ORIGINAL RESEARCH
The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people Riitta Suhonen, Minna Stolt, Marja-Liisa Gustafsson, Jouko Katajisto & Andreas Charalambous Accepted for publication 5 October 2013
Correspondence to R. Suhonen: e-mails: [email protected]; [email protected] Riitta Suhonen PhD RN Professor Department of Nursing Science, University of Turku, Finland Minna Stolt PhD University Teacher/Podiatrist Department of Nursing Science, University of Turku, Finland Marja-Liisa Gustafsson Public Health Nurse MNSc PhD Student/Senior Lecturer Department of Nursing Science, University of Turku, Finland Jouko Katajisto MSocSci Senior Lecturer Department of Mathematics and Statistics, University of Turku, Finland Andreas Charalambous PhD RN Lecturer of Oncology Nursing Department of Nursing Studies, Cyprus University of Technology, Limassol, Cyprus
SUHONEN
R.,
STOLT
M.,
GUSTAFSSON
M.-L.,
KATAJISTO
J.
&
The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people. Journal of Advanced Nursing 70(6), 1356–1368. doi: 10.1111/jan.12297 CHARALAMBOUS A. (2014)
Abstract Aim. To investigate the associations among the ethical climate, professional practice environment and individualized nursing care in care settings for older people. Background. The quality of care provision is affected by organizational environments, such as ethical climate and professional practice environment. Although, the association between professional practice environment and individualized nursing care has been pointed out, we know that little is known about how ethical climate is associated with the level of individualized nursing care delivery. Design. A cross-sectional explorative and correlational survey design. Methods. The study was conducted in 62 units in the vicinity of a Finnish city using a sample of nurses (N = 874, response rate 58%) who worked clinically with older people in different care settings in 2012. Survey data were collected using the Hospital Ethical Climate Survey, Revised Professional Practice Environment scale and Individualised Care Scale-B. Data were analysed statistically using descriptive statistics, correlation coefficients (Pearson) and multiple stepwise regression analyses. Results. Statistically significant correlations were found among the variables, ethical climate and individualized care and between individualized care and all professional practice environment sub-scales. Multiple stepwise regression showed associations among individualized care, ethical climate and internal work motivation, control over practice and leadership and autonomy. Conclusions. The study provided better understanding of the complex concept of individualized care by taking into consideration the ethical climate and the practice environment and their associations. To increase individualization in care provision, efforts need to be directed towards organizational aspects requiring the support of nursing leaders. Keywords: ethical climate, individualized care, nurse, older people care, professional practice environment, survey
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© 2013 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
Ethical climate, professional practice environment and individualized care
Why is this research or review needed? • The quality of care is associated with the organizational and care environments. Every attempt to make care of older people and care environments attractive for the nursing professionals should be considered. • There is need for developing quality nursing care and services for an increasing number of older people. • To explore the role of the ethical climate and the professional practice environment on the delivery of individualized nursing care.
What are the three key findings? • Individualization of care was influenced by the ethical cli-
2001, Rafferty et al. 2007) suggesting that there is an increasing need for developing the care environment. Given the increasing number of older people worldwide (U.S Census Bureau 2009, WHO 2012) those who need institutional care is also increasing posing challenges to the healthcare services. In addition, the projected shortage of skilled professionals (Chenoweth et al. 2010) and the concern that newly graduated nurses do not consider caring for older people as an option for their future careers (Kloster et al. 2007, Chenoweth et al. 2010) are factors that need to be addressed. For these reasons, research on working conditions, environment and climate is of vital importance, especially in older people care contexts.
mate of the organization and the professional practice environment at the point of care delivery. • Statistically significant associations were found in the multiple stepwise regression analyses between individualized care and the organizational variables, namely ethical climate, internal work motivation, control over practice, leadership and autonomy. • The associations found stress the need to focus any efforts on specific aspects of the organization to promote individualization in the care provision.
How should the findings be used to influence policy/ practice/research/education? • Nurses’ working conditions and thereby quality of care provided for patients can be developed by focussing developmental activities for the working environment and climate. As these can be changed by effective management, every attempt should be made by nurse leaders and managers to retain skilled work force.
Introduction Understanding and developing the organizational environment is of global importance (Rathert & May 2007) as the work environment has an effect on the behaviour of employees in organizations (Olson 1998) and this has played a substantial role in the successful implementation of quality initiatives in patient care provision (McGillis Hall & Doran 2004, Chan et al. 2006, Rafferty et al. 2007). Outcomes for nursing, individual nursing staff and institutions are also associated with the organizational context where care is delivered (Aiken et al. 2001, Wlody 2007, Charalambous et al. 2010). However, healthcare staff report similar shortcomings in their work environments related to the quality of care and the services, although the healthcare systems differ between countries (Aiken et al.
