Evaluation of ethical climate in health services: a systematic review

Abstract

Ethical climate refers to the perceptions shared by health professionals of how ethical issues should be handled in their organization. This study aimed to identify scientific evidence of studies that used the Hospital Ethical Climate Survey in ethical climate assessment. This is a systematic review of 33 articles selected from Scopus, PubMed and Medline databases. Ethical climate was associated with workers’ health issues and it was evaluated as moderate to positive by health professionals. The topic was classified as positive for the “peers,” “patients” and “managers” factors, and negative for “physicians” and “hospital” factors. The review concluded that assessing the ethical climate is important for improving the work environment and that the Hospital Ethical Climate Survey is a valid and reliable instrument for such evaluation.

Keywords:
Ethics; Health services; Nursing

Resumo

O clima ético refere-se à perceptibilidade dos profissionais de saúde quanto ao tratamento ético das questões do trabalho. Este estudo buscou identificar as evidências científicas das produções que utilizaram o instrumento Hospital Ethical Climate Survey na avaliação do clima ético. Trata-se de revisão sistemática realizada nas bases de dados Scopus, PubMed e Medline, sendo selecionados 33 artigos. Evidenciou-se que o clima ético foi associado às questões de saúde do trabalhador e avaliado como de moderado a positivo pelos profissionais de saúde. O clima ético foi classificado como positivo para os fatores “pares”, “pacientes” e “gestão”, e como negativo para os fatores “médicos” e “hospital”. Compreende-se a importância da avaliação do clima ético para a sustentabilidade e melhorias do ambiente de trabalho. Neste caso, o Hospital Ethical Climate Survey se apresentou válido e fidedigno ao ser aplicado em serviços de saúde.

Palavras-chave:
Ética; Serviços de saúde; Enfermagem

Resumen

El clima ético se refiere a la percepción de los profesionales de la salud sobre el tratamiento ético de las cuestiones laborales. Este estudio buscó identificar evidencias científicas de producciones que utilizaron el instrumento Hospital Ethical Climate Survey en la evaluación del clima ético. Se trata de una revisión sistemática realizada en las bases de datos Scopus, PubMed y Medline, con 33 artículos seleccionados. Se demostró que el clima ético estaba asociado a problemas de salud en el trabajo. En la evaluación por factores, el clima ético se clasificó como positivo para los factores “pares”, “pacientes” y “gestión”, y como negativo para los factores “médicos” y “hospital”. Se concluyó que es importante evaluar el clima ético para garantizar la sostenibilidad y mejorar el clima laboral. En este caso, la aplicación del Hospital Ethical Climate Survey en los servicios de salud resultó válida y confiable.

Palabras clave:
Ética; Servicios de salud; Enfermería

Ethical climate can be defined as the perceptions shared by health professionals of how ethical issues concerning healthcare and workplace relations should be handled ^1,2. These issues refer to problems in patient care, diagnosis and treatment, institutionally and among health teams ³. Ethics in this environment is influenced by the organizational behavior and is usually positive when the workplace favors the exercise of autonomy and the inclusion of all professionals involved in care, allowing them to discuss and participate in the decision-making process ¹.

This indicator has been assessed in hospital and non-hospital services ^1,2, using instruments that include the Ethical Climate Questionnaire for services, industrial and trade organizations ²; Ethical Decision-Making Climate Questionnaire for intensive care units ⁴; and Hospital Ethical Climate Survey (Hecs) for hospital areas ^5–7.

Hecs was developed in 1998 in Chicago, in the United States, to assess the perceptions shared by nurses on the ethical climate; it was validated in a study with 360 professionals from two acute care hospitals located in a city in the Western United States ¹. This instrument consists of five factors or subscales: “patients,” “physicians,” “peers,” “hospital (hospital management)” and “managers” (unit management) ¹. Each factor assesses whether interpersonal relationships can help or hinder the ethical decision-making process, considering everyone involved in the problem situation ^1,8.

