The relationship between Ethical Work Climate and nurses' perception of Moral Distress and Compassion Competences

Background: Ethical work climate have a significant impact on nurse well-being by promoting ethical behaviour and values. Specifically, an ethical work climate can reduce the likelihood of moral distress occurrence. Moreover, ethical work climate can enhance nurses' compassion competences. As nurses work in an environment that supports ethical behaviour along with other values, they are more likely to feel supported and empowered to provide the required compassionate care to patients leading to improved patients outcomes for along with elevated job satisfaction for nurses. Objective : To Identify the relationship between ethical work climate and nurses' perception of moral distress and compassion competences. Settings : The study was conducted at Alexandria Main University Hospital, in all critical care units, as well as all intensive care units. Subjects : All nursing staff was working during the time of data collection in the previously mentioned units (N=191). Tools : Three tools were used for data collection. Tool (I) Revised Ethical Climate Questionnaire (RECQ), Tool (II) Moral Distress Scale-Revised (MDS-R), and Tool (ІII) Compassion Competence Scale (CCS). Results : The study showed that there was a significant negative correlation between EWC and MD, while significant positive correlation between EWC and CC. Conclusion: There was a significant relation between the ethical work climate with nurses' perception of moral distress and compassion competences which indicate the positive effect of the ethical work climate on moral distress and compassion competences. Recommendations: Develop workshops and discussion of ethical issues and policies to improve EWC and reduce MD, Should make compassion a priority within the health care system to grow a more compassionate environment, or in other word work place spirituality.


Introduction
Ethical work climate (EWC) is crucial for the effectiveness of an organization.It reflects the organization's moral principles, policies, procedures and practices, and their influence on the ethical values and behaviors of nurses (Martin & Cullen, 2006).Also, promotion of a favorable working climate that significantly affects the ethical behavior and attitude of nurses is a primary priority for healthcare providers and as it has a significant impact on nurses' competence, job satisfaction, and ethical principles (Safan et al., 2018).
Wang and Hsieh (2012) defined EWC as "the shared perception of ethically correct behavior and the way the organization should address ethical situations".Putranta and Kingshott (2011) classified into three dimensions based on ethical theories: egoism, benevolence and principled.Firstly, egoism centered on self-interests and how one can maximize their own benefits.Secondly, benevolence focuses on actions that benefit all groups, not just one's self-interest and lastly, principled involves behaviors that adhere to established policies, rules, and procedures and apply to all groups of people.
Ethical work climate can be beneficial for leaders in managing dysfunctional behaviors and improving nurses' dedication, commitment, satisfaction, and loyalty to their organization.Moreover, it fosters a sense of commitment among nurses towards their organization and enhances their ability to perform effectively and ethically.Conversely, an unethical work climate can negatively impact nursing staff, leading to lower job satisfaction, performance, and various forms of stress such as physical, psychological, and moral distress (MD) (Abo Amer et al., 2020).
Moral distress has become a significant ethical issue among health care professionals, especially clinical nurses in clinical practice (Ulrich et al., 2010).MD defined as "one or more negative self-directed emotions or attitudes that arise in response to one's perceived involvement in a situation that one perceives to be morally undesirable" (Campbell et al., 2016).According toCorley et al. (2005), the experience of MD is often due to the inability to act according to their ethical beliefs.They also found that 80% of nurses experienced moderate to high levels of moral distress at their working environment.Moreover, MD occurs when "nurses believe that they are being involuntarily complicit in acting unethically, they are doing something that they believe to be morally wrong but have little power to act differently or to change the situation" (Hamric et al. ,2012).They classified MD into two dimensions namely: intensity and frequency.Firstly, intensity which refers to the amount of perceived MD; secondly frequency which refers to the number of times nursing staff face with it in a limited interval.
Experiencing MD can lead to various adverse outcomes for clinical nurses, resulting in a series of distressing symptoms that may occur such as frustration, powerlessness, anger, sleep disturbances, fatigue, insecurity, and guilt (Zhang et al., 2018).Furthermore, MD can increase the likelihood of turnover, early retirement, extended periods absence from work, decreased job satisfaction and level of compassion competence.
Compassion involves responding to the needs of the patient being nursed, taking into consideration their physiological, psychological, and emotional challenges (Dewar & Christley, 2013).Therefore, Compassion is a crucial component of highquality healthcare, particularly in the nursing field (Bickford et al., 2019).
Compassion competence (CC) is defined as 'an individual's skill or ability with regard to understanding and reducing another's suffering' (Lee & Seomun, 2016).They classified CC into three dimensions namely: communication, sensitivity and insight.Firstly, communication evaluates a nurse's interpersonal skills, which are essential when caring for patients from diverse cultural backgrounds; it includes not only language proficiency but also the ability to understand and support patients while providing guidance.Secondly, sensitivity measures a nurse's cabability to recognize and react to changes in patients' emotions, which can help nurses understand patients and improve their nursing care quality and lastly, insight which evaluates a nurse's ability to utilize their professional knowledge to understand patients' needs and provide appropriate care (Lee & Seomun, 2016).
Compassion plays a vital role in creating a productive work environment.It promotes loyalty among nurses and reduces stress levels, additionally; the adherence of organizations to their policies and regulations can lead to an increase in CC ( Dutton, Workman & Hardin, 2014).

