One of the major needs to meet the challenges of the health system is to promote interprofessional collaboration [1]. Interprofessional collaboration in the health system means that people from different health professions communicate with each other and consult about patient care. This communication should be established in the framework of honesty, mutual trust and respect, and based on the authorities, capabilities, reciprocal responsibilities and consideration of available resources, facilities, equipments and resolving patient problems [2].
Collaboration between the professional team of a hospital, especially the physician and the nurse plays a vital role in patient care, thereby enabling the exchange of information to provide an appropriate patient care plan. It has objective and effective implications for the improvement of patients and Nurses’ Job Satisfaction, leading to lower hospital costs and deaths, improving patients’ health, and increasing the quality of care [3]. Each of the professionals involved in patient care at the hospital looks at their patients’ problems from a professional perspective, and only through an effective collaboration, a comprehensive patient care plan can be developed [4].
The nurse, the physician, and the patient are the three vertices of a triangle who achieve care goals only by interacting with each other. Creating collaboration between physicians and nurses enhances their understanding of each other’s roles, enhances trust between them, avoids unrealistic interprofessional expectations, and enhances expected outcomes for patients [5]. Nurse-Physician Collaboration is a prominent manifestation of professional ethics, which aims to achieve the common goal of treatment that is patient care, and affects the outcome of the treatment directly and indirectly. Physicians and nurses, as the key members of the treatment team must engage in evaluating and implementing a patient care plan by developing an effective and professional communication. Establishing collaboration between employees of an organisation depends primarily on the extent to which ethical values are valued by general policies and managerial policies, adherence to corporate ethics, and the creation and reinforcement of the appropriate ethical climate in that organisation [3,5].
Organisational climate is a phenomenon that is always present in the organisation and it encompasses the mental and emotional space and attitudes of individuals in a concealed and intangible way. The “climate” is not the workplace, nor the way that people respond to it, but is the perceptual channel through which the environmental influences on people’s attitudes and behaviours are determined [6]. Organisational climate is a broad term that plays an important role in understanding the organisation and its behaviours, and the ethical climate is a type of organisational climate [7].
Ethical climate in therapeutic environments includes the specific organisational conditions that facilitate the discussion of patients’ health problems and their resolution, and provides a framework for ethical decision making in clinical settings [8]. It seems that important psychological and emotional aspects of nurses are influenced by the ethical climate of the organisation, so that the undesirable ethical climate in the organisation can cause negative, scary and closed ones, and also distrust, hatred, thereby making people get away from each other [9].
Considering the importance of the existence of co-operative relationships between physician and nurse for improving the quality of patient care, this study aimed to investigate the relationship between the hospital ethical climate and nurses’ attitude to interprofessional collaboration.
Materials and Methods
This was a descriptive study. A total of 196 nurses working in the intensive care units of selected hospitals of Shahid Beheshti University of Medical Sciences in Shahid Beheshti University was selected by convenience sampling method.
To measure the ethical climate of the hospital, Olson proposed the HECS questionnaire in 1995 [10]. He designed the tool in accordance with hospital conditions based on the Victor & Cullen questionnaire, so that it could measure the impact of workplace and organisation on the ability of nurses and social workers to solve ethical problems. The questionnaire includes 26 items in 5 dimensions influential in creating hospital climate. The dimensions include the partners dimension, items (1,10,17,23), the physicians dimension, items (5,9,14,16,22,26), the organisation dimension (hospital), items (4,8,9,13,21,25), the patients dimension, items (2,6,11,18) and the nursing managers dimension (head nurse, supervisor and metron), items (3,7,12,15,20,24). Questionnaire responses are measured on a 5-point Likert’s scale, with a score of 1 being almost never and a score of 5 almost always. Therefore, the higher the score in this questionnaire, the greater the ethical climate in the hospital. Content validity of the questionnaire “the investigation of the hospital ethical climate” was measured using content validity index of 0.89. In this study, the hospital ethical climate questionnaire of Olson was used with the opinion of the supervisors, advisors, and esteemed master reviewers based on the above mentioned validities.
The Jefferson questionnaire, was used to assess nurses’ attitudes to interprofessional collaboration [11], which includes 15 Likert’s-type items answered on a 4-point scale (1=strongly disagree, 2=somewhat Disagree, 3=somewhat agree, 4=strongly agree). The minimum score and the maximum score for each person’s answer will be 15 and 60, respectively. The total score was used as a standard to measure the level of cooperation between physicians and nurses. Based on this score, people were divided into four groups: positive attitude (a score of 49-60), relatively positive attitude (a score of 38-48), relatively negative attitude (a score of 27-37) and negative attitude (a score of 15-26).
