Interventions to promote an ethical climate: a scoping review

Abstract

This review aims to identify and describe interventions to promote an ethical climate in health institutions. Method: a scope review carried out on PubMed, Virtual Health Library, EBSCOhost, and Google Scholar from October to December 2022. Data were analyzed using numerical and thematic synthesis and included two quasi-experimental and one experimental studies. Physicians, nurses, and other team members participated in this review, which describes the carried out interventions and obtained results. The interventions included workshops, ethics rounds, and an early action protocol that lasted from two weeks to six months. This review found a difference in the ethical climate for all participants in one study, only for nurses in another study, and no significant differences in the last studies. Few studies implement and evaluate interventions to promote an ethical climate. More studies are needed to improve content, didactics, and assessment methods in different contexts with several professionals.

Keywords
Evaluation of the efficacy-effectiveness of interventions; Ethics, professional; Ethics, institutional; Organizational culture; Health services

Resumo

Esta revisão visa identificar e descrever intervenções realizadas para promover o clima ético em instituições de saúde. Foi feita revisão de escopo nas bases PubMed, Biblioteca Virtual em Saúde, EBSCOhost e Google Acadêmico, entre outubro e dezembro de 2022. Os dados foram analisados mediante síntese numérica e temática. Foram incluídos três estudos: dois quase-experimentais e um experimental. Médicos, enfermeiros e outros membros da equipe participaram da pesquisa. São descritas intervenções realizadas e resultados obtidos. As intervenções foram workshops, rodadas de ética e protocolo de ação precoce. A duração variou de duas semanas a seis meses. Houve diferença do clima ético para todos os participantes em um estudo; apenas para enfermeiros em outro; e não houve diferença em uma das pesquisas. Poucos artigos implementam e avaliam intervenções para promover o clima ético. Assim, são necessárias mais investigações que aprimorem conteúdo, didática e modos de avaliação em contextos variados e com diferentes profissionais.

Palavras-chave
Avaliação de eficácia-efetividade de intervenções; Ética profissional; Ética institucional; Clima ético hospitalar; Serviços de saúde

Resumen

Esta revisión busca identificar y describir intervenciones para promover un clima ético en instituciones sanitarias. Se realizó una revisión de alcance en las bases de datos PubMed, Biblioteca Virtual en Salud, EBSCOhost y Google Scholar entre octubre y diciembre de 2022. Los datos se analizaron mediante síntesis numérica y temática. Se incluyeron tres estudios: dos cuasiexperimentales y uno experimental. Los participantes fueron médicos, enfermeros y otros miembros del equipo. Se describen las intervenciones y los resultados obtenidos. Las intervenciones fueron talleres, rondas de ética y protocolo de acción temprana, con una duración de dos semanas a seis meses. Un estudio reveló diferencia en el clima ético para todos los participantes; otro para solo los enfermeros; y un estudio no reportó diferencia. Pocos estudios evalúan intervenciones en esta materia. Se necesitan más estudios para mejorar los contenidos, la didáctica y los métodos de evaluación en diferentes contextos con distintos profesionales.

Palabras clave
Evaluación de eficacia-efectividad de las intervenciones; Ética profesional; Ética institucional; Clima ético hospitalario; Servicios de salud

Victor and Cullen ¹ define ethical climate as a set of perceptions that shape ethical behavior within an organization. In the health sector, the work environment to which professionals are exposed is characterized by numerous ethical challenges, such as controlling the emotional involvement that each situation requires, the need to manage financial and, mainly, human resources, which creates an overload of work, in addition to interpersonal relationships between professionals themselves, with patients and families, which can cause conflicts ². In this sense, a work environment that is welcoming, safe, and based on professional ethics makes these challenges easier to resolve. Given this context, the organizational ethical climate constitutes a way of understanding how these ethical issues are handled by the institution and the workers in question, directly reflecting on the work environment and the quality of care ³.

An unfavorable ethical climate can make the workplace hostile and cause psychological suffering for those involved. On the other hand, a favorable ethical climate can reduce moral suffering and the possibility of burnout, in addition to providing work practices based on ethics and promoting the humanization of care ³. Therefore, it is essential to identify the factors that positively or negatively influence the ethical climate to understand how the functioning of work relationships is directly or indirectly linked to worker health.