For each factor, the ethical climate can be classified as negative, moderate or positive, depending on the quality of the relationships and how ethical the deliberation will be among the parties involved ^1,8,9. An ethical climate assessment may indicate turnover intention, job dissatisfaction ¹⁰, worker distress ¹¹, moral stress ¹², and tendency to commit medical errors ¹³. These indicators can morally embarrass workers, reason why they must be identified.

An ethical assessment can also help recognize elements that strengthen or weaken the ethical and moral performance of workers, which is reflected on the quality and safety of care provided to patients. With this evaluation, actions can be planned to improve the work environment and facilitate shared decision-making based on deontology and the principles of the institutions. Considering all these benefits, this study aimed to analyze scientific evidence of studies using Hecs to assess ethical climate.

Method

This is a systematic review of six stages: 1) review question formulation; 2) definition of selection criteria and databases; 3) development and completion of a form for data collection and extraction; 4) critical evaluation of primary studies; 5) analysis and descriptive synthesis of the review results; and 6) knowledge synthesis ¹⁴.

In the first stage, based on the Picot strategy – population (P), intervention (I), comparison (C), outcome (O) and time (T) ¹⁴ –, we defined the following review question: “What are the scientific evidences of ethical climate assessment published in the literature using the Hecs instrument?” The second stage defined the selection criteria and databases – Scopus, PubMed and Medline Complete. This review included only original full articles, published in English, Portuguese or Spanish, which used Hecs to assess the ethical climate with health professionals.

In the Scopus database, the following combinations of keywords were used: “ethical climate and nursing and questionnaire or instrument or scale or validation,” and 54 studies were found; in PubMed, “ethical climate and nursing or nurse” found 90 publications; and in Medline, “ethical climate and hospital ethical climate and nursing or nurse” resulted in 87 studies.

We conducted database search and analysis of all studies in May 2019, in a dual independent review process, by the author and a previously trained scientific initiation scholarship student. Five studies were excluded because they were not in English, Portuguese or Spanish, totaling 226 publications, which were submitted to the selection process according to Figure 1.

Figure 1
Flowchart of the dual independent screening process for the articles included in this review

In the third stage, all 33 selected articles were assessed regarding data quality and relation with the research problem. For the analysis, a data extraction table was developed, with the following information: authors, database, study field, country and year of publication, journal, language, objectives, method, abstract, theme (if the article addresses the theme), main results and conclusions.

The fourth stage consisted of a critical evaluation of primary studies using an evidence classification system. Different classifications could be used, depending on the type of study question of selected primary studies. The method selected was the seven levels of classification: 1) systematic review or meta-analysis; 2) randomized controlled clinical trial; 3) clinical trials without randomization; 4) cohort and case-control studies; 5) systematic review of descriptive and qualitative studies; 6) descriptive or qualitative study; and 7) opinion of authorities and/or report of expert committees ¹⁵.

The fifth stage involved the analysis and descriptive synthesis of the review results, allowing the assessment of individual studies and data comparison. Data extraction aims to find results that answer the review question, emphasizing differences and similarities between the studies selected, without inferences from the reviewer.

In the sixth stage (“knowledge synthesis”), the results, conclusions and limitations of the studies are presented together with the authors’ considerations and reflections. Our investigation maintained the authorship and reliability of the articles included in this review.

Results

Most studies were conducted in North America (30.3%; n=10), specifically in the United States (27.3%; n=9) ^{1,3,10,11,16–20}, between 2014 and 2015 (36.4%; n=12) ^{13,16–18,21–28}, published by Nursing Ethics (33.3%; n=11) ^{8,9,12,13,19,25,27,29–32}, rated by Qualis Periódicos as A1, with impact factor of 2.597. Hospital settings were the most frequent study field (84.8%; n=28) ^{1,3,5–9,11–13,16–21,23,24,26,29–37}, in acute/critical care units (24.2%; n=8) ^{1,11,16,18,20,29,32,37}. Nurses participated in all studies ^{1,3,5–13,16–37}, but some also had the participation of physicians ^{6,11,17,30,37}, nursing auxiliaries ^6,22,27,30, social workers ^10,17, and pharmacists ¹⁷.