After obtaining permission (Code: IR.SBMU.PHNM.1395.591) from the Ethics Committee of Shahid Beheshti University of Medical Sciences, the questionnaires were distributed by the researcher, after self-presentation and expressing the aims of the research and obtaining informed consent orally and ensuring the confidentiality of information, among the research participants in the intensive care unit. After completing within maximum two days, the questionnaires were collected. It is worth noting that sampling took two months (5 days a week), and completing the questionnaires took approximately 20 minutes. Inclusion criteria were at least a bachelor’s degree in nursing and a minimum of six months of clinical practice as a nurse. Exclusion criteria were undergraduate degree in nursing, no work experience in the study areas or work experience less than 6 months in the study areas.
Statistical Analysis
Data were analysed using SPSS software. The mean, frequency percentage and standard deviation were used to determine the level of ethical climate and nurses’ attitude to physician-nurse collaboration, and independent two-sample t-test and one-way ANOVA were used to determine the relationship between individual characteristics and the perception of ethical climate. The significance level was considered <0.05.
Results
This study included 196 nurses working in the intensive care units of hospitals affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran. The mean age of participants was 33.4±8.11. The majority (50.51%) of the study participants had a job in the ICU ward (99) and the rest in the CCU ward (97). The demographic characteristics of the participants are presented in [Table/Fig-1].
The demographic characteristics of the study participants.
| Variable | Absolute frequency | Relative frequency |
|---|
| Sex | Men | 142 | 72.45 |
| Women | 54 | 27.55 |
| Marital status | Single | 85 | 43.37 |
| Married | 101 | 51.53 |
| Others | 10 | 5.10 |
| Level of education | Bachelor’s degree | 164 | 63.67 |
| Master’s degree | 30 | 15.31 |
| PhD | 2 | 1.02 |
| Experience of attendance at ethics workshop | Yes | 97 | 49.49 |
| No | 99 | 50.51 |
| Hospital’s name | Shohadaye Tajrish | 42 | 21.4 |
| Ayatollah Taleghani | 35 | 17.8 |
| Masih Daneshvari | 23 | 11.7 |
| Shaheed Modarres | 31 | 15.8 |
| Loghman Hakim | 17 | 8.6 |
| Imam Hossein | 48 | 24.4 |
| Type of employment | Formal | 99 | 50.51 |
| Non-formal workforce | 19 | 9.69 |
| For a project | 37 | 18.88 |
| Contractual | 41 | 20.92 |
The results indicate that the average score of ethical climate was equal (3.26±0.56) from the viewpoint of the respondents (nurses) and at the undesirable level. The highest and the lowest mean scores among the five dimensions of the ethical climate, from the nurses’ perspective, were related to the dimensions of partners and physicians respectively. Also, the mean score of nurses’ attitude to physician-nurse collaboration was equal (51.17±4.98), and the highest and lowest mean scores among the four dimensions of nurses’ attitude to physician-nurse collaboration were related to the dimensions of education and cooperation and the physician’s authority and dominance respectively. According to the results of this study, there was no significant statistical relationship between the variable of the hospital ethical climate and nurses’ attitude to physician-nurse collaboration (p-value=0.695).
The [Table/Fig-2] compares the mean score of the hospital ethical climate in terms of nurses’ individual characteristics, and [Table/Fig-3] compares the mean score of nurses’ attitudes to interprofessional collaboration in terms of nurses’ individual characteristics.
The Mean of the hospital ethical climate scores by individual characteristics.
| Variable | The hospital ethical climate | p-value |
|---|
| Mean | Standard deviation |
|---|
| Sex | Women | 84.18 | 14.92 | 0.685 |
| Men | 85.13 | 13.73 |
| Marital status | Single | 85.75 | 15.02 | 0.759 |
| Married | 84.24 | 14.56 |
| Others | 83.8 | 11.36 |
| Level of education | Bachelor’s degree | 14.68 | 85.83 | 0.036 |
| Master’s degree | 13.42 | 80.1 |
| PhD | 12.02 | 77.5 |
| Experience of attendance at ethics workshop | Yes | 14.22 | 85.11 | 0.819 |
| No | 14.98 | 84.64 |
| Type of employment | Formal | 11.73 | 83.88 | 0.010 |
| For a project | 16.73 | 77.37 |
| Contractual | 14.80 | 90.57 |
| Non-formal workforce | 17.77 | 85.61 |
| Type of ward | CCU | 13.21 | 83.89 | 0.355 |
| ICU | 15.81 | 85.83 |
The Mean of the scores of nurses’ attitudes to interprofessional collaboration by individual characteristics.