© 2013 John Wiley & Sons Ltd
Background Some evidence exists that care settings for older patients could be more attractive for workers. Castle et al. (2006) report low work satisfaction perceived by nursing staff in care settings for older people. Work satisfaction has been found to be associated with work, working climate and care delivery activities and processes (Castle et al. 2006, Hasson & Arnetz 2008). Furthermore, it has also been found that personalizing care had significant influence on work satisfaction (Edvardsson et al. 2011) and commitment (Tellis-Nayak 2007). Thus, the working environment and climate may have an important contribution on nurse retention and quality care. The growth in the global understanding of the work environment and the organizational climate has taken place over many years (Olson 1998, Ives Erickson et al. 2004) in parallel with the ethically driven requirement for individualized or person-centred care (ICN 2006, Thompson et al. 2006). Individualized nursing care delivery has also been found to be associated with some organizational variables including organization of work, leadership and management (Suhonen et al. 2007, 2009, Tellis-Nayak 2007). In addition, nurses have demonstrated the effect of organizational variables on their work reporting that individual persons’ needs and the requirements of the organization are not congruent (Hart 2005), which may produce ethical problems (Olson 1998, Wlody 2007). However, only a few studies have examined the associations among individualized nursing care, the professional practice environment and the ethical climate (Tellis-Nayak 2007, Charalambous et al. 2010, Edvardsson et al. 2011). Thus, there is a need to examine the organizational variables including professional, environmental and ethical climate issues in association with nursing care delivery (Scott et al. 2003, Ives Erickson et al. 2004,
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Suhonen et al. 2009) more closely to find out how these variables affect patient care and care quality. Ethical climate The ethical climate is one specific part of the overall organizational climate (Victor & Cullen 1987, Olson 1995) and has been defined in terms of the organizational practices and conditions that impact on the way different problems with ethical implications are discussed and managed (Olson 1998, Hart 2005). Victor and Cullen (1987) define the organizational ethical climate more specifically in terms of a system of values, norms, beliefs, behaviours and habits that impact the behaviours of employees in a specific organization. According to Olson (1995), nurses’ views of the ethical climate include the way ethical issues in the work place are discussed and managed. Studies about the ethical climate in organizations are limited, especially in the healthcare arena. It is important to investigate and understand the ethical climate because it has been found to be associated with employees’ job satisfaction (Rathert & May 2007), decisions to leave their current vacancy (Hart 2005, Ulrich et al. 2007), moral distress (Pauly et al. 2009 L€ utzen et al. 2010) and the quality of care (Rathert & May 2007, Tellis-Nayak 2007). Previous studies on ethical climate revealed the inadequacy in ethical climate in acute care hospitals as this was perceived by nursing professionals (e.g. Corley et al. 2005, Pauly et al. 2009). Based on these studies, nurses have reported a moderate level of moral distress intensity. However, information of ethical climate in care settings for older people is lacking. The professional practice environment The professional practice environment has received attention in research and clinical practice because it is associated with staff outcomes (Lake 2007, Rathert & May 2007), nursing shortages, intention to leave the profession, job satisfaction (Kramer & Hafner 1989), care quality (Kramer & Hafner 1989, Lake 2007) and patient outcomes (McGillis Hall & Doran 2004). The professional practice environment is concerned with the autonomy and accountability of professionals (Kramer & Schmalenberg 2003). It has been found to be important in increasing the professional empowerment of nurses and to the establishment of effective work teams (Laschinger & Havens 1996, Massachussets General Hospital 2007). The professional practice environment includes structural factors, for example communication systems and resources and social and behavioural factors, including teamwork (Curry et al. 2000, Ives Erickson et al. 2004), social 1358
relations, leadership and management (Ives Erickson et al. 2004, Suhonen et al. 2009) and climate or atmosphere (Walker et al. 1999). A good professional practice environment facilitates the highest levels of clinical practice as it allows nurses to work effectively in an inter-disciplinary group of caregivers, mobilizing resources quickly and appropriately (Lake 2007) and demonstrating control over practice (Lewis & Urmston 2000). However, shortcomings and needs for development have been identified in practice environments (e.g. Charalambous et al. 2010). Charalambous et al. (2010) found that nurses believed that they did not have control over practice and also experienced some problems in working as a team. Tourangeau et al. (2009) indicated the opportunities for improvement of professional practice environment in the long-term care for older people. The need for these improvements was based on the fact that nurse professionals reported moderate levels of emotional exhaustion and more than every third reported plans to leave their employment. Individualized nursing care Individualized nursing care has been defined in terms of nursing activities in the processes of nursing care delivery (Radwin & Alster 2002, Suhonen et al. 2008) and perceptions of individuality in the care received (Suhonen et al. 2005) or provided (Suhonen et al. 2010). The abstract concept of individualized care has been used synonymously with ‘person and patient-centred’ and ‘tailored’ care (Lauver et al. 2002, McCormack & McCance 2006, Suhonen et al. 2008). Related to this, the individualization of care has been regarded as one attribute of person-centred care (Morgan & Yoder 2012), which is holistic care taking into consideration individuals’ needs, experiences, preferences, desires, behaviours, perceptions, feelings and understandings (Radwin & Alster 2002, Suhonen et al. 2007, 2010, Charalambous et al. 2012). The individualization of care cannot be achieved without finding ways to understand different people’s life situations, their preferences and the level of their desire and ability to participate in care decisions and take control over their own care (Suhonen et al. 2004). The concept of individualized care consists of coming to know patients’ characteristics in three ways: in their clinical individual situation, in their personal life situation or context, and in the decisional control over their own care to be provided. (Suhonen et al. 2005, 2010). Nurses have reported high levels of individuality in the care, especially in supporting older patients’ individuality through nursing activities and holding strong opinions as regards to the level of individuality in the care they provided (Suhonen et al. 2012). However, preceding © 2013 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
Ethical climate, professional practice environment and individualized care
studies also revealed shortcomings in providing individualized care for older people (Teeri et al. 2006, Caspar et al. 2009). Ethical climate, professional practice environment and individualized care A considerable number of research studies have been conducted on the ethical climate of healthcare organizations (Olson 1998, Pauly et al. 2009, Silen et al. 2011), the professional practice environment (Ives Erickson et al. 2004, 2009) and individualized nursing care (Suhonen et al. 2004, 2009, Caspar et al. 2009, Radwin et al. 2009). However, studies on the relationships, if any, between these concepts are scarce. Ethical issues, such as staff attitudes and values, have been found to be the most important facilitators and development forces of individualized care (Walker et al. 1999, Curry et al. 2000). Tellis-Nayak (2007) reported that a good ethical climate produced the energy for individualizing nursing care. It has also been reported that individual nurses’ values reflect the broader contextual value base of the organizations where they work (Olson 1998) and so context-related factors are important to facilitate personcenteredness and the development of cultures sustaining person-centred care (McCormack et al. 2011). Previous studies associated individualized care with the work environment (see Suhonen et al. 2009). The positive relationship among the improvement of the work environment, the implementation of individualized nursing care, the clinical supervision and the significant improvements in nurses’ autonomy, professional development opportunities, recognition for their work and teamwork (Hallberg et al. 1993) has been acknowledged for many years. However, the study by Hallberg et al. (1993) drew their conclusions merely on two units for people having severe memory disorders. More recently, supporting these earlier findings, the provision of individualized care has been found to be associated with a good working environment (Cohen-Mansfield & Parpura-Gill 2008, Suhonen et al. 2009). Rathert and May (2008) conceptualized person-centred work environments that incorporate benevolent ethical climates and facilitate patient-centred care and quality improvement. Moving into work at the healthcare team level, McCormack et al. (2010) highlighted the importance of the development of teamwork, workload, time management and staff relations to create a culture where there is space for the formation of person-centred relationships. Charalambous et al. (2010) found that nurses’ perceptions about the level of individuality in care were associated with variables reflecting professional practice environment, such as handling conflict, work motivation, control over © 2013 John Wiley & Sons Ltd
practice, leadership and autonomy, relationships with physicians and cultural sensitivity. Takase et al. (2005) investigated the relationship between nurses’ perception of their working environment and work performance and intention to quit their jobs. They found that nurses’ work values explained their performance and their intentions to quit their jobs. They found that nurses’ job performance was maintained in an environment offering professional incentives and highlighting the nurses’ personal and group work ethics. The preceding body of research demonstrated the preliminary associations between individualized care, the ethical climate and the professional practice environment, but also the lack of research exploring these associations in the care of older people.