While many studies conclude their findings by stating that the ethical climate must be promoted in health institutions, interventions are more difficult to find in the literature and lack systematization and evidence regarding their effectiveness ⁴. Thus, this article aimed to identify and describe interventions to promote the ethical climate in healthcare institutions.

Method

This is a scoping review, which consists of a systematized and exploratory study to identify relevant scientific production in a given area of knowledge, guided by the assumptions of the Joanna Briggs Institute (JBI) – Methodology for JBI Scoping Review ⁵. The review comprised the following phases: definition and alignment of objectives and research questions; development of inclusion criteria according to the objectives and questions; elaboration and planning of the search and selection strategy for studies; identification of relevant texts; selection of studies; data extraction; data mapping; and summarization of results.

The studies included in this scoping review were listed using the PCC acronym: P=population: health institutions; C=concept: interventions and their results; and C=context: ethical climate. Thus, the guiding question for this review was: What interventions were carried out to promote the ethical climate in health institutions, and what were their results?

The studies were selected from different portals and databases: the Medical Literature Analysis and Retrieval System Online (MEDLINE) was accessed via PubMed. In contrast, the Latin American and Caribbean Health Sciences Literature (LILACS) and the Spanish Bibliographic Index of Health Sciences (IBECS) were accessed through the Virtual Health Library (VHL). Furthermore, the EBSCOHost platform and the Google Scholar tool were used.

The inclusion criteria were original articles published in English, Portuguese, and Spanish describing interventions carried out to promote the ethical climate in health institutions and/or services. No time limit was defined, and the aim was to include as many studies as possible. Theoretical research and literature reviews were excluded.

The research team defined a search strategy, considering the Health Sciences Descriptors (DeCS) and/or Medical Subject Headings (MeSH) selected and maintaining the Boolean operator “and” respecting the peculiarities and characteristics of each database. The Health Sciences Descriptors in English were “ethical climate and health and interventions” (Chart 1). In Google Scholar, the same search strategy was used. Two independent researchers performed the searches simultaneously between October and December 2022.

Chart 1
Search descriptors (Porto Alegre/RS, 2022)

English	Portuguese	Spanish
((“Ethics”) or (“ethical climate”)) and (“educational activities”)	((“Ética”) or (“clima ético”)) and (“atividades educacionais”)	((“Ética”) or (“clima ético”)) and (“actividades educativas”)
(“ethical climate”) and (interventions)	((“clima ético”)) and (“intervenções”)	((“clima ético”) and (intervenciones)
((“Ethics”) or (“ethical climate”)) and (“educational activities”) and (“healthcare professionals”)	((“Ética”) or (“clima ético”)) and (“atividades educacionais”) and (“profissionais de saúde”)	((“Ética”) or (“clima ético”)) and (“actividades educativas”) and (“profesionales de la salud”)

The PRISMA Extension for Scoping Reviews (PRISMA ScR) ⁶ methodology was chosen to systematize the study inclusion process. The texts were pre-selected in three consecutive stages: 1) reading the title, 2) reading the summary, and 3) reading the article in full, according to the flowchart shown in Figure 1.

Figure 1
Flowchart of the study selection process according to PRISMA recommendations (Porto Alegre/RS, 2022)

Two reviewers evaluated the full versions of the selected texts, considering the inclusion and exclusion criteria, which resulted in the final study sample. At each stage, the reviewers reached a consensus through discussion. The studies that comprise the analysis corpus present qualifying, training, or intervention strategies to promote the organizational ethical climate, evaluating their results.

The researchers created a data extraction form to record the characteristics of the included studies and the primary information for the research, containing the following sections: author, year of publication, country, journal, method, participants, intervention carried out, and results. The results were compiled and communicated in data analysis to present an overview of all the material. These results are presented through a numerical and thematic description ⁵. The numerical description presented the characteristics of the included studies, such as author, year of publication, country, journal, participants, and approaches adopted. The thematic description was organized according to the description of the interventions and their results.

The fidelity and veracity of the information in the original articles supporting the review were guaranteed through rigorous research methodology, referencing, processing, and presentation of data.

