Social Work in Health Care, 54:252–268, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2015.1005271
Perceptions of the Hospital Ethical Environment Among Hospital Social Workers in the United States GREG L. PUGH, MSW, PhD School of Social Work, Portland State University, Portland, Oregon, USA
Hospital social workers are in a unique context of practice, and one where the ethical environment has a profound influence on the ethical behavior. This study determined the ratings of ethical environment by hospital social workers in large nationwide sample. Correlates suggest by and compared to studies of ethical environment with nurses are explored. Positive ratings of the ethical environment are primarily associated with job satisfaction, as well as working in a centralized social work department and for a non-profit hospital. Religiosity and MSW education were not predictive. Implications and suggestions for managing the hospital ethical environment are provided. KEYWORDS hospital social work, ethical environment, job satisfaction
The concept of the ethical environment is of growing interest to hospitals and the professions that hospitals employ. Thus far, the research on hospital ethical environment has focused primarily on the perceptions of nurses. The perception of the hospital ethical environment among social workers is relatively unexplored, and it would be interesting and informative to know what social workers think of the hospital ethical environment, and what other factors are related to those perceptions. The business and nursing literature provide some suggestions of related variables, and the existing social work literature about the hospital setting and ethics suggest some of the
Received June 30, 2014; accepted January 5, 2015. Address correspondence to Greg L. Pugh, MSW, PhD, School of Social Work, Portland State University, 1800 SW 6th Ave., ASC 600, Portland, OR 97210. E-mail: [email protected] 252
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same variables. However, both of these bodies of knowledge suffer from a number of limitations, primarily in terms of small convenience samples that may not be representative of the acute care, non-specialty hospital setting. This research sought to determine hospital social workers’ perceptions of ethical environment nationwide, and to explore the relationship of other variables, drawn from the literature, to the perception of ethical environment in a large, representative sample. In addition, there are contradictory findings within and between the existing literatures that this study sought to clarify.
LITERATURE REVIEW The ethical environment of any given organization is both the way the organization deals with ethical issues or concerns, and the perception of those dealings by organizational employees (Hamric & Blackhall, 2007; Parker et al., 2003). The ethical environment helps determine how ethical problems are to be addressed, is communicated to employees when those problems are addressed, and that employee perception helps create and sustain the ethical environment (Hart, 2005; Hamric & Blackhall, 2007). Research has shown that the ethical environment of an organization directly influences the ethical actions or behavior of employees (Appelbaum, Deguire, & Lay, 2005; Deshpande & Joseph, 2009; Olson, 1998; Peterson, 2002; Schluter, Winch, Holzhauser, & Henderson, 2008; Sims & Keon, 1999; Trevino, Butterfield, & McCabe, 1998; Vardi, 2001). A poor ethical environment, in which ethical behavior is not discussed, encouraged, or actively supported by the organization, communicates to employees that they are not expected to personally maintain or hold others accountable for ethical behavior (Appelbaum et al., 2005; Deshpande & Joseph, 2009; Peterson, 2002; Sims & Keon, 1999; Trevino et al., 1998; Vardi, 2001). Ethical environment is a concept situated between ethical climate and organizational culture. All three are group-level constructs that are measured by aggregating the perceptions of group members, in this case, organizational employees (Parker et al., 2003). Whereas culture communicates large concepts such as values and beliefs, climate refers to the routines and rewards of smaller work units (Vandenberghe, 1999). Ethical environment encompasses aspects of both culture and climate with a focus on the issue of organizational ethics. At times, the concepts may overlap or even be the same. This allows for comparing the research and concepts across studies and disciplines. In the literature, the concept of ethical climate is a more easily measured unit-specific attribute (Olsen, 1998; Trevino et al., 1998; Vardi, 2001; Victor & Cullen, 1988), environment is a referent-specific measure across an organization (McDaniel, 1997; Trevino, et al., 1998), and culture is larger, more complex, and difficult to study (Agarwal & Malloy, 1999; Vardi, 2001).