Table 1 presents authors, design, levels of evidence, variables associated with ethical climate, and the main results of the studies comprising the sample. Cross-sectional studies were the most common study design (90.9%; n=30), with level of evidence 6.

Table 1
Synopsis of selected articles

Identification	Study design	Level of evidence	Variables associated with ethical climate	Main results
Olson; 1998 1	Methodological	6	None	Hecs proved to be a valid and reliable instrument for the assessment of ethical climate.
Bahcecik, Oztürk; 2003 5	Cross-sectional	6	Sociodemographic data	Ethical climate was associated with time of experience and age of the professional.
Hart; 2005 3	Cross-sectional	6	Turnover intention Intention to leave nursing	Nurses who perceived ethical climate as positive reported a greater intention to remain in the area. Relationship between ethical climate and intention to leave nursing.
Ulrich and collaborators; 2007 10	Cross-sectional	6	Job satisfaction Turnover intention Ethical stress	Participants less inclined to turnover and with a low level of ethical stress considered the ethical climate more positively. Positive ethical climate increased job satisfaction and reduced turnover intentions.
Hamric, Blackhall; 2007 11	Cross-sectional	6	Moral distress Labor data	Nurses with a high level of moral distress rated the ethical climate more negatively. Nurses considered the ethical climate more negatively than physicians.
Pauly and collaborators; 2009 29	Cross-sectional	6	Moral distress	The more positive the ethical climate, the lower the levels of moral distress.
Lützén and collaborators; 2010 12	Cross-sectional	6	Ethical stress	Negative perception of the ethical climate increased moral stress.
Silén and collaborators; 2011 33	Cross-sectional	6	Moral distress	Positive ethical climate is associated with a lower frequency of moral distress.
Joolaee and collaborators; 2013 34	Cross-sectional	6	Job satisfaction	The more positive the ethical climate perception, the higher the satisfaction level reported by nurses.
Claeys and collaborators; 2013 35	Methodological and cross-sectional	6	None	Ethical climate was positive in the units. The lowest score was for the “hospital” factor, and the highest was for the “peers” factor.
Han; 2014 21	Cross-sectional	6	Turnover intention	The more positive the ethical climate, the lower the turnover intention.
Hwang, Park; 2014 13	Cross-sectional	6	Labor data Turnover intention Experience with medical error	Significant differences were found between ethical climate and years of nursing and teaching experience. Nurses with a positive perception of the ethical climate presented lower rate of turnover intention and were less likely to commit medical errors.
Suhonen and collaborators; 2014 22	Cross-sectional	6	Individualized nursing care	Nurses who rated the ethical climate more positively were more likely to realize care provided was more individualized.
Sauerland and collaborators; 2014 16	Mixed	6	Moral distress Moral residue	Nurses who reported higher levels of moral distress rated the ethical climate more negatively.
Khalesi and collaborators; 2014 23	Cross-sectional	6	None	The highest rate of ethical climate was for the “managers” factor, and the lowest for the “physicians” factor. Hecs proved to be a valid and reliable instrument for the assessment of ethical climate.
Ghorbani and collaborators; 2014 24	Cross-sectional	6	Sociodemographic data	Sociodemographic data did not influence the perceptions of nurses about the ethical climate.
Whitehead and collaborators; 2015 17	Cross-sectional	6	Moral distress Labor data	More positive perceptions of the ethical climate were associated with lower levels of moral distress. Physicians rated the ethical climate more positively than nurses.
