The relationship between hospital ethical climate and continuing education in nursing ethics

Concerning gender, similar to our findings, Ozden et al. reported a significant difference between the gender of nurses and ethical climate perceptions, claiming that their result reflected the general situation of the majority of participants in the survey being female, as Turkish nurses were predominantly female [11]. In our study, 92% of the participants were female, which is similar to the overall proportion of nurses in Japan [38]. There are several reports that male nurses feel more difficulty with working in a female-centered workplace as compared to female nurses in terms of interacting with female patients and female nurses and anxiety regarding their future career development [39]. Therefore, male nurses might recog- nize their perception of ethical climate more negatively than female nurses. Further, the t-test results showed that there was no significant statistical difference between the perception of the ethical climate of manager nurses and staff nurses. However, adjusting for variables such as years of experience and gender, managers have significantly higher per- ceptions of ethical climate. In previous literature, Hwang and Park reported that manager nurses perceive ethical climate more positively than staff nurses [12]. Our study is in accor- dance with their study, demonstrating a similar result even after adjusting for years of experi- ence. These studies, including ours, indicate that the managers might generally commit to the ethical procedures and policies of the organization and collaborate with doctors and colleagues on ethical issues.

Regarding the hospital and specialty of the unit, previous studies suggested that the staff in different hospitals had different perceptions of the ethical climate [11, 12, 15]. Ozden et al.’s study [11], which was conducted in a university-attached hospital and an education and research hospital, similar to our study, reported a significant difference in the ethical climate among hospitals. Our study supports their report. On the other hand, a review of the related studies presents conflicting results regarding the relationships between the unit and nurses’ perceptions of ethical climate. Hwang and Park [12] argued that the HECS scores were not related to the specialties of the units, while Ozden et al. [11] and Lemmenes et al. [40] confirmed that they were indeed related to this variable. This inconsistency might be relevant to the differences between the researched hospitals. Our results showed that the ethical climate differs among the units; in particular, nurses in the operating room showed significantly lower mean scores of J-HECS26. Rosenstein and O’Dan- iel noted that the operating room is physically small, there is a strong interdependence on effective team functioning, and working in this unit is highly stressful [41]. According to Sonoda, Onozuka, and Hagihara, operating room nurses have also been reported to be men- tally stressed not only by doctors but also by colleagues [42]. Circulating nurses in the opera- tion room may feel frustrated by the scrub nurses [42], presumably leading to a negative

perception of the workplace. The low mean score of nurses in the operating room in our study might reflect a negative relationship with these colleagues in the operation room or at the workplace. Continuing education Other than the aforementioned demographic characteristics, we found that ethics education may have influenced the nurses’ perception of the ethical climate. This study showed that nurses who had attended in-service training at the workplace perceived their ethical climate positively; however, the nurses who had participated in the workshops/ academic conferences found their hospital ethical climate to be negative, which differed from our expectations. This result was verified through multiple regression analysis and analysis of covariance. Previous studies showed conflicting results regarding the effect of ethics education on the HECS scores. While some studies showed no relationship between ethical climate and PLOS ONE Ethical climate and ethics education PLOS ONE | https://doi.org/10.1371/journal.pone.0269034 July 21, 2022 10 / 15