Results

After the article screening process, three were included in the scoping review: two quasi-experimental studies and one experimental study. Two were published in 2021, and the other in 2015. The countries of publication were Iran, the United States, and Sweden. Two studies involved the entire healthcare team, and the other was conducted only with nurses. The Hospital Ethical Climate Survey (HECS) ⁷ was used to evaluate the effects of interventions in two of the selected studies, and the Ethical Climate Questionnaire ⁸ was used in one of the studies. The interventions varied in nomenclature, format, and duration, but all involved discussions of ethical issues (Table 2).

Table 2
Characterization of articles according to author, year of publication, country, journal, method, participants, and type of intervention carried out (Porto Alegre/RS, 2023)

Author/Year	Title	Country	Journal	Method	Participants	Intervention
Silén, Haglund, Hansson, Ramklint; 2015 9	“Ethics rounds do not improve the handling of ethical issues by psychiatric staff”	Sweden	Nordic Journal of Psychiatry	Quasi-experimental study. Hospital Ethical Climate Survey	55 healthcare professionals from four psychiatric outpatient clinics participated	Six rounds of ethics, lasting one hour, using an imaginative approach, discussing a clinical situation, with the inclusion of ethical issues
Maghsoudi, Mohsenpour, Hamed; 2021 10	“Comparison of ethical decision-making and interpersonal communication skills training effects on nurses’ ethical climate”	Iran	Clinical Ethics	Experimental study. Ethical Climate Questionnaire	Nurses working in the wards of general university hospitals participated in the research (n=90)	Two six-hour workshops for training in ethical decision-making and interpersonal communication skills
Pavlish and collaborators; 2021 11	“An ethics early action protocol to promote teamwork and ethics efficacy”	United States	Dimensions of Critical Care Nursing	Quasi-experimental study. Hospital Ethical Climate Survey	182 professionals participated, including 149 nurses and 32 physicians from six intensive care units (ICU) located in three academic medical centers	An early action protocol in ethics was presented to professionals online and individually, lasting 15 minutes, to later apply it in a daily care process existing in the ICU

The interventions and results obtained are presented for thematic analysis. Each category is described in detail below.

Interventions carried out

The intervention carried out by Maghsoudi, Mohsenpour and Nazif ¹⁰ was experimental. The participants were nurses working in wards of general university hospitals and were randomly divided into three groups: intervention 1 (clinical ward), intervention 2 (surgical, orthopedic and dermatological wards) and control group (urological and cardiac wards). All participants in the three groups completed the Ethical Climate Questionnaire ⁸ at the beginning of the study and at the end of the fourth week. The questionnaire consists of 26 items, divided into six subscales: caring, rule-based, professional, instrumental, productive, and independent climates. It is scored using a five-point Likert scale, where the higher the final score, the better the ethical climate.

The intervention consisted of two six-hour workshops over two consecutive weeks (12 hours). Each workshop’s content differed for each intervention group: while group 1 received training on ethical decision-making skills, group 2 received training on interpersonal communication skills. The didactics used were the same: lectures, question-and-answer methods, group discussion, and work in various scenarios. Those responsible for carrying out the workshops were the researchers themselves ⁹.

The intervention carried out by Pavlish and collaborators ¹¹ was quasi-experimental. Participants were physicians and nurses from six intensive care units (ICU) at three academic medical centers. After three and six months of intervention, participants were compared by completing HECS ⁷. The scale comprises 26 items, divided into five subscales: peers, patients, managers, hospitals, and physicians. It is scored using a five-point Likert scale, with 3.5 or more considered the cutoff point for determining a good organizational ethical climate.

The intervention is an early ethical action protocol that consists of discussing risk factors, determining the level of risk of an ethical conflict occurring, and initiating an action plan. This must happen with the daily ICU routine when bedside rounds are performed. To do this, all participants had to access an online guidance module lasting 15 minutes individually before the start of the study. Researchers frequently visited study sites to ensure the protocol was being applied and to provide support ¹⁰.