Numminen and collaborators; 2015 25	Cross-sectional	6	Self-assessed professional competence Turnover intention Job satisfaction	Nurses with a higher level of competence, satisfied with their jobs and who never planned to change jobs, presented a more positive perception of the ethical climate.
Jahantigh and collaborators; 2015 26	Cross-sectional	6	Sociodemographic data Desired ethical climate	A significant relationship was observed between age/work environment and the ethical climate. A significant difference was observed between the perceptions shared by nurses of the ethical climate and the desired mean score for ethical climate.
Suhonen and collaborators; 2015 27	Cross-sectional	6	None	The ethical climate was positive in general, with a higher score for the “peers” factor and a lower score for the “physicians” factor.
Sauerland and collaborators; 2015 18	Cross-sectional	6	Moral distress	Significant inverse relationship between moral distress and ethical climate.
Numminen and collaborators; 2015 28	Cross-sectional	6	Practice environment Turnover intention	Nurses who were satisfied with the quality of care evaluated the ethical climate more positively. Nurses with turnover intention evaluated the practice environment and the ethical climate less positively.
Jahantigh, Zare, Shahrakipour; 2016 36	Cross-sectional	6	Sociodemographic data Ethical behavior	The relationship between sociodemographic data/ethical behavior and the ethical climate was not significant.
Bartholdson and collaborators; 2016 30	Cross-sectional	6	Labor data	Nurses rated the ethical climate positively less frequently than physicians.
Boer and collaborators; 2016 37	Longitudinal	4	Labor data Moral distress	Nurses rated the ethical climate more negatively than physicians. The positive ethical climate helps nurses and physicians cope with moral distress.
Jang, Oh; 2019 31	Cross-sectional	6	Job satisfaction Ethical leadership	Job satisfaction was positively correlated with the ethical climate. No significant association was found between ethical climate and ethical leadership.
Özden and collaborators; 2019 9	Cross-sectional	6	Ethical leadership Job satisfaction Sociodemographic and labor data	Significant positive correlation was found among ethical leadership, ethical climate and job satisfaction. A statistically significant difference was found between ethical climate and working hours, work type, work conditions and job satisfaction. Nurses who had been longer in the institution presented higher scores for leadership and ethical climate. Nurses who were more satisfied with the profession and relationships with their colleagues rated the ethical climate more positively.
Asgari and collaborators; 2019 32	Cross-sectional	6	Job satisfaction	A significant relationship was found between ethical climate and job satisfaction.
Lemmenes and collaborators; 2018 19	Cross-sectional	6	Sociodemographic and labor data	Nurses under 30 years of age rated the ethical climate more positively than nurses over 30 years of age. Significant relationship between ethical climate and specialties: adult critical care nurses presented higher total mean scores.
Constantina, Papastavrou, Charalambous; 2019 8	Cross-sectional	6	Labor data	Nurses with an undergraduate degree rated the ethical climate more positively than nurses with a graduate degree.
Altaker, Howie-Esquivel, Cataldo; 2018 20	Cross-sectional	6	Moral distress Psychological empowerment	Nurses who rated the ethical climate more positively had lower levels of moral distress. A positive correlation was found between HECS and Psychological Empowerment Instrument.
Charalambous and collaborators; 2018 7	Methodological	6	None	Hecs proved to be a valid and reliable instrument for the assessment of ethical climate.
Pergert, Bartholdson, Sandeberg; 2019 6	Cross-sectional	6	Labor data	Physicians rated the ethical climate more positively than nurses and nursing assistants.