The study Aim The aim of the study was to investigate the associations among the ethical climate, the professional practice environment and individualized nursing care in care settings for older people. The study was driven by the following hypothesis: Nurses’ higher assessments of the ethical climate and the professional practice environment are associated with higher assessments of individuality in care provision.
Design This study employed a cross-sectional explorative and correlational survey design.
Sample and settings Data were collected between 1 February–27 April 2012 from 1513 nurses (874 responded, response rate 58%) working clinically in older people care settings (62 different units) in the vicinity of a large city in Southern Finland. These settings were as follows: specialized acute medical care hospitals’ inpatient wards (one university hospital, two regional hospitals and one city hospital, 12 units, n = 136), the municipal health centre hospitals inpatient wards (18 units, n = 313), institutional nursing homes (17 units, n = 255) and residential homes with assistance (15 units, n = 170). The total sample of different level nurses was recruited from the units participating in the study. The inclusion criteria for the nurses were to: (1) be a Registered Nurse, practical nurse or nurse auxiliary; (2) be working clinically in the social or healthcare unit for older people; (3) be aged 18 years or older; and (4) volunteer to participate in the study. In 1359
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Finland, care for older people is provided under the social and healthcare legislation and in different types of organizations (Ministry of Social Affairs & Health 2008).
Data collection Data were collected using questionnaires including three validated instruments, the Hospital Ethical Climate Survey (HECS; Olson 1998), the Revised Professional Practice Environment (RPPE) scale (Ives Erickson et al. 2004, 2009) and the second part of the Individualised Care Scale-Nurse (ICS-Nurse-B); Suhonen et al. 2010, 2011). In addition, the participants’ socio-demographic variables were collected. The Hospital Ethical Climate Survey (HECS) The HECS (Olson 1995, 1998), originally developed in the United States of America for the measurement of nurses’ perceptions of the ethical climate in their work setting (Olson 1998), is a self-administered questionnaire consisting of 26 items with a 5-point scale ranging from 1–5 (1 = almost never true to 5 = almost always true) and has five sub-scales organized according to the relationships of nurses with: Peers, Patients, Managers, Hospital and Physicians (Olson 1998). The higher the HECS score, the more positive the ethical climate. Permission to use the HECS in this current study was obtained from L. Olson on 20 January 2011. The Revised Professional Practice Environment (RPPE) Scale The RPPE scale (Ives Erickson et al. 2004, 2009) was developed in the USA for the measurement of professional practice environment characteristics. The RPPE scale is divided into 39 items in eight sub-scales: Handling Disagreement and Conflict (nine items, including three negatively worded); Internal Work Motivation (eight items); Control over Practice (five items); Leadership and Autonomy in Clinical Practice (five items); Staff Relationships with Physicians (two items); Teamwork (four items, including three negatively worded); Cultural Sensitivity (three items); and Communication about Patients (three items including one negatively worded). Each item of the RPPE scale has a 4-point measure (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). Permission to use the RPPE scale was granted from Boston General Hospital by D. Jones on 4 November 2011. The Individualised Care Scale (ICS-Nurse) The Individualised Care Scale (ICS-Nurse version; Suhonen et al. 2010, 2011) was originally developed in Finland for the measurement of nurses’ views about individualized care 1360
in two dimensions (ICS-Nurse-A and B). The ICS-Nurse-A seeks nurses’ views on how they support patient individuality through nursing activities in general and the ICS-NurseB seeks the extent to which nurses perceive the care they provide to patients is individualized. The ICS-Nurse version was developed from the earlier patient version (Suhonen et al. 2004, 2005). In this study, only the ICS-Nurse-B was used, which consists of 17 items divided into three subscales considering individuality in: the clinical situation (seven items), the personal life situation (four items) and in decisional control over care (six items). The response format is a 5-point Likert-type scale where 5 = strongly agree, 4 = agree to some extent, 3 = do not agree nor disagree, 2 = disagree to some extent and 1 = strongly disagree. Completed questionnaires were returned into letter boxes, designed for that purpose and situated in each unit. The research team collected the completed questionnaires at the end of the data collection period and the completed questionnaire was considered as consent for participation in the study. The research team members placed telephone reminders to each unit every 2 weeks following the commencement of the study.
Ethical considerations Research Ethics Committee approval was given by the Ethics Committee of the University of Turku (24/2011, 12 December 2011) and permission to collect the main and pilot-test data were obtained from the chief medical and nursing administrators of the participating organizations. Initially, ward managers or nurse leaders of the organizations were informed about the study, in writing and orally, by the research team members. In addition, a written guideline for collecting the data was sent to each unit. The managers and leaders of each unit then sent the questionnaires with a covering letter to each eligible potential participant. The covering letter provided information about: the purpose of the study, the voluntary and anonymous participation in the study, the management of confidentiality in the study and the right of the participants to withdrawn at any stage from the study.
Data analysis Data were analysed statistically using the IBM SPSS 20.0 statistical software (IBM Corporation). Firstly, descriptive statistics (frequencies, percentages, means and standard deviations with 95% confidence intervals (CIs)) were computed for the demographic characteristics and for the three validated questionnaires, at the item level and the © 2013 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
Ethical climate, professional practice environment and individualized care
sum-variable level. Secondly, one-way analysis of ANOVA (F-test, d.f. and P-value) was used to examine the differences between the care settings in nurses’ assessments of ethical climate, professional practice environment and perceptions of individuality in care provided. Thirdly, Pearson’s correlation coefficients were computed between the study variables under consideration. Fourthly, Stepwise Multiple Regression analysis (Forward selection method) was used to examine how the HECS scores, assessing the ethical climate and the RPPE sub-scale scores, assessing the professional practice environment, explained the variance in the ICS-Nurse-B scores, assessing perceived individuality in care. The results demonstrate the overall explanatory power of the predictor variables (R2) and the relative importance of individual predictor variables in the specific analyses and uses the standardized regression coefficient (beta). Variance Inflation Factor (VIF) and tolerance values were examined to detect multicollinearity (O’Brien 2007). These indices define the share of variability in each variable that is not explained by its linear relationships with the other independent variables in the model (O’Brien 2007). Finally, Cronbach’s alpha coefficients were used to assess the internal consistency reliability of the scales; P ≤ 005 was considered statistically significant in all statistical analyses.
