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

demographic variables of gender, marital status, education degree, hospital, unit (surgery, internal medicine, mixed surgery/internal medicine, psychiatry, obstetric, pediatrics, operating room, emergency department, stroke care unit (SCU), intensive care unit (ICU)/ coronary care unit (CCU), neonatal intensive care unit (NICU)), license (Midwife, Advanced licensed nurse), job position, and continuing education were evaluated using t-test, one-way analysis of variance (ANOVA), and Kruskal-Wallis test. Multivariate linear regression models were devel- oped to analyze the relationship between the J-HECS26 and the independent variables: demo- graphic variables and continuing education. Model 1 included the years of experience (continues), gender, job position, license (dummy variable), hospital (dummy variable), and 11 units (dummy variable). Model 2 included all the variables in Model 1, along with in-service training on ethics in the workplace. Model 3 included Model 2 variables plus workshops/ aca- demic conferences on nursing ethics. The means of J-HECS26 score were compared between the data for nurses who have attended and those who did not attend in-service training in the workplace on ethics, and workshops/ academic conferences on nursing ethics, using analysis of covariance adjusted for year of experience (continues), gender, job position, license (dummy variable), hospital (dummy variable), and 11 units (dummy variable). The level of sig- nificance chosen for this study was .05. Results Demographics

The demographic data are shown in Table 1. Of the total 605 nurses, 561 (92.7%) who answered the questionnaire were females and 44 were males (7.3%) with a mean age of 31.4 ± 8.3 years. The mean number of years of their experience was 9.3 ± 8.0. Among the sam- ple population, 167 (27.7%) had a nursing diploma, 369 (61.0%) had a bachelor’s degree, and 20 (3.3%) had a master’s / doctoral degree, while 48 (7.9%) were junior college graduates. Con- cerning ethics educational opportunities, 430 (71.1%) nurses had ethics education, while 175 (28.9%) nurses did not. Regarding the type pf education, 393 (65.0%) nurses attended in-ser- vice training at the workplace and 122 (20.2%) attended workshops/ academic conferences (Table 1). Nurses’ level of ethical climate The mean score of J-HECS26 was 94.8 ± 14.8. The mean scores for the five sub-scales of the HECS, namely, managers, hospital, physicians, peers, and patients were 22.5 ± 5.9, 21.0 ± 3.6, 19.8 ± 4.2, 16.3 ± 2.5, and 15.2 ± 2.0, respectively (Table 2). Demographic variables and J-HECS26 An independent sample correlation, t-test, and ANOVA were conducted to examine whether there is any relationship between J-HECS26 and the demographic variables. There was a weak negative correlation between J-HECS26 and age (r = -0.130, p = 0.002), years of experience (r = -0.136, p = 0.001). In the results of the t-test, one-way ANOVA, and Kruskal-Wallis test, a significant difference was found between J-HECS26 and demographic variables of the hospital

(p = 0.001) and units (p < 0.001); notably, the score of nurses working in operating rooms was the lowest (p < 0.001) (Table 3). Female nurses scored higher than males (p = 0.042) and the nurses who have had ethics education got a higher score than those who have not had any (p = 0.035). Regarding continuing education, nurses who have attended in-service training at the workplace scored higher in J-HECS26 than non-participants (p < 0.001). Further, the nurses who had attended workshops/ academic conferences on nursing ethics scored lower PLOS ONE Ethical climate and ethics education PLOS ONE | https://doi.org/10.1371/journal.pone.0269034 July 21, 2022 5 / 15