• Hecs: Hospital Ethical Climate Survey.

Ethical climate presented association with other variables (84.8%; n=28) ^{3,5,6,8–13,16–22,24–26,28–34,36,37}. In most studies, ethical climate was associated with moral distress, as assessed by the Moral Distress Scale (24.2%; n=8) ^{11,16–18,20,29,33,37}; job satisfaction, according to the Job Satisfaction Scale ¹⁰, Minnesota Job Satisfaction Questionnaire ³⁴, Minnesota Satisfaction Questionnaire ³¹, Minnesota Satisfaction Scale ⁹, and Brayfield and Rothe Job Satisfaction Index ³² (15.2%; n=5); and turnover intention, assessed using the Anticipated Turnover Scale ³ and the Turnover Intention ²¹ (6.1%; n=2). In addition, questions about job satisfaction ²⁵ and turnover intention ^10,13,25,28 were used, which were developed by the authors of the studies (15.2%; n=5). Table 2 shows the mean and standard deviation values used in the overall classification and by Hecs factors.

Table 2
Overall classification and by factors of the Hospital Ethical Climate Survey

Identification*	Ethical climate classification by HECS factors					Overall classification of ethical climate/HECS
	Patients	Peers	Physicians	Managers	Hospital
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Ulrich and collaborators; 2007 10	–	–	–	–	–	97.3 (14.4)
Pauly and collaborators; 2009 29	3.71 (0.573)	4.12 (0.617)	3.35 (0.741)	3.40 (1.071)	3.11 (0.747)	3.48 (0.612)
Silén and collaborators; 2011 33	–	–	–	–	–	95.00 (**)
Joolaee and collaborators; 2013 34	–	–	–	–	–	3.36 (0.69)
Claeys and collaborators; 2013 35	3.90 (0.49)	4.15 (0.49)	3.75 (0.59)	3.85 (0.77)	3.64 (0.59)	3.85 (0.46)
Han; 2014 21	3.35 (0.40)	3.61 (0.50)	2.76 (0.60)	3.28 (0.60)	2.78 (0.50)	3.11 (**)
Hwang, Park; 2014 13	3.60 (0.60)	3.7 (0.70)	3.0 (0.80)	3.8 (0.80)	3.3 (0.60)	3.5 (0.60)
Suhonen and collaborators; 2014 22	–	–	–	–	–	3.85 (0.56)
Sauerland et al.; 2014 16	–	–	–	–	–	94.39 (18.3)
Khalesi and collaborators; 2014 23	2.80 (0.64)	2.90 (0.65)	2.46 (0.69)	3.04 (0.66)	2.61 (0.72)	2.75 (0.58)
Ghorbani and collaborators; 2014 24	3.94 (0.64)+ 4.01 (0.65)++	4.12 (0.5)+ 4.05 (0.64)++	3.31 (0.76)+ 3.46 (0.73)++	4.23 (0.77)+ 4.24 (0.76)++	3.37 (0.81)+ 3.48 (0.88)++	3.76 (0.54)+ 3.82 (0.61)++
Whitehead and collaborators; 2015 17	–	–	–	–	–	58.2 (11.1)
Numminen and collaborators; 2015 25	4.10 (0.52)	4.33 (0.54)	3.74 (0.58)	3.50 (0.91)	3.54 (0.64)	3.84 (0.45)
Jahantigh and collaborators; 2015 26	14.70 (2.76)	15.42 (2.66)	20.98 (4.40)	22.07 (3.93)	21.6 (4.15)	94.78 (15.35)
Suhonen and collaborators; 2015 27	3.96 (0.54)	4.29 (0.55)	3.58 (0.71)	3.94 (0.87)	3.64 (0.67)	3.85 (0.56)
Sauerland and collaborators; 2015 18	–	–	–	–	–	96.6 (17.77)
Jahantigh, Zare, Shahrakipour; 2016 36	–	–	–	–	–	94.78 (15.35)
Boer and collaborators; 2016 37	–	–	–	–	–	3.86 (0.46)
Jang, Oh; 2019 31	3.69 (0.40)	4.01 (0.48)	3.61 (0.57)	3.98 (0.56)	3.46 (0.47)	3.59 (0.41)
Özden and collaborators; 2019 9	–	–	–	–	–	92.62 (17.0)
Asgari and collaborators; 2019 32	3.29 (**)	3.72 (**)	1.58 (**)	3.8 (**)	2.61 (**)	3.51 (0.53)
Lemmenes and collaborators; 2018 19	3.60 (0.60)	3.94 (0.65)	2.93 (0.81)	3.04 (1.06)	2.97 (0.74)	3.22 (0.65)
Constantina, Papastavrou, Charalambous; 2019 8	3.74 (0.69)	3.99 (0.64)	3.06 (0.79)	3.88 (0.92)	3.4 (0.72)	3.58 (0.62)
Altaker, Howie-Esquivel, Cataldo; 2018 20	–	–	–	–	–	3.9 (0.5)

• ^*
  Nine articles1^,3^,5^–7^,11^,12^,28^,30have no mean and standard deviation values in the overall classification of ethical climate;
• ^**
  has no standard deviation;
• ⁺
  hospital A;
• ⁺⁺
  hospital B; – means no classification by factors;
• SD: standard deviation; Hecs: Hospital Ethical Climate Survey.