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Although there is a significant body of literature on the ethical climate of businesses and corporations, it wasn’t until the late 1990’s that the ethical environments of hospitals and the perceptions of nurses were explored. After excluding work outside the United States, and work not acute-care hospitalbased, there are 11 studies on the perceptions of ethical environments in hospitals, all conducted with samples of nurses. Three of the 11 studies (Corley, Minick, Elswick, & Jacobs, 2005; McDaniel, 1997, 1998) used the Ethical Environment Questionnaire (EEQ) designed by McDaniel (1997). Four used the Hospital Ethical Climate Scale (HECS) (Hart, 2005; O’Donnell et al., 2008; Olson, 1998; Ulrich et al., 2007) designed by Olson (1998). One study (Hamric & Blackhall, 2007) used the EEQ in part of their study and then the HECS in another. The final three used the Ethical Climate Questionnaire (ECQ) (Deshpande & Joseph, 2009, Joseph & Deshpande, 1997; Rathert & Fleming, 2008) designed by Victor and Cullen (1988). Ethical environment has not been considered in the social work literature, but it is an important factor for hospital social workers, given its apparent influence on ethical behavior in the hospital setting (Deshpande & Joseph, 2009; Olson, 1998; Peterson, 2002; Schluter, Winch, Holzhauser, & Henderson, 2008). This research on the ethical environment of hospitals has consistently found that a poor ethical environment is highly predictive of unethical behaviors among employees. The social work literature on the hospital setting does suggest that the implicit and explicit communication of ethical environment may discourage social workers from engaging in ethical discussions and deliberations (Jansson & Dodd, 1998, 2002; Kugelman, 1992). A poor ethical environment may well increase the frequency and intensity of ethical problems in organizations (McDaniel, 1998; Ulrich & Soeken, 2005). If the ethical environment prevents taking ethical action, employees can experience moral distress (Corley et al., 2005). The relationship between ethical environment and unethical behavior is stronger in organizations without codes of ethics or other visible ethical statements, and in fact, a poor ethical environment may be a more powerful influence on employee behavior than an organizational code (Peterson, 2002; Trevino et al., 1998). However, these findings and relationships are preliminary and further research is needed (Deshpande, Joseph, & Prasad, 2006). The research on the hospital ethical environment has focused almost exclusively on nurses (Corley et al., 2005; Deshpande & Joseph, 2009; Hart, 2005; Joseph & Deshpande, 1997; McDaniel, 1997, 1998; Olson, 1998; Peterson, 2002; Rathert & Flemming, 2008; Schluter et al., 2008;), with one sample including a small number of hospital social workers, reported on in three articles (Grady et al., 2008; O’Donnell et al., 2008; Ulrich et al., 2007). As one of the only non-medical professionals providing direct patient services in hospitals designed for medical care and not social services (Greene & Kulper, 1990), social workers are in a unique position from which to evaluate ethical environment. In this host setting, it is also worth noting
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that power and authority lie with physicians (Abramson & Mizrahi, 1996; Davidson, 1990). This context suggests that social workers’ perceptions of ethical environment may be unique, or at least different from nurses. To date, social work research on ethics in the hospital setting has focused on the type and nature of the ethical issues social workers encounter (Doyle, Miller, & Mizra, 2009; Foster, Sharp, Scesny, McLellan, & Cotman, 1993; Proctor, Morrow-Howell, & Lott, 1993), and on other ethical actions or behaviors. Ethical actions or behaviors refers to the varied dependent variables that have been investigated in the hospital social work ethics literature, such as ethical reasoning or decision making (Kugelman, 1992; Proctor, et al, 1993), ethical confidence and moral action (Grady et al., 2008; O’Donnell et al., 2008), ethical competence (Boland, 2006), ethical activism (Jansson & Dodd, 2002), ethical preparedness and participation (Foster, et al., 1993), and influence in resolving ethical dilemmas (Joseph & Conrad, 1989). O’Donnell et al (2008) focused on ethical stress, moral action, and job satisfaction among the hospital social workers included in their sample. It is generally found that social workers are limited in their ethical actions, especially in involvement and influence in ethical decision making in the hospital (Boland, 2006; Grady et al., 2008; Jansson & Dodd, 1998, 2002). It is also noted that organizational factors, such as ethical environment, affect the ethical actions of hospital social workers (Doyle et al., 2009; Proctor et al., 1993). In terms of other variables related to ethical environment (or subsequent ethical actions), the existing research has had inconsistent findings in terms of correlations with personal variables such as race, religiosity, and gender (Doyle et al., 2009; O’Donnell et al., 2008). Professional variables, such as professional education seems to improve ethical actions (Boland, 2006; Doyle et al., 2009; Foster et al., 1993; Joseph & Conrad, 1989), although O’Donnell et al. (2009) did not find differences by BSW versus MSW degree. Some have found correlations between age and tenure (Boland, 2006; Jansson & Dodd, 2002) while others have not (Foster et al., 1993; Grady et al., 2008; O’Donnell et al., 2008). Although not directly explored in terms of ethical actions, there is also a need to consider whether the social worker roles in psychosocial care and support versus discharge planning are relevant to the ethical environment (Kadushin & Kulys, 1995). Finally, organizational variables, such as the size of the social work department (Jansson & Dodd, 2002) and the status of the hospital as for-profit or non-profit (O’Donnell et al., 2008) seem unrelated to ethical actions. From the research on hospital ethical environment with nurses, a similar set of findings and additional variables worth exploring are suggested. Correlations between race and ratings of the ethical environment have been detected in some studies (McDaniel, 1998; Ulrich et al., 2007), but not others (Deshpande et al., 2006; O’Donnell et al., 2008), as well as findings that women are more critical of ethical environment (McDaniel, Schoeps, & Lincourt, 2001), or that there are no differences by gender (Deshpande
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et al. 2006, O’Donnell et al., 2008). University education has been related to higher ratings of ethical environment (Deshpande et al., 2006; Malloy & Agarwal, 2003; Schluter et al., 2008). Increasing age and years of experience have been related to higher ratings in some studies (Goldman & Tabak, 2010; McDaniel, 1998), but not in others (Malloy & Agarwal, 2003; McDaniel, 1998). O’Donnell et al. (2008) also found that the more supportive the ethical climate, the higher the job satisfaction among nurses and social workers. Finally, the ethical environment literature has detected weak and contradictory relationships to organizational profit status (Agarwal & Malloy, 1999; Brower & Shrader, 2000). The literature on hospital social workers and ethics, and the literature on nurses and the hospital ethical environment both point to the importance of ethics in the hospital setting. The findings between the two disciplines and approaches need to be reconciled and relationships between variables identified above clarified. The social work samples are generally lacking in size and representativeness, but do suggest the ethical environment and other organizational forces are important (Doyle et al., 2009; Grady et al., 2008; Joseph & Conrad, 1989). The nurse samples are larger and more plentiful, and provide the best evidence for the importance of the hospital ethical environment and its impact on ethical actions, although many of the findings are inconsistent.