Validity and reliability The HECS was translated from American-English to Finnish using standard, forward-back translation methods (Sidani et al. 2010). Two official translators completed the translations and three researchers assessed the different translated versions. The content validity of the HECS has been confirmed in a concept analysis (Olson 1995) and the Content Validity Index has been assessed favourably by an expert panel at 089 (Olson 1998). The construct validity of the HECS has also been confirmed in a confirmatory factor analysis (Olson 1998) and favourable Cronbach’s alpha coefficients of 091 (Olson 1998) and 092 (Silen et al. 2011) have been reported. The RPPE scale has earlier been translated into Finnish (Charalambous et al. 2010, Papastavrou et al. 2012) with a Cronbach’s alpha coefficient of 087 in the Papastavrou et al. (2012) study. The ICS-Nurse-B had internal consistency reliability (alpha) of 084 in a Finnish study (Suhonen et al. 2010) and of 088 and 087 in an international study (Suhonen et al. 2011). In this study, Cronbach’s alpha for the HECS was 092, for the RPPE was 089 and for the ICS-B was 089. A pilot-study was conducted in one regional hospital using a sample of 112 nurses (70 responded, response rate © 2013 John Wiley & Sons Ltd
Table 1 Descriptive statistics of the study variables. Variables
Number of items
N
Mean
1 Perceptions of individuality in the care provided (ICS-B-Nurse) 17 865 392 2 Hospital Ethical 26 869 385 Climate (HECS) 9 864 266 3 Handling Disagreement and Conflict 4 Internal Work 8 862 314 Motivation 5 Control over Practice 5 863 234 5 863 292 6 Leadership and Autonomy in Clinical Practice 7 Staff Relationships 2 857 287 with Physicians 8 Teamwork 4 855 280 9 Cultural Sensitivity 3 861 307 10 Communication 3 859 304 about Patients
SD
Range
056 056
1–5 1–5
040
1–4
047
1–4
066 055
1–4 1–4
081
1–4
058 060 050
1–4 1–4 1–4
63%) in December 2011 to assess the feasibility of the data collection protocol and to test the instruments, especially the translated HECS. Cronbach’s alpha coefficients were 090 for the HECS, 079 for the RPPE scale and 094 for the ICS-Nurse-B. No needs for changes were made based on the pilot-study.
Results Participants The mean age of the respondents was 42 (SD 126) years (range 18–68) and most respondents were females (n = 829, 95%). Slightly over one quarter of the sample (n = 870) were registered nurses (29%), 63% were licensed practical nurses and 8% were nurse auxiliaries. The average length of work experience in health and social care was 14 (SD 105) years (range 1 month–45 years) and most of the respondents (n = 870) worked full-time (94%). The rest of the respondents worked part-time (4%) or worked casual shifts (2%).
Description of the study variables Nurses perceived that the care they provided to older people was individualized to some extent (Mean 392 SD 056) (Table 1). Nurses regarded that the environment they worked in shared an ethical climate to a moderate extent 1361
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Table 2 Differences between care settings in nurses’ perceptions of ethical climate, professional practice environment and individuality n care provided.
Variable Ethical climate (HECS) Professional practice environment (RPPE) Individuality in care provided (ICS-B-Nurse) *ANOVA, F-test. d.f., degrees of freedom.
SD,
Care setting Specialized acute medical care hospitals Mean (SD)
Municipal health centre hospitals Mean (SD)
Nursing homes Mean (SD)
Residential homes with assistance Mean (SD)
F* (d.f.)
P-value
379 (051)
379 (058)
389 (054)
393 (055)
310 (3, 865)
0026
290 (028)
281 (037)
284 (036)
284 (037)
227 (3, 863)
0079
393 (050)
387 (057)
389 (059)
404 (054)
349 (3, 861)
0015
Standard deviation.
Table 3 Correlations between the study variables. Variables
1
2
3
4
5
6
1 ICS-B-Nurse 2 HECS 3 Handling Disagreement and Conflict 4 Internal Work Motivation 5 Control over Practice 6 Leadership and Autonomy in Clinical Practice 7 Staff Relationships with Physicians 8 Teamwork 9 Cultural Sensitivity 10 Communication about Patients
(089) 0371** 0226**
(092) 0527**
(057)
0296** 0359** 0667**
0445** 0424** 0635**
0243** 0303** 0354** 0284**
7
0359** 0286** 0445**
(075) 0326** 0402**
(081) 0474**
(071)
0354**
0301**
0318**
0309**
0391**
(078)
0321** 0561** 0420**
0376** 0537** 0350**
0180** 0518** 0262**
0296** 0373** 0299**
0343** 0428** 0335**
0232** 0346** 0251**
8
9
10
(067) 0325** 0227**
(072) 0383**
(047)
Figures in the diagonal are Cronbach’s alpha values. **P < 0001.
(Mean 385 SD 055). The best dimensions of the professional practice environment as assessed by nurses were the internal work motivation (Mean 314 SD 047), cultural sensitivity (Mean 307 SD 060) and communication about patients (Mean 304 SD 050). ANOVA revealed differences between care settings in nurses’ perceptions of ethical environment and individuality in care provided (Table 2).
Correlations between the variables A statistically significant Pearson’s correlation coefficient of 0371 was found between the ethical climate and the individuality in the care provided (Table 3). The highest correlation coefficients with professional practice environment (the RPPE sub-scales) were found between ICS-Nurse-B and Leadership and Autonomy in Clinical Practice (r = 0667), 1362
Control over Practice (r = 0359) and Cultural Sensitivity (r = 0354). In addition, correlations were found between the ICS-Nurse-B and Teamwork (r = 0303), Internal Work Motivation (r = 0296), Communication about Patients (r = 0284), Staff Relationships with Physicians (r = 0243) and Handling Disagreement and Conflict (r = 0226). Even though all correlations between the individuality in the care provided and the professional practice environment were low, they were statistically significant.
Stepwise multiple regression analyses The predictive ability of the ethical climate (HECS total) and professional practice environment (RPPE sub-scales) in individuality in care provided were evaluated by regressing the ICS-Nurse-B on the HECS and RPPE sub-scales, in stepwise © 2013 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
Ethical climate, professional practice environment and individualized care
Table 4 Stepwise multiple regression of the ethical climate (HECS) and three factors of the professional practice environment (RPPE) on the Individuality in care provided (ICS-B-Nurse).