As indicated in Table 2, among the studies that evaluated the ethical climate by factors, 84.6% (n=11) had higher scores for the factors of “patients,” “peers,” and “managers,” and lower scores for “hospital” and “physicians” ^{8,13,19,21,23,24,27,29,31,32,35}, rated as negative. The ethical climate assessed with Hecs was moderate to positive. Only one study presented a negative classification ²³.

The studies evaluated Hecs in two different ways: by the sum and by the mean values. Eight (24.2%) ^{9,10,16–18,26,33,36} assessed it based on the sum of the items; 16 (48.5%) ^{8,13,19–25,27,29,31,32,34,35,37} by the general mean values of the instrument; 12 (36.4%) ^{8,13,19,21,23–25,27,29,31,32,35} by the mean of each factor; and 5 (15.2%) ^{8,16,18,23,25} by the mean of each item referring to the values on the Likert scale.

Some studies ^20,35 described, from the analysis of mean values, the value to classify the ethical climate as positive (above 3.5) and negative (below 3.5). Other research ^{9,16,18,24,32} classified the ethical climate by the sum of scores, considering 130 as the maximum value and 26 as minimum value. The ethical climate was assessed as positive above 78 and as negative below this score ^26,36.

The articles not described in Table 2 carried out association/correlation analyses between ethical climate and other variables ^{3,11,12,28,30}, were validation studies ^1,7, or used percentages to assess the ethical climate in general and/or by Hecs items ^5,30. Hecs was also used in a reduced form, from 26 to 14 ⁶ and 17 ³⁰ items in hematology-oncology units; to 15 ¹¹ and 25 ³⁷ items in acute/critical care units; and to 16 ¹⁷ items in hospital sectors.

The overall reliability of the instrument ranged from 0.85 to 0.95 and was assessed using Cronbach's alpha (63.6%; n=21) ^{1,3,5,7–12,18–20,22–24,27,31–33,35,37}. Reliability by factors was calculated in 21.2% (n=7) of the articles, with the factors of “peers” ranging from 0.70 to 0.88; “patients” from 0.58 to 0.85; “managers” from 0.73 to 0.93; “hospital” from 0.58 to 0.83; and “physician” from 0.71 to 0.89 ^{1,7,8,19,23,27,35}.

Discussion

Regarding the characterization of the studies, they were mostly conducted in the United States, in hospital settings – mainly in critical units – which is justified by the fact that Hecs was developed in Chicago and in hospital areas. The selection of these studies to assess the ethical climate in critical units may be due to the modus operandi of the work, which provides more specific and complex care that can generate more dilemmas and ethical conflicts to be resolved, requiring decision-making and moral deliberation ¹⁶.

In some of them, the ethical climate assessed by Hecs had an association/correlation with moral distress, turnover intention, and job satisfaction. Scientific evidence shows that a positive ethical climate is linked with a reduction of factors causing moral distress and stress in the work environment, turnover intention, and intention to leave the profession, as well as team strengthening and job satisfaction ^{10,12,13,21,25,32–34,37}.

Moral distress was the variable presenting more significant associations with ethical climate ^16,20,32, particularly related to the obstacle of shared decision-making among professionals ¹⁸. Insecurity of professionals regarding patient care and staff shortage to meet high-intensity demands causes suffering, resulting in an uncooperative environment and increasing the negative perception of the ethical climate ¹⁶.

In pediatric and neonatal units, for example, where professionals provide high-complexity care to children, situations favoring the development of moral distress are associated with the experience of witnessing the suffering of patients and family members ¹⁶. In this context, a balanced relationship among team members can improve work flow, relieving tension during care ²⁹.

