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

attendance of ethical workshop/ training [11, 17], Borhani et al. reported a positive effect of education on ethical climate, indicating that the nurses who participated in an ethics workshop perceived their ethical climate as more positive [23]. These differences might depend on the style of education or programs. Previous literature pointed out that interactive workshops, rather than uni-directional lectures, enlighten nurses more [43]. An ethical climate represents “shared perceptions” of organizational practices related to ethical decision-making [3]. In-ser- vice training in the workplace gives nurses a consistent awareness of the ethics practiced in the particular hospital where they are employed. As a result, nurses who attend in-service training may be more positive about the ethical climate of their workplace than those who did not. On the other hand, nurses who participated in off-the-job workshops/ academic confer- ences perceive their climate more negatively than those who did not participate. At workshops/ academic conferences, nurses acquire the most advanced ethical knowledge, values, and per- ception. However, it is unclear whether this knowledge will be properly utilized in the nursing practice of their workplace. In fact, one study shows that off-the-job training may not directly apply to the workplace of nurses [44]. Therefore, what they have learned there may not have been relevant to their practical situation; thus, they may not have been able to apply what they

have learned or share it with their colleagues. These frustrations might explain the negative relationship between ethical climate and the out-of-hospital ethical training found in this study. Therefore, what they have learned at off-the-job workshops/ conferences should be reviewed and incorporated into their workplace with caution to ensure that their acquired knowledge finds more use in practice. Additionally, having education outside the hospital is not enough to enhance the work- place’s ethical climate. Ethical climate is nurses’ shared perception. Even if a nurse adapts the latest knowledge at an academic conference or out-of-hospital educational opportunities, it may be difficult to put it into practice if it is not properly shared with colleagues. On the con- trary, the same knowledge is shared by the nurses of the same hospital at in-hospital training, which can transform the acquired knowledge into practical use. Ulrich also states that receiv- ing ethical education alone may leave nurses dissatisfied unless it is properly practiced in the workplace [45]. This supports our result that in-hospital training is more related to the positive ethical climate. Moreover, the motivation for nurses to receive continuing professional education is to improve knowledge, patient care delivery, and professional relationships [46]. There is a possi- bility that the nurses who had attended the out-of-hospital education had negative feelings about their current workplace, involving concerns related to ethical issues and seeking solu-

tions. Accordingly, the nurses who had attended the out-of-hospital ethical education might have a negative perception of the ethical climate of their workplace in this study. Resolving the frustrations and concerns of these nurses may lead to reducing their moral distress and pre- venting their intention to leave the organization. Simultaneously, the HECS may be useful in identifying the nurses who need support from the workplace to make the best of their eagerness to improve the ethical atmosphere. In summary, our study has new implications for the importance of the provision of ethics education and clarifies that offering in-service ethical training that meets the actual needs of their workplace may provide nurses a shared perception of ethical climate. Our result demon- strates that not only individual efforts but also organizational efforts are essential for improv- ing the ethical climate of a workplace. Further research should elucidate the kind of education and organizational support that is effective in enhancing the ethical climate. PLOS ONE Ethical climate and ethics education PLOS ONE | https://doi.org/10.1371/journal.pone.0269034 July 21, 2022 11 / 15