Variable
Multiple R
R2
R2 change
HECS-26 RPPE Internal Work Motivation RPPE Control over Practice RPPE Leadership & Autonomy in Clinical Practice
0362 0391 0396 0402
0131 0153 0157 0162
0131 0022 0004 0005
Beta coefficient 0325 0160 0092 0103
T 6826 4464 2508 2182
P-value
VIF
Tolerance
The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people Riitta Suhonen, Minna Stolt, Marja-Liisa Gustafsson, Jouko Katajisto & Andreas Charalambous Accepted for publication 5 October 2013
Correspondence to R. Suhonen: e-mails: [email protected]; [email protected] Riitta Suhonen PhD RN Professor Department of Nursing Science, University of Turku, Finland Minna Stolt PhD University Teacher/Podiatrist Department of Nursing Science, University of Turku, Finland Marja-Liisa Gustafsson Public Health Nurse MNSc PhD Student/Senior Lecturer Department of Nursing Science, University of Turku, Finland Jouko Katajisto MSocSci Senior Lecturer Department of Mathematics and Statistics, University of Turku, Finland Andreas Charalambous PhD RN Lecturer of Oncology Nursing Department of Nursing Studies, Cyprus University of Technology, Limassol, Cyprus
SUHONEN
R.,
STOLT
M.,
GUSTAFSSON
M.-L.,
KATAJISTO
J.
&
The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people. Journal of Advanced Nursing 70(6), 1356–1368. doi: 10.1111/jan.12297 CHARALAMBOUS A. (2014)
Abstract Aim. To investigate the associations among the ethical climate, professional practice environment and individualized nursing care in care settings for older people. Background. The quality of care provision is affected by organizational environments, such as ethical climate and professional practice environment. Although, the association between professional practice environment and individualized nursing care has been pointed out, we know that little is known about how ethical climate is associated with the level of individualized nursing care delivery. Design. A cross-sectional explorative and correlational survey design. Methods. The study was conducted in 62 units in the vicinity of a Finnish city using a sample of nurses (N = 874, response rate 58%) who worked clinically with older people in different care settings in 2012. Survey data were collected using the Hospital Ethical Climate Survey, Revised Professional Practice Environment scale and Individualised Care Scale-B. Data were analysed statistically using descriptive statistics, correlation coefficients (Pearson) and multiple stepwise regression analyses. Results. Statistically significant correlations were found among the variables, ethical climate and individualized care and between individualized care and all professional practice environment sub-scales. Multiple stepwise regression showed associations among individualized care, ethical climate and internal work motivation, control over practice and leadership and autonomy. Conclusions. The study provided better understanding of the complex concept of individualized care by taking into consideration the ethical climate and the practice environment and their associations. To increase individualization in care provision, efforts need to be directed towards organizational aspects requiring the support of nursing leaders. Keywords: ethical climate, individualized care, nurse, older people care, professional practice environment, survey
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© 2013 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH
Ethical climate, professional practice environment and individualized care
Why is this research or review needed? • The quality of care is associated with the organizational and care environments. Every attempt to make care of older people and care environments attractive for the nursing professionals should be considered. • There is need for developing quality nursing care and services for an increasing number of older people. • To explore the role of the ethical climate and the professional practice environment on the delivery of individualized nursing care.
What are the three key findings? • Individualization of care was influenced by the ethical cli-
2001, Rafferty et al. 2007) suggesting that there is an increasing need for developing the care environment. Given the increasing number of older people worldwide (U.S Census Bureau 2009, WHO 2012) those who need institutional care is also increasing posing challenges to the healthcare services. In addition, the projected shortage of skilled professionals (Chenoweth et al. 2010) and the concern that newly graduated nurses do not consider caring for older people as an option for their future careers (Kloster et al. 2007, Chenoweth et al. 2010) are factors that need to be addressed. For these reasons, research on working conditions, environment and climate is of vital importance, especially in older people care contexts.
mate of the organization and the professional practice environment at the point of care delivery. • Statistically significant associations were found in the multiple stepwise regression analyses between individualized care and the organizational variables, namely ethical climate, internal work motivation, control over practice, leadership and autonomy. • The associations found stress the need to focus any efforts on specific aspects of the organization to promote individualization in the care provision.
How should the findings be used to influence policy/ practice/research/education? • Nurses’ working conditions and thereby quality of care provided for patients can be developed by focussing developmental activities for the working environment and climate. As these can be changed by effective management, every attempt should be made by nurse leaders and managers to retain skilled work force.
Introduction Understanding and developing the organizational environment is of global importance (Rathert & May 2007) as the work environment has an effect on the behaviour of employees in organizations (Olson 1998) and this has played a substantial role in the successful implementation of quality initiatives in patient care provision (McGillis Hall & Doran 2004, Chan et al. 2006, Rafferty et al. 2007). Outcomes for nursing, individual nursing staff and institutions are also associated with the organizational context where care is delivered (Aiken et al. 2001, Wlody 2007, Charalambous et al. 2010). However, healthcare staff report similar shortcomings in their work environments related to the quality of care and the services, although the healthcare systems differ between countries (Aiken et al.