In general, the ethical climate was assessed as moderate to positive ^{13,19,21,25,27,29,31,32,35,36}. However, questions that analyzed the relationship between nurses and physicians presented the lowest mean values ^13,21,24,26. The studies identified difficult interaction between these professional categories, possibly due to poor communication and discussion about diagnosis and treatment issues ³⁸. For being closer to patients, nursing professionals could provide important information for the treatment, but nurses are often excluded from the decision-making process ³⁸.

Relationship problems can be associated with different perceptions about what the ideal work environment should be. This is what studies conducted in oncology and critical care units suggest, which, when comparing perceptions of different professional categories, detected a more positive assessment of the ethical climate among physicians ^6,11. This may be related to the different responsibilities and competencies of each profession within every unit ^30,37. In this context, nurses would have a more critical view of the work process for being in health services for a longer period, seeking to understand conflict situations and deliberating about them with the team under their responsibility ³⁰.

Unlike the relationship between nurses and physicians, studies showed positive perceptions among peers, indicating a relationship of support and cooperation ^{13,19,21,25,27,29,31,35}. These relationships are associated with the practice of exercising leadership and listening among colleagues, which contribute to the necessary interaction to perform care activities in a homogeneous way ^8,25. Therefore, healthy relationships help to improve the decision-making process and to deal with dilemmas, in addition to providing more secure care to patients ^8,30. In this perspective, most studies showed positive ethical climate regarding “patients,” indicating a relationship of mutual respect ^{13,19,25,27,29,31,35}. When a professional respects the patient's autonomy in the treatment and insertion in care provision, the interaction improves with more trust in the relationships ³⁰.

However, the perception shared by professionals was negative for “hospital.” The lack of support and openness to questioning negatively influenced ethical issues ^{13,21,23,25,29,31,35}. Managers would have to assist in the development and maintenance of a healthy environment, promoting discussion with workers ²⁶. Then, they should lead the way and handle problems that affect institutions, adopting ethical standards to guide professionals on how to handle impasses ^23,31.

Hospital managers, a factor that in most studies received a positive evaluation, need to improve teamwork, investing in enhancements in the workplace and showing their willingness to improve the organizational climate and assistance ³⁹. The appreciation of professional categories supports work diversification and the creation of respectful relationships, which encourages team performance ³⁴.

Regarding the instrument analyses, the original Hecs validation study ¹ assessed the ethical climate using mean values, but without instrument normalization, considering that some studies used the sum of scores ^{9,10,16–18,26,33,36}. This situation can make analysis difficult due to the lack of standardization. However, a reduced Hecs was used in critical units in other countries ^6,11,30,37, which makes it an instrument that can be easily adapted to different locations.

Therefore, Hecs is valid and reliable for assessing the ethical climate in a hospital environment, since the instrument reliability was above 0.70 in the studies that used Cronbach's alpha calculation ^{1,3,5,7–12,18–20,22–24,27,31–33,35,37}. This score justifies the instrument application to all health professionals, not only nurses ^{1,3,5–13,16–37}, but also to physicians ^{6,11,17,30,37}, nursing assistants ^6,22,27,30, social workers ^10,17 and pharmacists ¹⁷.

Final considerations

In most studies, ethical climate was associated with issues related to workers’ health, such as moral distress, job satisfaction, and turnover intention. In addition, ethical climate classification based on Hecs was moderate to positive, with higher scores for “peers,” “patients” and “managers,” which were classified as positive, and lower scores for “physicians” and “hospital,” considered as negative.

In general, Hecs proved to be valid and reliable for ethical climate assessment. However, the instrument has to be adapted and validated to Brazil to evaluate the ethical climate in health services with different professional categories, allowing the development of studies on associations between ethical climate and other health issues of workers, such as burnout, stress, and moral harassment, considering intervention actions. From this perspective, efforts should be made to improve the ethical climate and the quality of healthcare, reducing psychological problems among health professionals.

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Publication Dates

• Publication in this collection
  20 Jan 2021
• Date of issue
  Oct-Dec 2020

History

• Received
  28 Sept 2019
• Reviewed
  07 Oct 2020
• Accepted
  08 Oct 2020