METHODS Sampling Frame At the time of this study (2010), there were 3,558 non-federal hospitals in the United States (American Hospital Directory, n.d.), that employed 38,194 social workers (U.S. Department of Labor, Bureau of Labor and Statistics, 2006). Sample size calculations for this population indicate that a sample of 1,038 social workers would be sufficient for a 95% confidence interval and a 3% margin of error (standard formula from Dillman, 2007, p. 206). As a list of these social workers was not available, the sample was selected first as a random closed population cluster sample of hospitals (Sue & Ritter, 2007) based on size. By collating multiple hospital information sources (American Hospital Association, 2010; American Hospital Directory at http://www.ahd.com; Hospital Data at http://www.hospital-data.com; Baby Boomer Caretaker at http://www.babyboomercaretaker.com/hospitals/), and selecting only hospitals with over 200 beds, a list of 1,404 of the 3,558 hospitals was created, and a sample of 500 hospitals was randomly selected from that list. The decision to select hospitals with over 200 beds was based on the premise that small rural hospitals often do not have social workers, while larger facilities would have a more standard social work service model. Given that the random selection was of hospitals, the social workers at the
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selected hospitals will self-select into the study, and thus be considered a convenience sample (Schonlau, Fricker, & Elliott, 2002), although the representational weaknesses associated with a convenience sample are attenuated by other elements of the survey design and process (Dillman, 2007).
Design and Procedures Given the size and geographical dispersion of the desired sample, the study was implemented via the World Wide Web on the surveygizmo.com commercial service. The websites of each of the selected hospitals were reviewed for contact information for the social work department, or, if available, for the director, manager, supervisor, or lead social worker of the department. During data collection, each hospital was telephoned directly, not more than twice, to request participation in the study by providing a single e-mail address for a contact person to which to send the study invitation, description, and link to, and reminder about, the secure online survey. That contact person determined if any further permissions or approval was necessary. The design and process is based on the Dillman (2007) Tailored Design Method, with some modifications to facilitate a Web-based survey methodology based on Web survey design resources (Schonlau et al., 2002; Sue & Ritter, 2007). The most important modification is brevity (Schonlau et al., 2002; Sue & Ritter, 2007). The study was reviewed and approved by the institutional review board (IRB) at the university where the project was conducted. A single reminder e-mail was sent to the contact person’s e-mail at every hospital seven days after the initial invitation e-mail. The entire invitation and data collection process occurred over three months in the Fall of 2010.
Instrument The Ethical Environment Questionnaire (EEQ) by McDaniel (1997) was used by permission, but due to copyright is not reproduced here. The EEQ was specifically developed for exploring the ethical environment of hospitals and prior research with nurses is available for comparison (Corley et al., 2005; Hamric & Blackhall, 2007; McDaniel, 1998; Ulrich & Soeken, 2005). The EEQ has not previously been utilized with social workers. An alternate instrument (the Hospital Ethical Climate Scale or HECS) was used in a large sample of nurses (Ulrich et al., 2007), which included a small sample of hospital social workers (Grady et al., 2008; O’Donnell et al., 2008), but was not available for use in this study. The EEQ consists of 20 questions, some reverse scored, and all rated on a five-point Likert scale from 1 = Strongly Agree, to 5 = Strongly Disagree. Higher scores indicated a more positive perception of the ethical environment. The question stem is “Regarding this hospital . . . ” and example questions include “The administration is concerned with ethical practice”
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and “Ethics accountability is not rewarded.” The instrument measures ethical environment as valid single factor structure without subscales (McDaniel, 1997), with good test–retest Pearson’s r of 0.88 and Cronbach’s alphas of 0.90 to 0.94 (Corley et al., 2005; McDaniel 1997; McDaniel et al., 2001; Ulrich & Soeken, 2005). Principle components analysis (PCA) with the current sample confirms a single factor structure, with an acceptable Kaiser-Meyer-Olkin value of sampling adequacy at .96, and a significant Bartlett’s test of sphericity (χ 2 (190) = 9417, p ≤ .001) indicating sufficient correlations for PCA (Field, 2009), and a Cronbach’s alpha of 0.93. In addition to the EEQ instrument, the survey asked for demographics and other descriptive information about of the respondents and about the hospitals where they worked (see Table 1). Single question measures of religiosity and of job satisfaction were also included. Religiosity was measured as, “Approximately how often do you attend religious services (of any kind)” on a scale of never, annually, month, and weekly, a question drawn from Deshpande et al. (2006). Job satisfaction was asked as “In general, I am satisfied with my job,” and rated on a five-point Likert scale from TABLE 1 Selected Sample Demographic and Descriptive Elements (N = 973) Variable
Category
n (a)
% (b)
Gender
Female Male Caucasian African American Latina/o Asian/Pacific Other/Multiracial MSW BSW Not for Profit For Profit Inpatient Outpatient Emergency Dept. Management Discharge Planning Psychosocial Care Centralized Decentralized Social Worker Nurse 1–5 6–10 11–15 16–20 21 or more
889 81 848 48 38 22 7 770 112 792 174 759 145 51 11 479 446 816 153 569 348 131 225 155 136 321
91 8.3 87 4.9 3.9 2.3 0.7 79 11.5 81 18 78 15 5.2 1.1 47 44 84 16 59 36 14 23 16 14 33
Race
Degree Hospital Profit Status Primary Assignment
Primary Function Department Structure Supervisor Department Size (number of social workers)
(a) Sample sizes may not equal 973 due to missing values and/or excluded “other” categories. (b) Percentages may be more or less than 100 due to rounding; missing values, and/or excluded “other” categories
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1 = Strongly Agree, to 5 = Strongly Disagree, as drawn from multiple studies (Trevino et al., 1998; Cunningham & Sagas, 2004; Kadushin & Kulys 1995). To encourage completion of the survey, a lottery for twenty $10 electronic gift certificates was used as an incentive. Survey data were downloaded from the Web hosting service directly into Statistical Package for Social Sciences (SPSS). Analyses included t-tests, ANOVA, and multiple regression modeling, with confirmatory testing and examination of assumptions as indicated. Both sequential multiple regression and hierarchical regression for nested data (using the MIXED procedure in SPSS) showed identical results, so for clarity and ease of presentation the sequential results are reported. It appears that in grouping the individual perceptions to form the measure of the hospital ethical environment the compensations of the MIXED procedure for nested data are unnecessary.