© 2013 John Wiley & Sons Ltd
Background Some evidence exists that care settings for older patients could be more attractive for workers. Castle et al. (2006) report low work satisfaction perceived by nursing staff in care settings for older people. Work satisfaction has been found to be associated with work, working climate and care delivery activities and processes (Castle et al. 2006, Hasson & Arnetz 2008). Furthermore, it has also been found that personalizing care had significant influence on work satisfaction (Edvardsson et al. 2011) and commitment (Tellis-Nayak 2007). Thus, the working environment and climate may have an important contribution on nurse retention and quality care. The growth in the global understanding of the work environment and the organizational climate has taken place over many years (Olson 1998, Ives Erickson et al. 2004) in parallel with the ethically driven requirement for individualized or person-centred care (ICN 2006, Thompson et al. 2006). Individualized nursing care delivery has also been found to be associated with some organizational variables including organization of work, leadership and management (Suhonen et al. 2007, 2009, Tellis-Nayak 2007). In addition, nurses have demonstrated the effect of organizational variables on their work reporting that individual persons’ needs and the requirements of the organization are not congruent (Hart 2005), which may produce ethical problems (Olson 1998, Wlody 2007). However, only a few studies have examined the associations among individualized nursing care, the professional practice environment and the ethical climate (Tellis-Nayak 2007, Charalambous et al. 2010, Edvardsson et al. 2011). Thus, there is a need to examine the organizational variables including professional, environmental and ethical climate issues in association with nursing care delivery (Scott et al. 2003, Ives Erickson et al. 2004,
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Suhonen et al. 2009) more closely to find out how these variables affect patient care and care quality. Ethical climate The ethical climate is one specific part of the overall organizational climate (Victor & Cullen 1987, Olson 1995) and has been defined in terms of the organizational practices and conditions that impact on the way different problems with ethical implications are discussed and managed (Olson 1998, Hart 2005). Victor and Cullen (1987) define the organizational ethical climate more specifically in terms of a system of values, norms, beliefs, behaviours and habits that impact the behaviours of employees in a specific organization. According to Olson (1995), nurses’ views of the ethical climate include the way ethical issues in the work place are discussed and managed. Studies about the ethical climate in organizations are limited, especially in the healthcare arena. It is important to investigate and understand the ethical climate because it has been found to be associated with employees’ job satisfaction (Rathert & May 2007), decisions to leave their current vacancy (Hart 2005, Ulrich et al. 2007), moral distress (Pauly et al. 2009 L€ utzen et al. 2010) and the quality of care (Rathert & May 2007, Tellis-Nayak 2007). Previous studies on ethical climate revealed the inadequacy in ethical climate in acute care hospitals as this was perceived by nursing professionals (e.g. Corley et al. 2005, Pauly et al. 2009). Based on these studies, nurses have reported a moderate level of moral distress intensity. However, information of ethical climate in care settings for older people is lacking. The professional practice environment The professional practice environment has received attention in research and clinical practice because it is associated with staff outcomes (Lake 2007, Rathert & May 2007), nursing shortages, intention to leave the profession, job satisfaction (Kramer & Hafner 1989), care quality (Kramer & Hafner 1989, Lake 2007) and patient outcomes (McGillis Hall & Doran 2004). The professional practice environment is concerned with the autonomy and accountability of professionals (Kramer & Schmalenberg 2003). It has been found to be important in increasing the professional empowerment of nurses and to the establishment of effective work teams (Laschinger & Havens 1996, Massachussets General Hospital 2007). The professional practice environment includes structural factors, for example communication systems and resources and social and behavioural factors, including teamwork (Curry et al. 2000, Ives Erickson et al. 2004), social 1358
relations, leadership and management (Ives Erickson et al. 2004, Suhonen et al. 2009) and climate or atmosphere (Walker et al. 1999). A good professional practice environment facilitates the highest levels of clinical practice as it allows nurses to work effectively in an inter-disciplinary group of caregivers, mobilizing resources quickly and appropriately (Lake 2007) and demonstrating control over practice (Lewis & Urmston 2000). However, shortcomings and needs for development have been identified in practice environments (e.g. Charalambous et al. 2010). Charalambous et al. (2010) found that nurses believed that they did not have control over practice and also experienced some problems in working as a team. Tourangeau et al. (2009) indicated the opportunities for improvement of professional practice environment in the long-term care for older people. The need for these improvements was based on the fact that nurse professionals reported moderate levels of emotional exhaustion and more than every third reported plans to leave their employment. Individualized nursing care Individualized nursing care has been defined in terms of nursing activities in the processes of nursing care delivery (Radwin & Alster 2002, Suhonen et al. 2008) and perceptions of individuality in the care received (Suhonen et al. 2005) or provided (Suhonen et al. 2010). The abstract concept of individualized care has been used synonymously with ‘person and patient-centred’ and ‘tailored’ care (Lauver et al. 2002, McCormack & McCance 2006, Suhonen et al. 2008). Related to this, the individualization of care has been regarded as one attribute of person-centred care (Morgan & Yoder 2012), which is holistic care taking into consideration individuals’ needs, experiences, preferences, desires, behaviours, perceptions, feelings and understandings (Radwin & Alster 2002, Suhonen et al. 2007, 2010, Charalambous et al. 2012). The individualization of care cannot be achieved without finding ways to understand different people’s life situations, their preferences and the level of their desire and ability to participate in care decisions and take control over their own care (Suhonen et al. 2004). The concept of individualized care consists of coming to know patients’ characteristics in three ways: in their clinical individual situation, in their personal life situation or context, and in the decisional control over their own care to be provided. (Suhonen et al. 2005, 2010). Nurses have reported high levels of individuality in the care, especially in supporting older patients’ individuality through nursing activities and holding strong opinions as regards to the level of individuality in the care they provided (Suhonen et al. 2012). However, preceding © 2013 John Wiley & Sons Ltd
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Ethical climate, professional practice environment and individualized care
studies also revealed shortcomings in providing individualized care for older people (Teeri et al. 2006, Caspar et al. 2009). Ethical climate, professional practice environment and individualized care A considerable number of research studies have been conducted on the ethical climate of healthcare organizations (Olson 1998, Pauly et al. 2009, Silen et al. 2011), the professional practice environment (Ives Erickson et al. 2004, 2009) and individualized nursing care (Suhonen et al. 2004, 2009, Caspar et al. 2009, Radwin et al. 2009). However, studies on the relationships, if any, between these concepts are scarce. Ethical issues, such as staff attitudes and values, have been found to be the most important facilitators and development forces of individualized care (Walker et al. 1999, Curry et al. 2000). Tellis-Nayak (2007) reported that a good ethical climate produced the energy for individualizing nursing care. It has also been reported that individual nurses’ values reflect the broader contextual value base of the organizations where they work (Olson 1998) and so context-related factors are important to facilitate personcenteredness and the development of cultures sustaining person-centred care (McCormack et al. 2011). Previous studies associated individualized care with the work environment (see Suhonen et al. 2009). The positive relationship among the improvement of the work environment, the implementation of individualized nursing care, the clinical supervision and the significant improvements in nurses’ autonomy, professional development opportunities, recognition for their work and teamwork (Hallberg et al. 1993) has been acknowledged for many years. However, the study by Hallberg et al. (1993) drew their conclusions merely on two units for people having severe memory disorders. More recently, supporting these earlier findings, the provision of individualized care has been found to be associated with a good working environment (Cohen-Mansfield & Parpura-Gill 2008, Suhonen et al. 2009). Rathert and May (2008) conceptualized person-centred work environments that incorporate benevolent ethical climates and facilitate patient-centred care and quality improvement. Moving into work at the healthcare team level, McCormack et al. (2010) highlighted the importance of the development of teamwork, workload, time management and staff relations to create a culture where there is space for the formation of person-centred relationships. Charalambous et al. (2010) found that nurses’ perceptions about the level of individuality in care were associated with variables reflecting professional practice environment, such as handling conflict, work motivation, control over © 2013 John Wiley & Sons Ltd
practice, leadership and autonomy, relationships with physicians and cultural sensitivity. Takase et al. (2005) investigated the relationship between nurses’ perception of their working environment and work performance and intention to quit their jobs. They found that nurses’ work values explained their performance and their intentions to quit their jobs. They found that nurses’ job performance was maintained in an environment offering professional incentives and highlighting the nurses’ personal and group work ethics. The preceding body of research demonstrated the preliminary associations between individualized care, the ethical climate and the professional practice environment, but also the lack of research exploring these associations in the care of older people.
