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

license education; thus, it may be associated with nurses’ perception of ethical climate. Grady posited access to continuing education as an indicator of the organization’s ethical climate and support for ethics [22]. Actions for promoting a positive ethical climate include providing sup- port for the continuing education on nursing ethics [12]. In the research regarding continuing education, Borhani et al. stated that the history of attendance to ethical workshops was related to a more positive evaluation of the ethical climate at the workplace [23], while other research- ers insisted that there was no statistical difference between HECS and receiving training related to ethics [11] or ethics workshops [17]. The study of the employees in the executive branch of the U.S. federal government has shown that ethics training had a consistently posi- tive influence on employee perception of ethical climate [25]. Moreover, in McDaniel’s inter- vention study of critical care, the ethical environment score of nurses who received the ethics educational program was higher than that of nurses who had not [26]. Although these earlier studies investigated the relationship of several factors with ethical cli- mate using the t-test, ANOVA, or single-liner model [11, 17, 24], adjusting for factors associ- ated with ethical climate may yield different results. Therefore, in this report, we would like to more strictly focus on the relationship between nursing ethics education and ethical climate using multiple regression analysis, then elucidate the detailed educational contents that might

influence nurses’ perception of ethical climate. In Japan, the main types of continuing educa- tion for registered nurses (RNs) and midwives are in-service training in the workplace and workshops/ academic conferences. We have, hence, focused on these types of ethics education. Methods Design, sample, and settings This study implemented a quantitative cross-sectional survey. The instrument used was a self- administered questionnaire. To the request for cooperation in the Kansai region, three teach- ing hospitals agreed to participate in this survey. These hospitals are teaching hospitals / aca- demic medical centers that are large, multi-unit, acute-care general hospitals. They are in charge of assisting in the training of undergraduate nursing students and newly graduated nurses. Since the main purpose of this study was to explore the relationship between ethics education and ethical climate, we selected these teaching hospitals where the nursing staff is considered to have a high interest in education. The questionnaires were delivered to the hospitals directly or through the mail, who then distributed them among the nurses who directly cared for patients. Upon completion, the questionnaires were collected by the researchers from the hospitals or mailed directly to the researcher by the nurses themselves. The survey was conducted from December 2019 to Janu- ary 2020, with a population of 2168 nurses working in 12 units at three teaching hospitals. While 2168 questionnaires were distributed, 770 responses were received, returning a rate of

35.5%. Out of the total responses, 165 having missing data for J-HECS26 were excluded from the analyses. The sample size was considered sufficient to meet 351 nurses, which is calculated by the Cochran formula [27]. Measurement tools Among the various scales of evaluation of ethical climate, the HECS is used most to measure the ethical climate of the nursing environment [5]. The HECS was developed by Olson [4] in the U.S. to measure how nurses perceive the ethical climate of their workplace through their perspective of relationships with peers, patients, managers, hospital, and physicians. It consists of 26 items and five subscales: peers (4 items), patients (4 items), managers (6 items), hospital (6 items), and physicians (6 items). The survey was designed in a Likert-type format with all PLOS ONE Ethical climate and ethics education PLOS ONE | https://doi.org/10.1371/journal.pone.0269034 July 21, 2022 3 / 15