RESULTS Sample and Measures Of the 500 hospitals invited to participate, 290 (58%) agreed to do so and 973 questionnaires were completed by social workers at those hospitals. Given the sampling frame of 38,194 social workers at 3558 hospitals, there is an average of 10.7 social workers per hospital, which makes the social worker response rate for this study 31.4% (973/(290∗ 10.7)). However, sampling hospitals with 200 beds or more may indicate a higher average number of social workers per hospital. The survey did ask the participants how many social workers were employed at their respective hospitals in ordinal ranges (see Table 1). Taking the median of those ranges (and 21 for the “more than 20” category) results in a sample average of 13.8 social workers per hospital, which is a response rate of 24.3% (973/(290∗ 13.8)). The SPSS missing values analysis was conducted to examine the missing data for any patterns, none of which were found. Little’s MCAR test was not significant (χ 2 (107) = 111, p = .372), so the missing values can be inferred to be missing completely at random (Tabachnick & Fidell, 2007). No imputations or other efforts were made to replace missing values. Participating hospitals were more likely to be larger with a mean of 458 beds versus 378 beds for nonparticipating hospitals (one sample t-test; t (926) = 5.50, p ≤ .001, two tailed). Participating hospitals were more likely to be non-profit (χ 2 (1) = 13.57, p ≤ .001), but the effect size was negligible (Phi coefficient -.165). There were no practical differences between participating hospitals and nonparticipating hospitals, and the sample is geographically representative by Census Region, with hospitals from 43 states participating. Selected demographic and descriptive elements of the sample are presented in Table 1. The sample is mostly female, Caucasian, and
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MSWs working in non-profit hospitals. The majority, 82%, work full-time (n = 968), on inpatient services, performing a mix of discharge planning and psychosocial care, and in centralized social work departments with social worker supervisors. The mean age of the sample is 43.5 (SD = 11.6) and they have worked in hospital social work a mean of 11 years (SD = 9.1), with a mean of 8.8 years (SD = 8.1) at their current hospital. The distribution of the EEQ scores (n = 972) were approximately normally distributed without floor or ceiling effects with a mean of 3.66 (SD = 0.61). This rating is significantly higher (one sample t-test, t (971) = 23.6, p ≤ .001, twotailed; test value 3.2) than the values of 3.25 (Corley et al., 2005) and 3.2 (McDaniel, 1997) reported in the previous studies with nurses. The response distribution (n = 959) on religious attendance as a proxy for religiosity was 236 Never, 238 Annually, 169 Monthly, and 316 Weekly. The response distribution for job satisfaction (n = 969) was 14 Strongly Disagree, 54 Disagree, 96 Neutral, 554 Agree, and 251 Strongly Agree, suggesting high job satisfaction.
Ethical Environment and Personal Variables Relationships between variables of interest include increasing age and work experience associated with higher EEQ scores, but the correlations are very weak (r = .09–.13). Women (n = 888, mean 3.64) rate the ethical environment lower than men (n = 81, mean 3.84), but the practical difference is small (two-tailed independent samples t-test, t (967) = 2.78, p ≤ .006; N2 = .01). No correlations are found with respect to race and ethical environment. Perceptions of ethical environment increase as job satisfaction increases with a strong effect size by partial eta-squared (Np2 = .25; one-way, between groups ANOVA, Welch F (4, 76.3) = 73.7, p ≤ .001, confirmed by post-hoc Games-Howell test). When the personal variables were entered into a regression model (Block 1 and 2 in Table 2), job satisfaction was the strongest contributor (R2 = .224) among the significant personal variables (R 2 = .237). Greater religiosity initially predicted higher EEQ scores, but was completely mediated by job satisfaction.
Ethical Environment and Professional Variables Professional degree (BSW vs. MSW), primary job function as either discharge planning or psychosocial care and support, work in either inpatient or outpatient settings, and working either full time or part time were not correlated with perceptions of ethical environment and provided no significant contributions to the regression modeling (regression steps not shown, but data on these variables are in Table 1).
