In Polish settings, according to literature review, no research tool is available to assess the hospital ethical climate. The present study was conducted to examine selected psychometric properties of the Polish version of the Hospital Ethical Climate Survey, assess the hospital ethical climate as perceived by nurses and midwives working in Polish hospitals, and analyse correlations between this climate and different variables. The process of adaptation, validation and examination of the psychometric properties of the HECS-Pol provides the opportunity to fill in the gaps in the current body of knowledge about this area, opens the way for continuous, more precise and nation-wide research, and makes it possible to unify international debate on the topic as well as to align findings on the hospital ethical climate with potential improvement measures.
The two fundamental elements in the evaluation process of a measurement instrument are its reliability and validity . The results obtained in this study confirm that the Polish 21-item version (with items Q1, Q2, Q4, Q8, Q9 removed from the study) of the Hospital Ethical Climate Survey is a reliable and stable tool with acceptable psychometric properties. This is in addition to completely standardised loadings on the final factor structure across the entire HECS-Pol, which demonstrate a solid structure of the tool. For comparison, in a validation study by Khalesi et al. , factor loadings for all hospital ethical climate items ranged between 0.50 and 0.80.
Five questions that were included in the original version of the scale (Q1: My peers listen to my concerns about patient care; Q2: Patients know what to expect from their care; Q4: Hospital policies help me with difficult patient care issues/problems; Q8: A clear sense of the hospital’s mission is shared with nurses; Q9: Physicians ask nurses for their opinions about treatment decisions) had to be removed from the HECS-Pol, because they did not meet the psychometric criteria. This may be due to cultural differences, the work organisation system of nurses and midwives or the composition of the study group.
The overall internal consistency of the Polish version of the Hospital Ethical Climate Survey in terms of Cronbach’s alpha was high (0.93) and revealed good properties of the scale. Acceptable values of Cronbach’s alpha ranged from 0.70 to 0.95 (depending on the literature), yet the values preferred for the psychometric quality of the scales ranged from 0.80 to 0.95 [30,31,32,33]. Cronbach’s alphas in different validation studies of HECS varied between 0.86 in the Greek version  to 0.94 in the Persian version .
Hospital ethical climate as perceived by polish nurses and midwives
In our study, the overall hospital ethical climate was perceived by nurses and midwives as average (M = 3.62, SD = 0.60). Slightly better results were obtained in Finland in settings involving care of older adults (M = 3.85; SD = 0.56) , in Iran (M = 3.79, SD = 0.56) , and in the United States among nurses and social workers (M = 3.70; SD = 0.55) ; worse results were returned in Cyprus among registered cancer nurses (M = 3.53; SD = 0.61) . This suggests that, with respect to the hospital ethical climate as perceived by nurses and midwives, differences between countries may be determined by both working and cultural conditions, for example: nursing shortage, type of hospital word, systems of values, communication system in a nursing groups and organisation, leadership style.
In the present study, the highest mean score for the hospital ethical climate was found in the ”peers” subscale and the lowest in the ”physicians” subscale. This indicates that the surveyed nurses and midwives shared good relations mainly within their respective professional groups, rather than with physicians. Effective cooperation between nurses and midwives as well as mutual understanding and readiness to assist each other in difficult situations all contribute to a more positive hospital ethical climate. In contrast, problems with communication, lack of support, issues concerning respect for other people’s opinions, mutual trust, and involvement in the decision-making process while working with physicians worsened the perceived hospital ethical climate among nurses and midwives and the quality of health care . Similar results were reported by Suhonen et al.  and Teraz et al. . Our findings are similar to those in the study by Bartholdson et al. , where nurses felt that they did not have influence on medical decisions. What is more, health care professionals needed teamwork, respect, good communication, and reflection to effectively deal with ethical issues . Considering the fact that in our study the subscale “physicians” received the lowest score, cooperation with physicians is an area which demonstrates considerable room for improvement. Physicians and nurses do not cooperate and provide care separately from each other – this can affect the quality of their services as well as the hospital’s ethical climate .