The study Aim The aim of the study was to investigate the associations among the ethical climate, the professional practice environment and individualized nursing care in care settings for older people. The study was driven by the following hypothesis: Nurses’ higher assessments of the ethical climate and the professional practice environment are associated with higher assessments of individuality in care provision.
Design This study employed a cross-sectional explorative and correlational survey design.
Sample and settings Data were collected between 1 February–27 April 2012 from 1513 nurses (874 responded, response rate 58%) working clinically in older people care settings (62 different units) in the vicinity of a large city in Southern Finland. These settings were as follows: specialized acute medical care hospitals’ inpatient wards (one university hospital, two regional hospitals and one city hospital, 12 units, n = 136), the municipal health centre hospitals inpatient wards (18 units, n = 313), institutional nursing homes (17 units, n = 255) and residential homes with assistance (15 units, n = 170). The total sample of different level nurses was recruited from the units participating in the study. The inclusion criteria for the nurses were to: (1) be a Registered Nurse, practical nurse or nurse auxiliary; (2) be working clinically in the social or healthcare unit for older people; (3) be aged 18 years or older; and (4) volunteer to participate in the study. In 1359
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Finland, care for older people is provided under the social and healthcare legislation and in different types of organizations (Ministry of Social Affairs & Health 2008).
Data collection Data were collected using questionnaires including three validated instruments, the Hospital Ethical Climate Survey (HECS; Olson 1998), the Revised Professional Practice Environment (RPPE) scale (Ives Erickson et al. 2004, 2009) and the second part of the Individualised Care Scale-Nurse (ICS-Nurse-B); Suhonen et al. 2010, 2011). In addition, the participants’ socio-demographic variables were collected. The Hospital Ethical Climate Survey (HECS) The HECS (Olson 1995, 1998), originally developed in the United States of America for the measurement of nurses’ perceptions of the ethical climate in their work setting (Olson 1998), is a self-administered questionnaire consisting of 26 items with a 5-point scale ranging from 1–5 (1 = almost never true to 5 = almost always true) and has five sub-scales organized according to the relationships of nurses with: Peers, Patients, Managers, Hospital and Physicians (Olson 1998). The higher the HECS score, the more positive the ethical climate. Permission to use the HECS in this current study was obtained from L. Olson on 20 January 2011. The Revised Professional Practice Environment (RPPE) Scale The RPPE scale (Ives Erickson et al. 2004, 2009) was developed in the USA for the measurement of professional practice environment characteristics. The RPPE scale is divided into 39 items in eight sub-scales: Handling Disagreement and Conflict (nine items, including three negatively worded); Internal Work Motivation (eight items); Control over Practice (five items); Leadership and Autonomy in Clinical Practice (five items); Staff Relationships with Physicians (two items); Teamwork (four items, including three negatively worded); Cultural Sensitivity (three items); and Communication about Patients (three items including one negatively worded). Each item of the RPPE scale has a 4-point measure (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). Permission to use the RPPE scale was granted from Boston General Hospital by D. Jones on 4 November 2011. The Individualised Care Scale (ICS-Nurse) The Individualised Care Scale (ICS-Nurse version; Suhonen et al. 2010, 2011) was originally developed in Finland for the measurement of nurses’ views about individualized care 1360
in two dimensions (ICS-Nurse-A and B). The ICS-Nurse-A seeks nurses’ views on how they support patient individuality through nursing activities in general and the ICS-NurseB seeks the extent to which nurses perceive the care they provide to patients is individualized. The ICS-Nurse version was developed from the earlier patient version (Suhonen et al. 2004, 2005). In this study, only the ICS-Nurse-B was used, which consists of 17 items divided into three subscales considering individuality in: the clinical situation (seven items), the personal life situation (four items) and in decisional control over care (six items). The response format is a 5-point Likert-type scale where 5 = strongly agree, 4 = agree to some extent, 3 = do not agree nor disagree, 2 = disagree to some extent and 1 = strongly disagree. Completed questionnaires were returned into letter boxes, designed for that purpose and situated in each unit. The research team collected the completed questionnaires at the end of the data collection period and the completed questionnaire was considered as consent for participation in the study. The research team members placed telephone reminders to each unit every 2 weeks following the commencement of the study.
Ethical considerations Research Ethics Committee approval was given by the Ethics Committee of the University of Turku (24/2011, 12 December 2011) and permission to collect the main and pilot-test data were obtained from the chief medical and nursing administrators of the participating organizations. Initially, ward managers or nurse leaders of the organizations were informed about the study, in writing and orally, by the research team members. In addition, a written guideline for collecting the data was sent to each unit. The managers and leaders of each unit then sent the questionnaires with a covering letter to each eligible potential participant. The covering letter provided information about: the purpose of the study, the voluntary and anonymous participation in the study, the management of confidentiality in the study and the right of the participants to withdrawn at any stage from the study.
Data analysis Data were analysed statistically using the IBM SPSS 20.0 statistical software (IBM Corporation). Firstly, descriptive statistics (frequencies, percentages, means and standard deviations with 95% confidence intervals (CIs)) were computed for the demographic characteristics and for the three validated questionnaires, at the item level and the © 2013 John Wiley & Sons Ltd
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sum-variable level. Secondly, one-way analysis of ANOVA (F-test, d.f. and P-value) was used to examine the differences between the care settings in nurses’ assessments of ethical climate, professional practice environment and perceptions of individuality in care provided. Thirdly, Pearson’s correlation coefficients were computed between the study variables under consideration. Fourthly, Stepwise Multiple Regression analysis (Forward selection method) was used to examine how the HECS scores, assessing the ethical climate and the RPPE sub-scale scores, assessing the professional practice environment, explained the variance in the ICS-Nurse-B scores, assessing perceived individuality in care. The results demonstrate the overall explanatory power of the predictor variables (R2) and the relative importance of individual predictor variables in the specific analyses and uses the standardized regression coefficient (beta). Variance Inflation Factor (VIF) and tolerance values were examined to detect multicollinearity (O’Brien 2007). These indices define the share of variability in each variable that is not explained by its linear relationships with the other independent variables in the model (O’Brien 2007). Finally, Cronbach’s alpha coefficients were used to assess the internal consistency reliability of the scales; P ≤ 005 was considered statistically significant in all statistical analyses.