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TABLE 2 Sequential Regression Model Predictors of Ethical Environment Questionnaire Scores (n = 948)
Variables
Block 1
Block 2
β
β
p
p
Block 3 Beta
β
p
Adj. R2 R2∗
Female Gender −.102 .002 −.085 .003 −.184 −.084 .003 Religiosity .073 .024 .036 .210 .018 .036 .202 Job Satisfaction .475 .000 .337 .464 .000 Centralized .144 .086 .002 Department Non Profit Status −.117 −.074 .009
CI
.013 .237
−.364, −.085 .005, .070 .224 .305, .386 .051, .237
.248
.013 −.206, −.029
∗ all p
Perceptions of the Hospital Ethical Environment Among Hospital Social Workers in the United States GREG L. PUGH, MSW, PhD School of Social Work, Portland State University, Portland, Oregon, USA
Hospital social workers are in a unique context of practice, and one where the ethical environment has a profound influence on the ethical behavior. This study determined the ratings of ethical environment by hospital social workers in large nationwide sample. Correlates suggest by and compared to studies of ethical environment with nurses are explored. Positive ratings of the ethical environment are primarily associated with job satisfaction, as well as working in a centralized social work department and for a non-profit hospital. Religiosity and MSW education were not predictive. Implications and suggestions for managing the hospital ethical environment are provided. KEYWORDS hospital social work, ethical environment, job satisfaction
The concept of the ethical environment is of growing interest to hospitals and the professions that hospitals employ. Thus far, the research on hospital ethical environment has focused primarily on the perceptions of nurses. The perception of the hospital ethical environment among social workers is relatively unexplored, and it would be interesting and informative to know what social workers think of the hospital ethical environment, and what other factors are related to those perceptions. The business and nursing literature provide some suggestions of related variables, and the existing social work literature about the hospital setting and ethics suggest some of the
Received June 30, 2014; accepted January 5, 2015. Address correspondence to Greg L. Pugh, MSW, PhD, School of Social Work, Portland State University, 1800 SW 6th Ave., ASC 600, Portland, OR 97210. E-mail: [email protected] 252
Perceptions of the Hospital Ethical Environment
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same variables. However, both of these bodies of knowledge suffer from a number of limitations, primarily in terms of small convenience samples that may not be representative of the acute care, non-specialty hospital setting. This research sought to determine hospital social workers’ perceptions of ethical environment nationwide, and to explore the relationship of other variables, drawn from the literature, to the perception of ethical environment in a large, representative sample. In addition, there are contradictory findings within and between the existing literatures that this study sought to clarify.
LITERATURE REVIEW The ethical environment of any given organization is both the way the organization deals with ethical issues or concerns, and the perception of those dealings by organizational employees (Hamric & Blackhall, 2007; Parker et al., 2003). The ethical environment helps determine how ethical problems are to be addressed, is communicated to employees when those problems are addressed, and that employee perception helps create and sustain the ethical environment (Hart, 2005; Hamric & Blackhall, 2007). Research has shown that the ethical environment of an organization directly influences the ethical actions or behavior of employees (Appelbaum, Deguire, & Lay, 2005; Deshpande & Joseph, 2009; Olson, 1998; Peterson, 2002; Schluter, Winch, Holzhauser, & Henderson, 2008; Sims & Keon, 1999; Trevino, Butterfield, & McCabe, 1998; Vardi, 2001). A poor ethical environment, in which ethical behavior is not discussed, encouraged, or actively supported by the organization, communicates to employees that they are not expected to personally maintain or hold others accountable for ethical behavior (Appelbaum et al., 2005; Deshpande & Joseph, 2009; Peterson, 2002; Sims & Keon, 1999; Trevino et al., 1998; Vardi, 2001). Ethical environment is a concept situated between ethical climate and organizational culture. All three are group-level constructs that are measured by aggregating the perceptions of group members, in this case, organizational employees (Parker et al., 2003). Whereas culture communicates large concepts such as values and beliefs, climate refers to the routines and rewards of smaller work units (Vandenberghe, 1999). Ethical environment encompasses aspects of both culture and climate with a focus on the issue of organizational ethics. At times, the concepts may overlap or even be the same. This allows for comparing the research and concepts across studies and disciplines. In the literature, the concept of ethical climate is a more easily measured unit-specific attribute (Olsen, 1998; Trevino et al., 1998; Vardi, 2001; Victor & Cullen, 1988), environment is a referent-specific measure across an organization (McDaniel, 1997; Trevino, et al., 1998), and culture is larger, more complex, and difficult to study (Agarwal & Malloy, 1999; Vardi, 2001).
