الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
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SUMMARY
In order to survive and gain a competitive advantage in this fast-changing environment,
health care organizations should pay much more attention to their work climate. Ethical issues
and conflicts are common place in today’s healthcare environment, so the EWC supports nurses
in dealing with the day-to-day ethical questions and problems within health organizations. Nurses
suffered from moral stress because of their professional status, role and deal with their daily
activities. Even though the main cause of MD is related to work climate. EWC had an influence
on staff nurses as: coping with MD, enhancing job satisfaction, and improving job performance.
Therefore, measuring the EWC and MD is important for all staff of health care organizations,
especially staff nurses, where their job performance is affected by them.
Aim of the study:
Identify the relationship between staff nurses’ perception of ethical work climate and moral
distress in Kafr Al-Dawar General Hospital.
Study design:
A descriptive correlation research design was used in this study.
Setting of the study:
This study was conducted at Kafr Al-Dawar General Hospital, in all inpatient care units
(N=12) and intensive care units (N=8) with bed capacity 310 beds, namely: surgical units
(surgical specialty A- B- and vascular surgery, orthopedic specialty), medical units (medical
specialty, cardiac specialty, liver disease and hematemesis specialty, psychological and nervous
specialty, urology specialty, ENT specialty, burn unit, poisoning unit, hemodialysis unit,
neurological care unit, cardiac care unit), pediatric and obstetric units (pediatric specialty,
obstetric specialty, preeclampsia unit, neonatal care unit “NICU”, and pediatric care unit
“PICU”), and critical care units (general intensive care, burn intensive care unit).
Subjects of the study:
The study was conducted at all staff nurses, who were available at the time of data collection,
in the previously mentioned settings (N=289), with at least one year of experience to have
knowledge and experience to answer the questions. They were distributed as the following:
surgical units (n=38 nurses), medical units (n=119 nurses), pediatric and obstetric units (n=91
nurses), and critical care units (n=41 nurses).
Tools of the study
The study utilized two tools for data collection:
Tool I: Hospital Ethical Climate Survey (HECS):
This tool is composed of two parts:
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Part (1): Demographic characteristics data sheet:
A demographic data sheet of study participants includes questions about age, gender,
educational qualifications, working unit, nursing experience, unit experience, and marital status.
(Appendix I)
Part (2): Hospital ethical climate survey:
This survey was developed by Olson (1998)(56), and validated by Olson et al. (2015)(8) to
measure perception of ethical work climate and it contains 26 items divided into five dimensions:
1) peers (4 items), 2) patients (4 items), 3) managers (6 items), 4) hospitals (6 items), and 5)
physicians (6 items). Responses were measured using a 5-point Likert scale ranging from (1)
almost never true to (5) almost always true. 75% and more indicates presence of EWC.
(Appendix II)
Tool II: Moral Distress Scale (MDS):
This scale was developed by Corley (1995)(110), and was used by Heck (2016)(62) to measure
staff nurses’ moral distress. It includes 38 items which are classified into six main categories: 1)
physician practice (12 items), 2) nursing practice (9 items), 3) institutional factors (4 items), 4)
futile care (7 items), 5) deception (3 items), and 6) euthanasia (3 items). Responses were
measured on a 5-point Likert rating scale ranging from (1) none to (5) great extent. 75% or more
indicates high MD level. (Appendix III)
Methods:
1. An official written permission was obtained from the Dean of Faculty of Nursing,
Damanhour University, and the responsible authorities of the study settings after an
explanation of the purpose of the study.
2. The two tools were translated into Arabic, and were tested for their content validity by
five experts in the field of the study and accordingly, the necessary modifications
were done. (Appendix V)
3. The reliability of the two tools was tested statistically using Cronbach’s Alpha
Coefficient test to measure the internal consistency of the items composing each
dimension of the tools. The result of Cronbach’s Alpha Coefficient test proved to be
strongly reliable for EWC 0.914, and 0.917 for MD.
4. A pilot study was carried out on 10% of the total sample size of staff nurses (n=28),
who were not included in the staff nurses in order to check and ensure the clarity and
feasibility of the tools and to identify obstacles and problems that may be encountered
during data collection and the necessary modifications were done.
5. Data was collected from the identified staff nurses, by the researcher through a hand-
delivered questionnaire at their working setting after explaining the aim of the study.
The data collection took about two months from 1/9 /2019 to 30/10/2019.
6. Data obtained was analyzed using the appropriate statistical tests.
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The main results of the present study were as follows:
1. There is a statistical significant relationship among total EWC and total MD.
2. The rank of EWC dimensions based on its percentage score, peers came in the first
rank, followed by patients, managers, hospitals, and finally physicians. Also, the
majority of the staff nurses perceived work climate as unethical.
3. Regarding MD categories, euthanasia comes in the first level followed by,
institutional factors, deception, nursing practices, futile care, and finally physician
practices. Also, the majority of staff nurses had high MD.
4. There is a highly statistically significant relationship between total EWC and all its
dimensions.
5. There is a highly statistically significant relationship between total MD and all its
categories.
6. There is a statistically significant relationship between all EWC dimensions except
patient and total MD.
7. There is a statistically significant relationship between all MD categories and total
EWC.
8. There were no statistically significant relationship between all demographic
characteristics and EWC.
9. There were no statistically significant relationship between all demographic
characteristics and MD.
In the light of the results of the current study, the following recommendations can be
suggested:
Hospital managers and nurse managers should:
1. Present continuous professional strategies and interventions for managing staff nurses’
moral stress and ethical problems to foster and enhance a supportive work
environment, improve job satisfaction, and limit turnover.
2. Enhance the staff nurses’ recognition, inspiration, emotional intelligence, individual
consideration, and empowerment to promote the work climate.
3. Create an equitable work environment, and maintain open and clear communication
with all staff members, through conducting frequent periodic meetings to discuss and
identify their work problems and complaints.
4. Establish reinforcement strategies and a reward system for nurses who behave as
ethical role models to enhance their effectiveness, efficiency, and loyalty.
5. Encourage sharing system among staff nurses in medical knowledge, information, and
clinical experience.
6. Promote staff nurses’ and physicians’ mutual respect and co-operation related to
patients’ treatment decisions.
7. Provide the staff nurses with continuous feedback about their performance and
promote the acceptance of individual differences.
8. Offer continuous job training to improve staff nurses’ skills practice, participative
decision making, problem-solving, and performance.
9. Share the hospital mission and vision, and clarify the hospital goals with staff nurses,
that help them to understand their roles and responsibilities in the hospital.
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10. Promote the staff nurses’ autonomy, through the delegation of additional authorities to
them.
Nurses’ staff should:
1. Collaborate with their peers and work as a team for dealing with patients’ care
problems and issues.
2. Develop their problem-solving ability, participative decision-making, skills practice,
and performance through attending training program.
3. Improve their communication skills with the top level managers using social and
emotional intelligence technique.
4. Promot nurses-physicians’ mutual respect and co-operation related to patients’
treatment decisions.
5. Follow the directions of other health professionals, who make the primary decisions
about patients, also involve in the decision-making process.
6. Attend orientation program concerning hospital mission, vision, policy, and
procedure.
Future/ further studies should be conducted:
• Determine the relationships between ethical climate, health policies, and
healthcare structures.
• Develop strategies to enhance positive ethical climates.
• Determine the relationship between moral distress and turnover.