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

items being positive and answers rated from 1 (almost never true) to 5 (almost always true). The HECS has been examined for validity and reliability and is widely used in various coun- tries [12, 13, 16, 28–31]. In Olson’s study [4], the total value of Cronbach’s alpha coefficient was found to be 0.91 and the values of the five subscales were as follows: peers– 0.73, patients– 0.68, managers– 0.81, hospital– 0.92, and physicians– 0.77. To focus on the ethical atmosphere in hospitals, we chose HECS to measure nurses’ perceptions of ethical climate. In Japan, there are two types of translations of HECS, namely, J-HECS26 and J-HECS. The former, which we translated into Japanese, consists of all the 26 items in the original version, while the latter con- sists of 18 items, whose reliability and validity were confirmed in the study targeting the medium-sized hospitals with 180–500 beds [32]. The reliability and validity of J-HECS26 were verified in the study conducted in large teaching hospitals with 600–1100 beds [33]. The Cron- bach’s alpha coefficient of J-HECS26 in this study was 0.94 and their subscale are 0.67–0.95, which are equivalent to the original HECS in the previous literature [33]. Sociodemographic characteristics The questionnaire in the current study also encompassed the following demographic variables: age, gender, years of experience, marital status, education degree, the hospital nurses work at, license, position, the specialty of the unit they belong to, the experience of ethics education,

and the opportunity of attending ethical training in and out of the hospitals (in-service training in the workplace, workshops / academic conferences on nursing ethics). Regarding ethics education In this research, we divided ethical education into two types; in-service training and the work- shops/ academic conference. The in-service training on ethics in the workplace includes the ethics training sponsored by the hospital’s Nursing Department and the study session on ethics held in the hospital ward. This type of training is intended to meet the actual needs of the workplace. The workshops/ academic conferences are held several times a year or annually by the nurses’ associations or organizations. In the workshops/ academic conferences, researchers give research presentations or attend lectures on advanced studies for carrier development and continuous education. They are often held for academic purposes and the topics are usually general ethical problems. Ethical consideration Ethical approval was obtained from the Research Ethics Committee of the Kyoto University (R0850). Each questionnaire had a cover letter explaining the purpose of the research. The identity of the participants was kept anonymous, and the return of the completed question- naires was considered as evidence of informed consent for participation in the study. Each questionnaire was assigned a code number that helped mask the individual identities, and the responses from the nurses were kept confidential. Statistical analysis

To ensure the collection and analysis of data without compromising confidentiality, each ques- tionnaire was treated anonymously, and each participant was indicated by a code number. The sample data were analyzed using the SPSS 24.0 J software for Windows (IBM Corporation). The mean and standard deviation for age and years of experience, and J-HECS26 and sub- scale items were calculated. As for the correlation between ethical climate and age, years of experience, a Pearson correlation was calculated. The means of J-HECS26 total score for the PLOS ONE Ethical climate and ethics education PLOS ONE | https://doi.org/10.1371/journal.pone.0269034 July 21, 2022 4 / 15