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Although there is a significant body of literature on the ethical climate of businesses and corporations, it wasn’t until the late 1990’s that the ethical environments of hospitals and the perceptions of nurses were explored. After excluding work outside the United States, and work not acute-care hospitalbased, there are 11 studies on the perceptions of ethical environments in hospitals, all conducted with samples of nurses. Three of the 11 studies (Corley, Minick, Elswick, & Jacobs, 2005; McDaniel, 1997, 1998) used the Ethical Environment Questionnaire (EEQ) designed by McDaniel (1997). Four used the Hospital Ethical Climate Scale (HECS) (Hart, 2005; O’Donnell et al., 2008; Olson, 1998; Ulrich et al., 2007) designed by Olson (1998). One study (Hamric & Blackhall, 2007) used the EEQ in part of their study and then the HECS in another. The final three used the Ethical Climate Questionnaire (ECQ) (Deshpande & Joseph, 2009, Joseph & Deshpande, 1997; Rathert & Fleming, 2008) designed by Victor and Cullen (1988). Ethical environment has not been considered in the social work literature, but it is an important factor for hospital social workers, given its apparent influence on ethical behavior in the hospital setting (Deshpande & Joseph, 2009; Olson, 1998; Peterson, 2002; Schluter, Winch, Holzhauser, & Henderson, 2008). This research on the ethical environment of hospitals has consistently found that a poor ethical environment is highly predictive of unethical behaviors among employees. The social work literature on the hospital setting does suggest that the implicit and explicit communication of ethical environment may discourage social workers from engaging in ethical discussions and deliberations (Jansson & Dodd, 1998, 2002; Kugelman, 1992). A poor ethical environment may well increase the frequency and intensity of ethical problems in organizations (McDaniel, 1998; Ulrich & Soeken, 2005). If the ethical environment prevents taking ethical action, employees can experience moral distress (Corley et al., 2005). The relationship between ethical environment and unethical behavior is stronger in organizations without codes of ethics or other visible ethical statements, and in fact, a poor ethical environment may be a more powerful influence on employee behavior than an organizational code (Peterson, 2002; Trevino et al., 1998). However, these findings and relationships are preliminary and further research is needed (Deshpande, Joseph, & Prasad, 2006). The research on the hospital ethical environment has focused almost exclusively on nurses (Corley et al., 2005; Deshpande & Joseph, 2009; Hart, 2005; Joseph & Deshpande, 1997; McDaniel, 1997, 1998; Olson, 1998; Peterson, 2002; Rathert & Flemming, 2008; Schluter et al., 2008;), with one sample including a small number of hospital social workers, reported on in three articles (Grady et al., 2008; O’Donnell et al., 2008; Ulrich et al., 2007). As one of the only non-medical professionals providing direct patient services in hospitals designed for medical care and not social services (Greene & Kulper, 1990), social workers are in a unique position from which to evaluate ethical environment. In this host setting, it is also worth noting
Perceptions of the Hospital Ethical Environment
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that power and authority lie with physicians (Abramson & Mizrahi, 1996; Davidson, 1990). This context suggests that social workers’ perceptions of ethical environment may be unique, or at least different from nurses. To date, social work research on ethics in the hospital setting has focused on the type and nature of the ethical issues social workers encounter (Doyle, Miller, & Mizra, 2009; Foster, Sharp, Scesny, McLellan, & Cotman, 1993; Proctor, Morrow-Howell, & Lott, 1993), and on other ethical actions or behaviors. Ethical actions or behaviors refers to the varied dependent variables that have been investigated in the hospital social work ethics literature, such as ethical reasoning or decision making (Kugelman, 1992; Proctor, et al, 1993), ethical confidence and moral action (Grady et al., 2008; O’Donnell et al., 2008), ethical competence (Boland, 2006), ethical activism (Jansson & Dodd, 2002), ethical preparedness and participation (Foster, et al., 1993), and influence in resolving ethical dilemmas (Joseph & Conrad, 1989). O’Donnell et al (2008) focused on ethical stress, moral action, and job satisfaction among the hospital social workers included in their sample. It is generally found that social workers are limited in their ethical actions, especially in involvement and influence in ethical decision making in the hospital (Boland, 2006; Grady et al., 2008; Jansson & Dodd, 1998, 2002). It is also noted that organizational factors, such as ethical environment, affect the ethical actions of hospital social workers (Doyle et al., 2009; Proctor et al., 1993). In terms of other variables related to ethical environment (or subsequent ethical actions), the existing research has had inconsistent findings in terms of correlations with personal variables such as race, religiosity, and gender (Doyle et al., 2009; O’Donnell et al., 2008). Professional variables, such as professional education seems to improve ethical actions (Boland, 2006; Doyle et al., 2009; Foster et al., 1993; Joseph & Conrad, 1989), although O’Donnell et al. (2009) did not find differences by BSW versus MSW degree. Some have found correlations between age and tenure (Boland, 2006; Jansson & Dodd, 2002) while others have not (Foster et al., 1993; Grady et al., 2008; O’Donnell et al., 2008). Although not directly explored in terms of ethical actions, there is also a need to consider whether the social worker roles in psychosocial care and support versus discharge planning are relevant to the ethical environment (Kadushin & Kulys, 1995). Finally, organizational variables, such as the size of the social work department (Jansson & Dodd, 2002) and the status of the hospital as for-profit or non-profit (O’Donnell et al., 2008) seem unrelated to ethical actions. From the research on hospital ethical environment with nurses, a similar set of findings and additional variables worth exploring are suggested. Correlations between race and ratings of the ethical environment have been detected in some studies (McDaniel, 1998; Ulrich et al., 2007), but not others (Deshpande et al., 2006; O’Donnell et al., 2008), as well as findings that women are more critical of ethical environment (McDaniel, Schoeps, & Lincourt, 2001), or that there are no differences by gender (Deshpande
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et al. 2006, O’Donnell et al., 2008). University education has been related to higher ratings of ethical environment (Deshpande et al., 2006; Malloy & Agarwal, 2003; Schluter et al., 2008). Increasing age and years of experience have been related to higher ratings in some studies (Goldman & Tabak, 2010; McDaniel, 1998), but not in others (Malloy & Agarwal, 2003; McDaniel, 1998). O’Donnell et al. (2008) also found that the more supportive the ethical climate, the higher the job satisfaction among nurses and social workers. Finally, the ethical environment literature has detected weak and contradictory relationships to organizational profit status (Agarwal & Malloy, 1999; Brower & Shrader, 2000). The literature on hospital social workers and ethics, and the literature on nurses and the hospital ethical environment both point to the importance of ethics in the hospital setting. The findings between the two disciplines and approaches need to be reconciled and relationships between variables identified above clarified. The social work samples are generally lacking in size and representativeness, but do suggest the ethical environment and other organizational forces are important (Doyle et al., 2009; Grady et al., 2008; Joseph & Conrad, 1989). The nurse samples are larger and more plentiful, and provide the best evidence for the importance of the hospital ethical environment and its impact on ethical actions, although many of the findings are inconsistent.