The intervention carried out by Silén and collaborators ¹² was quasi-experimental. The participants were healthcare professionals (administrators, nursing assistants, occupational therapists, psychologists, doctors, nurses, and social workers) from four comparable psychiatric outpatient clinics, considering the group of patients served and the size of the team (at least ten healthcare professionals of each outpatient clinic should participate in the intervention). The outpatient clinics were randomly divided into two groups: two in the intervention group and two in the control group. All participants completed the HECS ⁷ at the beginning of the study, halfway through (intervention group only), and two months after the last intervention. In this case, the scale was adapted: the “hospital” dimension was renamed to “organization,” and the “physician” dimension was renamed to “team.” This scale was initially developed to be used with nurses, which is why these two subscales were adapted for use with other professionals on the team. It followed the same scoring proposal described in the study mentioned above.

The intervention consisted of six months of ethical discussion rounds, lasting one hour each, with one round being held each month, totaling six rounds. The discussions were led by an ethicist philosopher, using the imaginative ethics approach. This type of didactics promotes listening and sharing participants’ experiences about a clinical situation with ethical issues. The aim is for them to be able to imagine moral experiences and values, challenge established ethical models, and express their opinions. In this approach, the moderator does not tell participants the morally appropriate solution but acts as a discussion facilitator. This guidance was given to the participants, and they chose which patient or topic would be discussed in each round ¹¹.

Results obtained

Maghsoudi, Mohsenpour and Nazif ¹⁰ show that participants in the three groups (intervention 1, intervention 2, and control) were comparable regarding demographic and contextual variables. No independent or interaction effect of demographic variables on changes in ethical work climate was found. The study participants were primarily married women with 40 years as the mean age and mean length of professional experience at the study site of 3.4 years.

The mean ethical climate was not different between the intervention and control groups at the beginning of the research. Significant results after the intervention were found: the groups in which the intervention was carried out obtained higher ethical climate scores at the end of the training when compared with the control group (p<0.001). Furthermore, there was a difference in the mean ethical climate between the intervention groups. Those who received training on ethical decision-making skills (intervention 1) had higher ethical climate means when compared with those who received training on interpersonal communication skills (intervention 2) (p<0.001) ⁹.

Pavlish and collaborators ¹¹ show that demographic and contextual characteristics differed between physicians and nurses: nurses were more likely to be women, Catholic, and with more years of experience. However, the perception of ethical climate did not differ between physicians and nurses before the intervention (p=0.070). After the intervention, the total mean ethical climate did not differ. However, when carrying out analyses separately, the nurses showed statistically significant changes; there was an increase in the mean ethical climate in the three months (p=0.001) and six months (p<0.001). Meanwhile, the analysis of physicians’ data failed to show any changes.

The results obtained by Silén and collaborators ¹² show no significant differences in demographic and contextual variables between the intervention and control groups. The participants were primarily women, with an mean age of 53 years and 6.5 years of work experience in outpatient clinics.

The mean ethical climate was different between the intervention and control groups at the beginning of the study, and this remained the same until the end, without significant changes. Thus, the authors concluded that ethical rounds in psychiatric outpatient clinics did not significantly change the ethical climate. The only statistically significant difference between the intervention group and the control group at the end of the research was in the “manager” dimension, in which the intervention group scored higher (p=0.006). Furthermore, considering the intragroup comparison measured halfway through the study in clinics in the intervention group, one of the clinics improved its score in the “patients” dimension (p=0.039), and the other improved its score in the “manager” dimension (p=0.026) ¹¹.

Discussion

The ethical climate has been increasingly studied in the healthcare area. This fact may be related to the evidence that a good ethical climate can reduce the occurrence of moral distress ¹²-¹⁶, burnout ³,¹⁷, errors ¹⁸ e and intention to quit the job ¹⁸,¹⁹, while it can increase the perception of satisfaction ¹⁹-²² and work-related quality of life ¹⁷,²³-²⁵.

Almost no studies present interventions and describe the results obtained after carrying them out. There is a gap related to this phenomenon, in which a synthesis, even of just a few existing studies and their results, can help researchers implement interventions in more significant numbers and, mainly, with greater potential for effectiveness.

Finding studies that implement and evaluate interventions for other phenomena is possible in the broader spectrum of ethics. For example, a study to promote ethical competence ²⁶, moral reasoning ²⁷, and reduce moral suffering ²⁸. Its results are satisfactory, supporting the idea that interventions to promote a positive ethical climate can be feasible and should be encouraged.