Poikkeus et al.  noticed a need to support the ethical competencies of nurses. This is becoming highly important as our research has shown how important it is to support nursing staff in difficult ethical decisions. Furthermore, managers should develop organisational recommendations and policies, e.g. case studies or descriptions of ethical competencies, in order to promote debate on ethical issues and to support ethical competencies of midwives and nurses in their work with patients , this could help to create a more positive ethical climate in the hospital. Managers should reduce the impact of ethical dilemmas on nurses’ work by providing social support, developing and training managers’ ability to understand nurses’ and midwives’ needs, and learning how to communicate and solve said ethical dilemmas . The perception of the hospital ethical climate may be impacted by managers’ ethical competencies and their involvement in support to solve everyday ethical problems related to patient care. Literature review showed the importance of teamwork, workload balancing, and staff relations for a workplace culture which offers room for the development of person-centred relationships .
A positive correlation was found between respondents’ work experience and the subscale “patients”. This may be related to the multitude of ethical problems occurring in nurses’ and midwives’ work, where, with increasing seniority, they shape and develop their individual techniques of communicating with patients, making decisions or solving ethical problems.
Younger and less experienced nurses sustained higher levels of stress and more frequently reported and struggled with ethical issues in their work . Notwithstanding, no statistical difference was found between overall values of the hospital ethical climate perceived by nurses and midwives and their age, occupational status, religious beliefs, place of residence, gender, and education. Demographic variables such as gender, age, and education were not significantly correlated with the mean score of ethical climate in the study by Ghorbani et al. , just as age and marital status in the study by Karca et al. .
In our study, education correlated with the hospital ethical climate in subscales “peers”, “patients” and “managers”. A better perception of this climate was reported by participants with the Master’s degree or other educational background (doctoral degree, vocational education) as compared to those with the Bachelor’s degree. Similar results were obtained by Ghorbani et al. , where mean scores of ethical climate increased as the educational level grew. In contrast to our study, Constantina et al.  found that nurses with higher education reported poorer average perception of the hospital ethical climate across all dimensions. A certain educational level (resulting in broader knowledge and skills, or work in an interdisciplinary team) entailed higher expectations and needs in the unit where nurses and midwives worked. Also, the level of education and work experience significantly influenced the perception of the ethical climate in the work environment . In our study, nurses and midwives with the MA degree, during their university education had acquired knowledge and skills necessary to plan and organise nursing/midwifery work, which means that they can effectively contribute to the ethical climate in their work environment.
According to scientific evidence, job satisfaction is shaped by salary, working conditions, and personal development, and is related to ethical climate [9, 17]. Higher work satisfaction contributes to a more positive hospital ethical climate. This is in line with the present study, as the hospital ethical climate was correlated with work and salary satisfaction, and also with working time. As indicated by Abou Hashish , a positive ethical climate promotes nurses’ and midwives’ sense of determination and reduces the risk of occupational burnout, thereby improving the organisation of nursing work. What is more, with adequate support facilitated by ethical climate, nurses are more likely to provide high-quality care to patients, which in turn enhances their satisfaction with work, fewer errors occurring in nursing practice . There is a relationship between the hospital ethical climate and self-perceived competences, the intention to resign from work, and satisfaction with the performed tasks in terms of the quality of health care .
In the present study, correlation was found between the hospital ethical climate and problems in nurses and midwives’ work for example: lack of time for direct face-to-face care, moral dilemmas in relation to patient care, low salary, physical and mental burden. In this context, the level of hospital ethical climate is not a permanent feature. Rather, it is affected by all of the indicated aspects, in particular the involvement of hospital managers, their leadership skills and team-leading methods, relations with other health care professionals, and workplace culture – this is in line with other published studies [34, 42, 43]. This result suggests possible directions for improving the organisation of the health care system and reveals the need to create an ethical hospital climate with all its important elements as included in the Hospital Ethical Climate Survey (HECS).
There are several limitations to our study. First of all, they may result from the fact that the studied group represented only two (the eastern and southern) regions of Poland. Second, some of the surveys were collected early into the COVID-19 pandemic, which may have impacted on how the hospital ethical climate was perceived by nurses and midwives. Furthermore, our study was cross-sectional, which made it difficult to determine the cause and effect. An in-depth analysis is therefore needed, e.g. utilising a mixed-method approach where quantitative analysis is supplemented with qualitative one.