Aim of the study:
This study aims to identify the relationship between ethical work climate and nurses' perception of moral distress and compassion competences at Alexandria Main University Hospital.

The research questions include the following:
-What is the level of ethical work climate as perceived by nurses?-What is the level of moral distress as perceived by nurses?-What is the level of compassion competences as perceived by nurses?-What is the type & degree of correlation between ethical work climate and each of moral distress and compassion competences?

Research Design
A descriptive correlational research design was used to conduct this study.Setting This study will be conducted at Alexandria Main University Hospital in all critical care units (N=8), as well as all intensive care units (N=15).Alexandria Main University Hospital is the largest governmental hospital in Alexandria and employs a large number of nurses with different qualifications and multispecialty of medical services.

Subjects
The study subjects will include all nurses working in the previously mentioned setting, with a working experience of least one year and who have direct contact with patients.(N=191) they are classified as follows: critical care units (N = 70), intensive care units (N = 121).

Tools:
Three tools were used in this study as follows: Tool (1): Revised Ethical Climate Questionnaire (RECQ) It was developed by Victor and Cullen (1988), and revised by Cullen, Victor, and Bronson (1993).This revised instrument consists of 12 items classified into three dimensions namely: Egoism, Benevolence, and Principled with four items under each dimension (Putranta & Kingshott, 2011).The response will be measured on 7-point Likert scale ranging from (1) strongly disagree to (7) strongly agree.The overall score level ranging from 12 to 84.The score ranging from (12 < 36) indicates lower perception of ethical work climate, score ranging from (36 < 60) indicates moderate perception of ethical work climate, and score ranging from (60 84) indicates higher perception of ethical work climate.

Tool (2): Moral Distress Scale-Revised (MDS-R)
This tool was developed by Corley (1995), then revised by Hamric et al. (2012).This tool consisted of 21 items measuring the frequency and intensity of moral distress.Scoring of the MDS-R is achieved by using a 5-point Likert scale.Frequency of moral distress ranged from 0 (never) to 4 (very frequently), and intensity ranged from 0 (none) to 4 (great extent).The Item scores for moral distress intensity and moral distress frequency are multiplied and summed for each of the 21-items creating a new variable for each item, the frequency x intensity (fxi) ranging from 0 to 16. Overall score level ranges from 0 to 336.The score ranges from (0 < 112) indicates low level of moral distress, score ranges from (112 < 224) indicates moderate level of moral distress, and score ranges from (224 336) indicates higher level of moral distress.

Tool (3): Compassion Competence Scale (CCS)
It was developed by Lee and Seomun (2016), it will be adopted by the researcher to investigate nurses' compassion competences.It consists of 17 items related to the following three dimensions: communication (eight items), sensitivity (five items) and insight (four items).The response will be measured on 5-point Likert scale ranged from (1) strongly disagree to (5) strongly agree.The overall score level ranges from 17 to 85.The score ranges from (17 < 39) indicates low level of compassion competence, score ranges from (40 < 63) indicates moderate level of compassion competence, and score ranges from (63 85) indicates high level of compassion competence.

Method
An approval for conducting the study was obtained from the Research Ethics Committee of the Faculty of Nursing, Alexandria University.An official Permission for conducting the study was obtained from the Faculty of Nursing, Alexandria University.An approval was obtained from hospital administrative authority to conduct the study after providing explanation of the aim of the study.All the study tools were translated into Arabic language; a back-to-back translated (Arabic to English) was done.The study tools were tested for their content validity by (5) experts in the field of the study and the necessary modifications were done.The reliability coefficient was 0.850 for tool one and 0.926 for tool two and 0.901 for tool three which were acceptable.A pilot study was carried out on 5% (n= 20) of the study sample in order to test the clarity and applicability of the research tools, all modifications were done.Using Cronbach's Alpha test.Data were gathered from the study subjects through hand delivered questionnaire by the researcher after explaining the purpose of the study.Written informed consent was obtained from the study subjects to collect the necessary data and the need explanations were given when requested.The time needed to fill the previously mention questionnaire was about (15-20) minuets.Data collections take a period of three months from 10/5/2022 to 10/7/2022.The confidentiality of the data and the anonymity of the study subjects were assured.