The interventions analyzed differed in content, didactics, participants, duration, evaluation form, and results. The study with the best results carried out workshops (lectures, question and answer methods, group discussion, and work in various scenarios) for 12 hours, and the most significant effectiveness was related to the theme of ethical decision-making ⁹. However, it is essential to consider that this study used the Ethical Climate Questionnaire ⁸ to evaluate its results. The questionnaire was designed to explore participants’ perceptions of how members of an organization typically make decisions about various events, practices, and procedures that require ethical criteria. The other two studies used HECS ⁷, which assesses how nurses and other professionals perceive their work environment. In other words, these are different evaluative contents about the ethical climate, which must be considered when interventions are designed, implemented, and evaluated.

Pavlish and collaborators ¹¹ also conducted a study with significant results, which implemented an early action protocol in ethics for ICU physicians and nurses. However, only nurses significantly improved in terms of the ethical climate, and there was no difference for physicians. This led to questioning why the intervention was not representative of this group and suggested the possibility of conducting a comparative study between the categories. As for Silén and collaborators ¹², the study used the strategy of ethical discussion rounds and was conducted with several professionals from the healthcare team. The study did not demonstrate significant results for any group, suggesting questions about the intervention type and its effectiveness. Both used HECS to evaluate their findings. It is necessary to reflect that the HECS is a scale initially developed with and for nurses in a hospital context ⁷, which may raise questions about the effectiveness of its use for other professionals and contexts. Regarding this aspect, previous studies have demonstrated evidence of the validity of the HECS for these situations ²⁹,³⁰. It is also necessary to consider that quantitative measures may not be the most appropriate for analyzing ethical phenomena such as climate ¹¹.

It is also essential to reflect on the content of the interventions and the differences in perception of the ethical climate among different professionals. Regarding didactics, although rounds are widely used as an intervention strategy ¹¹, a previous study also failed to demonstrate their effectiveness in significantly changing practice contexts ³¹, even demonstrating that rounds possibly made the team more reflective, promoting cooperation ¹¹. The proposal for the early action protocol in ethics ¹⁰ incorporated reflection into clinical practice, encouraging professionals to think about an ethical issue related to one of their patients and to intervene in this scenario. This intervention was systematized and validated by the authors before being used. On the other hand, the rounds followed a more open proposal, including themes chosen by the participants throughout the meetings.

The intervention must include all professionals involved in care to promote teamwork, which is one of the fundamental bases of a good ethical climate ³⁰. However, different values are deemed more important for different professions since professionals have different responsibilities and work routines.

Other factors may be related to the results of the studies analyzed, such as the fact that voluntary participation does not control bias and that possible confounding factors may not have been collected and/or analyzed. In any case, training carried out in the workplace, in a participatory and/or interactive way and addressing real needs, promotes awareness on the topic, contributes to better results, reduces stress, and improves the climate ³².

The findings suggest that increasing the probability of interventions’ effectiveness requires listening to professionals, recognizing situations that produce suffering, and understanding the context in which moral problems develop ³³. Therefore, it is essential to encourage educational institutions and health services, including professionals, to implement interventions that promote an ethical climate, resulting, among other aspects, in greater professional satisfaction ³⁴.

Final considerations

The study highlighted the growing relevance of the ethical climate in health institutions. Attention is drawn to the few studies that implement and evaluate interventions to promote an ethical climate and the absence of Brazilian articles on the topic.

The interventions varied in content, didactics, participants, duration, evaluation form, and results. Systematized interventions based on participatory methodologies and carried out with nurses seem more compelling. However, in each case, it is necessary to evaluate the context of the application and who the participants will be to choose the most appropriate intervention and define the best tool or evaluation method.

More studies are needed, implementing interventions, improving the content, didactics, and assessment methods in varied contexts, and including different professionals. This corpus of knowledge is essential to promote more positive ethical climates in health institutions.

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Publication Dates

• Publication in this collection
  14 June 2024
• Date of issue
  2024

History

• Received
  11 Apr 2023
• Reviewed
  02 Feb 2024
• Accepted
  26 Feb 2024