Validity and reliability The HECS was translated from American-English to Finnish using standard, forward-back translation methods (Sidani et al. 2010). Two official translators completed the translations and three researchers assessed the different translated versions. The content validity of the HECS has been confirmed in a concept analysis (Olson 1995) and the Content Validity Index has been assessed favourably by an expert panel at 089 (Olson 1998). The construct validity of the HECS has also been confirmed in a confirmatory factor analysis (Olson 1998) and favourable Cronbach’s alpha coefficients of 091 (Olson 1998) and 092 (Silen et al. 2011) have been reported. The RPPE scale has earlier been translated into Finnish (Charalambous et al. 2010, Papastavrou et al. 2012) with a Cronbach’s alpha coefficient of 087 in the Papastavrou et al. (2012) study. The ICS-Nurse-B had internal consistency reliability (alpha) of 084 in a Finnish study (Suhonen et al. 2010) and of 088 and 087 in an international study (Suhonen et al. 2011). In this study, Cronbach’s alpha for the HECS was 092, for the RPPE was 089 and for the ICS-B was 089. A pilot-study was conducted in one regional hospital using a sample of 112 nurses (70 responded, response rate © 2013 John Wiley & Sons Ltd
Table 1 Descriptive statistics of the study variables. Variables
Number of items
N
Mean
1 Perceptions of individuality in the care provided (ICS-B-Nurse) 17 865 392 2 Hospital Ethical 26 869 385 Climate (HECS) 9 864 266 3 Handling Disagreement and Conflict 4 Internal Work 8 862 314 Motivation 5 Control over Practice 5 863 234 5 863 292 6 Leadership and Autonomy in Clinical Practice 7 Staff Relationships 2 857 287 with Physicians 8 Teamwork 4 855 280 9 Cultural Sensitivity 3 861 307 10 Communication 3 859 304 about Patients
SD
Range
056 056
1–5 1–5
040
1–4
047
1–4
066 055
1–4 1–4
081
1–4
058 060 050
1–4 1–4 1–4
63%) in December 2011 to assess the feasibility of the data collection protocol and to test the instruments, especially the translated HECS. Cronbach’s alpha coefficients were 090 for the HECS, 079 for the RPPE scale and 094 for the ICS-Nurse-B. No needs for changes were made based on the pilot-study.
Results Participants The mean age of the respondents was 42 (SD 126) years (range 18–68) and most respondents were females (n = 829, 95%). Slightly over one quarter of the sample (n = 870) were registered nurses (29%), 63% were licensed practical nurses and 8% were nurse auxiliaries. The average length of work experience in health and social care was 14 (SD 105) years (range 1 month–45 years) and most of the respondents (n = 870) worked full-time (94%). The rest of the respondents worked part-time (4%) or worked casual shifts (2%).
Description of the study variables Nurses perceived that the care they provided to older people was individualized to some extent (Mean 392 SD 056) (Table 1). Nurses regarded that the environment they worked in shared an ethical climate to a moderate extent 1361
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Table 2 Differences between care settings in nurses’ perceptions of ethical climate, professional practice environment and individuality n care provided.
Variable Ethical climate (HECS) Professional practice environment (RPPE) Individuality in care provided (ICS-B-Nurse) *ANOVA, F-test. d.f., degrees of freedom.
SD,
Care setting Specialized acute medical care hospitals Mean (SD)
Municipal health centre hospitals Mean (SD)
Nursing homes Mean (SD)
Residential homes with assistance Mean (SD)
F* (d.f.)
P-value
379 (051)
379 (058)
389 (054)
393 (055)
310 (3, 865)
0026
290 (028)
281 (037)
284 (036)
284 (037)
227 (3, 863)
0079
393 (050)
387 (057)
389 (059)
404 (054)
349 (3, 861)
0015
Standard deviation.
Table 3 Correlations between the study variables. Variables
1
2
3
4
5
6
1 ICS-B-Nurse 2 HECS 3 Handling Disagreement and Conflict 4 Internal Work Motivation 5 Control over Practice 6 Leadership and Autonomy in Clinical Practice 7 Staff Relationships with Physicians 8 Teamwork 9 Cultural Sensitivity 10 Communication about Patients
(089) 0371** 0226**
(092) 0527**
(057)
0296** 0359** 0667**
0445** 0424** 0635**
0243** 0303** 0354** 0284**
7
0359** 0286** 0445**
(075) 0326** 0402**
(081) 0474**
(071)
0354**
0301**
0318**
0309**
0391**
(078)
0321** 0561** 0420**
0376** 0537** 0350**
0180** 0518** 0262**
0296** 0373** 0299**
0343** 0428** 0335**
0232** 0346** 0251**
8
9
10
(067) 0325** 0227**
(072) 0383**
(047)
Figures in the diagonal are Cronbach’s alpha values. **P < 0001.
(Mean 385 SD 055). The best dimensions of the professional practice environment as assessed by nurses were the internal work motivation (Mean 314 SD 047), cultural sensitivity (Mean 307 SD 060) and communication about patients (Mean 304 SD 050). ANOVA revealed differences between care settings in nurses’ perceptions of ethical environment and individuality in care provided (Table 2).
Correlations between the variables A statistically significant Pearson’s correlation coefficient of 0371 was found between the ethical climate and the individuality in the care provided (Table 3). The highest correlation coefficients with professional practice environment (the RPPE sub-scales) were found between ICS-Nurse-B and Leadership and Autonomy in Clinical Practice (r = 0667), 1362
Control over Practice (r = 0359) and Cultural Sensitivity (r = 0354). In addition, correlations were found between the ICS-Nurse-B and Teamwork (r = 0303), Internal Work Motivation (r = 0296), Communication about Patients (r = 0284), Staff Relationships with Physicians (r = 0243) and Handling Disagreement and Conflict (r = 0226). Even though all correlations between the individuality in the care provided and the professional practice environment were low, they were statistically significant.
Stepwise multiple regression analyses The predictive ability of the ethical climate (HECS total) and professional practice environment (RPPE sub-scales) in individuality in care provided were evaluated by regressing the ICS-Nurse-B on the HECS and RPPE sub-scales, in stepwise © 2013 John Wiley & Sons Ltd
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Ethical climate, professional practice environment and individualized care
Table 4 Stepwise multiple regression of the ethical climate (HECS) and three factors of the professional practice environment (RPPE) on the Individuality in care provided (ICS-B-Nurse).
Variable
Multiple R
R2
R2 change
HECS-26 RPPE Internal Work Motivation RPPE Control over Practice RPPE Leadership & Autonomy in Clinical Practice
0362 0391 0396 0402
0131 0153 0157 0162
0131 0022 0004 0005
Beta coefficient 0325 0160 0092 0103
T 6826 4464 2508 2182
P-value
VIF
Tolerance
