level of moral courage.

Regarding moral distress level, the highest proportions of the studied nurses had a high level of moral distress. This may be due to a rigid hierarchy between physicians and nurses and they are often considered as subordinate to physicians. These findings in the same line with a study conducted in the USA by Allen et al. [17] who reported that the majority of nurses had a high level of moral distress. In disagreement with the previous findings, a study done in the Island by Gonzalez [18] who found the majority of nurses had a low level of moral distress.

In relation to OCB; two thirds of the studied nurses had a moderate level of OCB. This result may be due to lack of motivation and incentive. Additionally, most of nurses seek to achieve their personal goals rather than organizational goals. In this context, Bahrami et al. [19] conducted a study in Iran, who stated that the mean score of the OCB was moderate. Contradicting with previous results in Turkey, Altuntas and Baykal [20] revealed that the OCB level of nurses was high. Regarding correlation among study variables; the current findings emphasized that ethical work climate was significantly and positively correlated to moral courage and organizational citizenship behavior. On the other hand, it is negatively correlated to moral distress. These findings could be due to that ethical climate provides a framework for ethical decision making in the clinical environment and enables employees to cope with moral distress and other causes of dissatisfaction. Similar results found by Taraz et al. [21] who declared that there was a significant positive correlation between nurses’ ethical climate and their moral courage.

Conclusion and Recommendations

Ethical work climate was significantly and positively correlated to moral courage and organizational citizenship behaviors while it is negatively correlated to moral distress.

For hospital administrators

• Enhance ethical climate in hospitals by creation of suitable working environment for professional performance.

• Maintain ethical relationship with nurses that help them to improve their performance.

• Develop continuing education and discussions to promote positive ethical climates within the organization.

• Create a learning and informative environment for nurses where makes them competent to accomplish organizational objectives.

Further research

• Issues in nurse managers’ ethical leadership in creating positive ethical work environments.

Conflict of Interest

There is no conflict of interest regarding the publication of this paper.

Sources of Funding

There is no funding source for this study supported by any institution.

Ethical Clearance

Before data collection, the content of this study was approved by the ethics committee and dean of the Faculty of Nursing, Zagazig University. Nature and aim of the study were explained to the nurses who took part in this study. They were given an option to discontinue at any time without explanation and their personal information was maintained confidential.

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