Statistical analysis:
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.(Armonk, NY: IBM Corp) Qualitative data were described using number and percent.The Kolmogorov-Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, standard deviation and median.Significance of the obtained results was judged at the 5% level.

Results
The present study mainly concerned with Identify the relationship between ethical work climate and nurses' perception of moral distress and compassion competences.

Discussion
Regarding perception of EWC the results of this study revealed that a highest percentage of studied nurses were devoted to moderate level of EWC.This could be due to existence of ethical principles and adherence to these principles that contribute to nurses' trust in their organization.And a significant relation was found between EWC and studied nurses' age, educational level, and years of experience.This could be also explained that age plays a significant role in nurses' knowledge regarding ethics; educational level influences the perceptions of nurses regarding the ethical climate and by accumulation of experience.
Studies conducted in the field of nursing care revealed that nurses' perceptions of ethical climate were moderate (Mert, 2017;Elsayed, 2019).
In the contrary, study by Shayan et al. ( 2017) and who showed that the majority of study participants perceived low EWC.
Mohamed, Abed & Hassan (2020), finding revealed that demographic characteristics such as age, years of work experience, and educational level affect the nurses' perceptions of EWC.On the other hand, Owczarzak (2019) stated that demographics characteristics as age, years of work experience and educational qualification did not affect the nurses' perception of ethical climate.
In regards to MD, the present study results illustrate that the majority of studied nurses were devoted to a slightly moderate level of MD. this study result may be due to Lack of support from organizations and nurse manager, carry out the physician's orders for unnecessary tests and treatment for terminally ill patients, and working with unsafe levels of healthcare providers, who work without a license.
And a significant relation was found between MD and studied nurses' age, working unit, educational level, and years of experience.These finding can be due to low moral sensitivity and lack of proper understanding of clinical situations, which lead to the experience of MD by nursing staff.Regarding working unit these results could be related to nurses' more involvement in direct patient activities which increase their workload and physical demands on them.Also, nurses gain more experience facing moral challenges through educational level.
This result supported with a study was done by Wenwen et al. (2018), who mentioned that MD of nurses was low to moderate.While, this finding is inconsistent with studies were conducted, and reported that MD experienced by ICU nurses was high (Shoorideh et al., 2015).
The result of the present study goes in the same line with a study revealed that the intensity of MD had a significant difference with the age of nurses; in other words, older nurses experienced higher levels of MD at different clinical settings (Atashzadeh-Shoorideh et al., 2021).While, this study result is incompatible with a study performed by Mohamed, El-sayed & Mostafa (2022) indicated that there were no significant difference between demographic characteristics and MD including age, educational, department, and years of experiences.
Findings of the current study clarified that the high percentage of studied nurses were devoted to high level of CC.This result may be due to nurses' capacity to communicate through spreading awareness and offering emotional support and encouragement, enabling nurses to pay attention and listen to patients, and ability of nurses to use creativity in addressing identified problems and patient needs.
In the light of the result of present study, the finding revealed that there was a statistically significant difference between nurses' perception of CC and nurses' age, educational level, and years of experience.These results could be explained by age and years of experience have an effective role in interacting and handling patients' problems by nurses through the progression and accumulation of knowledge, skills and attitudes of nursing staff.
This result was consistent with the study conducted by Samson-Akpan et al. (2019) that showed the average level of nurses' perceived CC was high, While, the finding of current study is inconsistent with the study of Sinclair et al. (2017) which revealed nurses healthcare professionals and healthcare students emphasized their low CC.
The study result is congruent with Kim, Nam & Kwon (2017) who stated that was a statistically significant difference between CC and nurses' age, education level, and years of experience.While, the present finding is conflict with (Lee & Seo, 2022) who claimed that no significant difference with CC related to age, years of experience and educational level.
Concerning the relationship between EWC and MD, the current study finding stated that there was a significant weak negative correlation between the overall of EWC and nurses' perceptions of MD.From the researcher's point of view, it could be due to that EWC provides a framework for ethical decision making in the clinical environment and enables nurses to cope with MD and other causes of dissatisfaction.Organizations with clear policies on codes of conduct are more favorable and help nurses gain more experience facing moral challenges, develop effective coping mechanisms.
This finding in the same line with Küçükkelepçe, Özkan & Beşirik, (2022); Bayat, Shahriyari, & Keshvari, (2019) who stated that negative relationship between nurses' MD levels and EWC perceptions in nurses who work in intensive care unit.
On the other hand, a study was done by, Esmaelzadeh, Rajabdizavandi & Nematollahi (2023) who proposed that there was no correlation between EWC and MD.
Regarding relationship between EWC and CC, the current research findings revealed that a statistically significant weak positive correlation between overall nurses' perceptions of CC and EWC.This may be attributed to when organization addresses ethical situations effectively this gives an opportunity for nurses to properly deal with patients ability to reduce patients' suffering through empathy, the primary concern in this organization is the ethical code that governs their profession and affects the nurse's relationship with the patient.
The present study finding is agreement with a study performed by Maghsoudi, Mohsenpour & Nazif (2022); Nikmanesh et al. ( 2018) who stated that interpersonal communication skills of CC is enhanced through EWC among nurses.While, the present study finding is inagreement with a study performed by Zoghbi-Manrique-de-Lara (2016) who stated that EWC did not show significant effects on compassion.
In general the present study findings revealed that Impact of EWC on MD and CC was showed that when EWC increases by 1 unit, MD decreases 1.689units.While, EWC increases by 1 unit, lead to CC increases 0.231units.This study findings emphasized by the negative significant correlation among EWC and MD, while there was positive significant correlation between EWC and CC.