METHODS Sampling Frame At the time of this study (2010), there were 3,558 non-federal hospitals in the United States (American Hospital Directory, n.d.), that employed 38,194 social workers (U.S. Department of Labor, Bureau of Labor and Statistics, 2006). Sample size calculations for this population indicate that a sample of 1,038 social workers would be sufficient for a 95% confidence interval and a 3% margin of error (standard formula from Dillman, 2007, p. 206). As a list of these social workers was not available, the sample was selected first as a random closed population cluster sample of hospitals (Sue & Ritter, 2007) based on size. By collating multiple hospital information sources (American Hospital Association, 2010; American Hospital Directory at http://www.ahd.com; Hospital Data at http://www.hospital-data.com; Baby Boomer Caretaker at http://www.babyboomercaretaker.com/hospitals/), and selecting only hospitals with over 200 beds, a list of 1,404 of the 3,558 hospitals was created, and a sample of 500 hospitals was randomly selected from that list. The decision to select hospitals with over 200 beds was based on the premise that small rural hospitals often do not have social workers, while larger facilities would have a more standard social work service model. Given that the random selection was of hospitals, the social workers at the
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selected hospitals will self-select into the study, and thus be considered a convenience sample (Schonlau, Fricker, & Elliott, 2002), although the representational weaknesses associated with a convenience sample are attenuated by other elements of the survey design and process (Dillman, 2007).
Design and Procedures Given the size and geographical dispersion of the desired sample, the study was implemented via the World Wide Web on the surveygizmo.com commercial service. The websites of each of the selected hospitals were reviewed for contact information for the social work department, or, if available, for the director, manager, supervisor, or lead social worker of the department. During data collection, each hospital was telephoned directly, not more than twice, to request participation in the study by providing a single e-mail address for a contact person to which to send the study invitation, description, and link to, and reminder about, the secure online survey. That contact person determined if any further permissions or approval was necessary. The design and process is based on the Dillman (2007) Tailored Design Method, with some modifications to facilitate a Web-based survey methodology based on Web survey design resources (Schonlau et al., 2002; Sue & Ritter, 2007). The most important modification is brevity (Schonlau et al., 2002; Sue & Ritter, 2007). The study was reviewed and approved by the institutional review board (IRB) at the university where the project was conducted. A single reminder e-mail was sent to the contact person’s e-mail at every hospital seven days after the initial invitation e-mail. The entire invitation and data collection process occurred over three months in the Fall of 2010.
Instrument The Ethical Environment Questionnaire (EEQ) by McDaniel (1997) was used by permission, but due to copyright is not reproduced here. The EEQ was specifically developed for exploring the ethical environment of hospitals and prior research with nurses is available for comparison (Corley et al., 2005; Hamric & Blackhall, 2007; McDaniel, 1998; Ulrich & Soeken, 2005). The EEQ has not previously been utilized with social workers. An alternate instrument (the Hospital Ethical Climate Scale or HECS) was used in a large sample of nurses (Ulrich et al., 2007), which included a small sample of hospital social workers (Grady et al., 2008; O’Donnell et al., 2008), but was not available for use in this study. The EEQ consists of 20 questions, some reverse scored, and all rated on a five-point Likert scale from 1 = Strongly Agree, to 5 = Strongly Disagree. Higher scores indicated a more positive perception of the ethical environment. The question stem is “Regarding this hospital . . . ” and example questions include “The administration is concerned with ethical practice”
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and “Ethics accountability is not rewarded.” The instrument measures ethical environment as valid single factor structure without subscales (McDaniel, 1997), with good test–retest Pearson’s r of 0.88 and Cronbach’s alphas of 0.90 to 0.94 (Corley et al., 2005; McDaniel 1997; McDaniel et al., 2001; Ulrich & Soeken, 2005). Principle components analysis (PCA) with the current sample confirms a single factor structure, with an acceptable Kaiser-Meyer-Olkin value of sampling adequacy at .96, and a significant Bartlett’s test of sphericity (χ 2 (190) = 9417, p ≤ .001) indicating sufficient correlations for PCA (Field, 2009), and a Cronbach’s alpha of 0.93. In addition to the EEQ instrument, the survey asked for demographics and other descriptive information about of the respondents and about the hospitals where they worked (see Table 1). Single question measures of religiosity and of job satisfaction were also included. Religiosity was measured as, “Approximately how often do you attend religious services (of any kind)” on a scale of never, annually, month, and weekly, a question drawn from Deshpande et al. (2006). Job satisfaction was asked as “In general, I am satisfied with my job,” and rated on a five-point Likert scale from TABLE 1 Selected Sample Demographic and Descriptive Elements (N = 973) Variable
Category
n (a)
% (b)
Gender
Female Male Caucasian African American Latina/o Asian/Pacific Other/Multiracial MSW BSW Not for Profit For Profit Inpatient Outpatient Emergency Dept. Management Discharge Planning Psychosocial Care Centralized Decentralized Social Worker Nurse 1–5 6–10 11–15 16–20 21 or more
889 81 848 48 38 22 7 770 112 792 174 759 145 51 11 479 446 816 153 569 348 131 225 155 136 321
91 8.3 87 4.9 3.9 2.3 0.7 79 11.5 81 18 78 15 5.2 1.1 47 44 84 16 59 36 14 23 16 14 33
Race
Degree Hospital Profit Status Primary Assignment
Primary Function Department Structure Supervisor Department Size (number of social workers)
(a) Sample sizes may not equal 973 due to missing values and/or excluded “other” categories. (b) Percentages may be more or less than 100 due to rounding; missing values, and/or excluded “other” categories
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1 = Strongly Agree, to 5 = Strongly Disagree, as drawn from multiple studies (Trevino et al., 1998; Cunningham & Sagas, 2004; Kadushin & Kulys 1995). To encourage completion of the survey, a lottery for twenty $10 electronic gift certificates was used as an incentive. Survey data were downloaded from the Web hosting service directly into Statistical Package for Social Sciences (SPSS). Analyses included t-tests, ANOVA, and multiple regression modeling, with confirmatory testing and examination of assumptions as indicated. Both sequential multiple regression and hierarchical regression for nested data (using the MIXED procedure in SPSS) showed identical results, so for clarity and ease of presentation the sequential results are reported. It appears that in grouping the individual perceptions to form the measure of the hospital ethical environment the compensations of the MIXED procedure for nested data are unnecessary.