Conclusion
In the light of the study results, it can be concluded that, there was a negative statistical significant correlation between nurses' perception of EWC and MD.Moreover, there was a positive significant correlation between nurses' perception EWC and CC at Alexandria Main University Hospital.Additionally the present study results showed that nurses perceived EWC and MD as moderate level.While, perceived CC as high level.

Recommendations
Based on the study findings, the following recommendations can be suggested to improve the EWC of nursing organization that lead to increases nurses' satisfaction, CC and decrease MD.

The following recommendations directed to: A: For Organization:
-Should honoring the concept of Shared governance by allow the participation of nursing director in sound decision making related to nurses' rights, responsibilities and justice.
-Develop strategies for improving of EWC and reducing MD through workshops and discussion of ethical issues and policies to improve the quality of ethical problem solving throughout the organization.
-Should make compassion a priority within the health care system to grow a more compassionate environment, or in other word work place spirituality.B: For nurse managers: -Established a system to reward and support ethical nurses who behave as ethical role models.
-Should share the hospital mission and vision, and clarify the hospital goals with nursing staff that help them to understand their roles and responsibilities in the hospital that enhance CC and EWC.

C: For nursing staff:
-Improve communication skills (verbal and nonverbal) among nurses to enhance compassionate care for patient through attendance of workshops to ensure the importance of using effective communication skills with the patient.
-Should improving nurses' sense of responsibility toward efficiently use of available resources through developing training program to control organization cost as a one element of nurses' interest in improving EWC.

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Descriptive statistical measures, Frequency tables and cross tabulating were used to illustrate the results of categorical data.Quantitative data were summarized by arithmetic mean and standard deviation.-Statistical analysis tests, which included: ANOVA Test, Student t-test, Cronbach's Alpha, Pearson coefficient and linear Regression.
Coefficients R 2 : Coefficient of determination F, T: f and t values for the model C.I: Confidence interval LL: Lower limit UL: Upper Limit *: Statistically significant at p ≤ 0.05

Table ( 1
) presented characteristics of the study subjects.The results revealed that nearly three quarters (74.35%) of studied nurses were females.Also, (27.7%) of the studied nurses were in the age group 25<30 years.While only (3.7%) of them aged 20<25years.With respect to marital status more than two thirds (68.59%) of them were married, while only 2.62% of them were widow.Regarding the type of unit, more than half (63.35%) of them were working in Intensive care units.In relation to level of education the highest percentage of studied nurses (38.22%) had Bachelor of Nursing Science; in contrast (26.18%) of them had Technical Health Institute Diploma in Nursing.In relation to years of experience in nursing (37.7%) of studied nurses had more than or equal 20 years of experience.

Table ( 1): Frequency of studied nurses' according to their demographic characteristics and work-related data.
▪Intensive care units ▪ ▪ Secondary Technical Nursing Diploma ▪ Technical Health Institute Diploma in Nursing▪

Table ( 5): Simple Linear Regression for the effect of Ethical Work Climate on compassion competences (n = 191).
B: Unstandardized Coefficients R 2 : Coefficient of determinationF, T: f and t values for the model C.I: Confidence interval LL: Lower limit UL: Upper Limit *: Statistically significant at p ≤ 0.05