RESULTS Sample and Measures Of the 500 hospitals invited to participate, 290 (58%) agreed to do so and 973 questionnaires were completed by social workers at those hospitals. Given the sampling frame of 38,194 social workers at 3558 hospitals, there is an average of 10.7 social workers per hospital, which makes the social worker response rate for this study 31.4% (973/(290∗ 10.7)). However, sampling hospitals with 200 beds or more may indicate a higher average number of social workers per hospital. The survey did ask the participants how many social workers were employed at their respective hospitals in ordinal ranges (see Table 1). Taking the median of those ranges (and 21 for the “more than 20” category) results in a sample average of 13.8 social workers per hospital, which is a response rate of 24.3% (973/(290∗ 13.8)). The SPSS missing values analysis was conducted to examine the missing data for any patterns, none of which were found. Little’s MCAR test was not significant (χ 2 (107) = 111, p = .372), so the missing values can be inferred to be missing completely at random (Tabachnick & Fidell, 2007). No imputations or other efforts were made to replace missing values. Participating hospitals were more likely to be larger with a mean of 458 beds versus 378 beds for nonparticipating hospitals (one sample t-test; t (926) = 5.50, p ≤ .001, two tailed). Participating hospitals were more likely to be non-profit (χ 2 (1) = 13.57, p ≤ .001), but the effect size was negligible (Phi coefficient -.165). There were no practical differences between participating hospitals and nonparticipating hospitals, and the sample is geographically representative by Census Region, with hospitals from 43 states participating. Selected demographic and descriptive elements of the sample are presented in Table 1. The sample is mostly female, Caucasian, and
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MSWs working in non-profit hospitals. The majority, 82%, work full-time (n = 968), on inpatient services, performing a mix of discharge planning and psychosocial care, and in centralized social work departments with social worker supervisors. The mean age of the sample is 43.5 (SD = 11.6) and they have worked in hospital social work a mean of 11 years (SD = 9.1), with a mean of 8.8 years (SD = 8.1) at their current hospital. The distribution of the EEQ scores (n = 972) were approximately normally distributed without floor or ceiling effects with a mean of 3.66 (SD = 0.61). This rating is significantly higher (one sample t-test, t (971) = 23.6, p ≤ .001, twotailed; test value 3.2) than the values of 3.25 (Corley et al., 2005) and 3.2 (McDaniel, 1997) reported in the previous studies with nurses. The response distribution (n = 959) on religious attendance as a proxy for religiosity was 236 Never, 238 Annually, 169 Monthly, and 316 Weekly. The response distribution for job satisfaction (n = 969) was 14 Strongly Disagree, 54 Disagree, 96 Neutral, 554 Agree, and 251 Strongly Agree, suggesting high job satisfaction.
Ethical Environment and Personal Variables Relationships between variables of interest include increasing age and work experience associated with higher EEQ scores, but the correlations are very weak (r = .09–.13). Women (n = 888, mean 3.64) rate the ethical environment lower than men (n = 81, mean 3.84), but the practical difference is small (two-tailed independent samples t-test, t (967) = 2.78, p ≤ .006; N2 = .01). No correlations are found with respect to race and ethical environment. Perceptions of ethical environment increase as job satisfaction increases with a strong effect size by partial eta-squared (Np2 = .25; one-way, between groups ANOVA, Welch F (4, 76.3) = 73.7, p ≤ .001, confirmed by post-hoc Games-Howell test). When the personal variables were entered into a regression model (Block 1 and 2 in Table 2), job satisfaction was the strongest contributor (R2 = .224) among the significant personal variables (R 2 = .237). Greater religiosity initially predicted higher EEQ scores, but was completely mediated by job satisfaction.
Ethical Environment and Professional Variables Professional degree (BSW vs. MSW), primary job function as either discharge planning or psychosocial care and support, work in either inpatient or outpatient settings, and working either full time or part time were not correlated with perceptions of ethical environment and provided no significant contributions to the regression modeling (regression steps not shown, but data on these variables are in Table 1).
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TABLE 2 Sequential Regression Model Predictors of Ethical Environment Questionnaire Scores (n = 948)
Variables
Block 1
Block 2
β
β
p
p
Block 3 Beta
β
p
Adj. R2 R2∗
Female Gender −.102 .002 −.085 .003 −.184 −.084 .003 Religiosity .073 .024 .036 .210 .018 .036 .202 Job Satisfaction .475 .000 .337 .464 .000 Centralized .144 .086 .002 Department Non Profit Status −.117 −.074 .009
CI
.013 .237
−.364, −.085 .005, .070 .224 .305, .386 .051, .237
.248
.013 −.206, −.029
∗ all p