| Variable | Nurses’ attitudes to interprofessional collaboration | p-value |
|---|
| Mean | Standard deviation |
|---|
| Sex | Women | 50.15 | 4.45 | 0.075 |
| Men | 51.56 | 6.08 |
| Marital status | Single | 5.36 | 51.16 | 0.919 |
| Married | 4.87 | 51.12 |
| Others | 2.04 | 51.8 |
| Level of education | Bachelor’s degree | 5.03 | 51.02 | 0.344 |
| Master’s degree | 4.83 | 51.97 |
| Phd | 3.53 | 51.5 |
| Experience of attendance at ethics workshop | Yes | 3.72 | 51.91 | 0.041 |
| No | 5.89 | 50.45 |
| Type of employment | Formal | 4.13 | 51.33 | 0.241 |
| For a project | 6.35 | 51.95 |
| Contractual | 4.32 | 51.84 |
| Non-formal workforce | 6.44 | 49.83 |
| Type of ward | CCU | 4.38 | 51.77 | 0.095 |
| ICU | 5.47 | 50.58 |
Discussion
In the present study, the mean score of the ethical climate according to nurses’ perspective is 3.26±0.56, which is at an undesirable level, as illustrated by the study by Borhani F et al., Pauly B et al., and Ulrich C et al., [12-14]. It shows that the factors influencing nurses’ view of the ethical climate of hospitals in different cultures are similar [12-14]. In this study, the ethical climate, from the nurses’ perspective, was highest in the areas of nursing colleagues and managers, thereby indicating the existence of a positive atmosphere of cooperation among the nurses; thus, in support of each other, they create and feel a more favourable ethical climate, while the areas of hospital and physicians have the lowest score, which may be due to the inappropriate working system and inadequate communication of some physicians [15]. The studies of Hart SE and Borhani F et al., are in agreement with the results of the present study [9,12]. In the present study, the mean score of nurses’ attitudes to physician-nurse collaboration was 51.17±4.98, which is classified at the positive attitude level according to the range of 49-60. In a study by Thomas EJ et al., nurses had a positive attitude to collaboration with physicians, which is in line with the results of the present study [16].
In the current study, the mean score obtained from nurses’ attitudes to physician-nurse collaboration varied in four dimensions. Thus, the dimension of “collaborative learning and collaboration” has the highest score, which indicates that professional cooperation training to physicians and nurses makes them more familiar with each other’s professional roles. The lowest score also belongs to the dimension of “the physician’s authority and dominance”, although this score is also in the positive range. This issue is a reflection of the attitudes of physicians to nursing and current organisational policies. Borhani F et al., and Thomas EJ et al., obtained similar results in their studies, which are consistent with the results of the present study [12,16]. The studies show that nurses have a negative attitude to physicians’ dominance, in other words, nurses do not affirm physicians’ sovereignty and superiority in case of patient care [12,15-17].
In the present study, among the 15 items included in the tool of attitude to physician-nurse collaboration, the item “nurses should warn the physician, when they feel the physician’s prescription has adverse effects on the patient” with 140 repeats, had the highest score, and the item “physicians must be responsible and competent in all health care matters” with 63 repeats, had the lowest score. Similar results were obtained in the study by Thomas EJ et al., [16]. This result indicates that nurses are fully aware of their caring roles, and somehow, nurses are the advocates for their patients, and when they find out that the physician’s performance or treatment is dangerous to the patient, they go into action and give logical and principled hints [16]. The results of this study showed that there is no statistically significant relationship between nurses’ perceptions of the dimensions of hospital ethical climate and their attitude to physician-nurse collaboration. This means that the positive or negative attitude of nurses to the ethical climate of the hospital environment does not affect their attitudes to working with physicians.
The results of this study confirm that, although the participating nurses did not feel and perceive the ethical climate in their entire hospital organisation (not just the workplace), it has not stopped them from wanting to communicate better and more with physicians, and as the results show, nurses continue to want to collaborate with physicians, and have a positive attitude to interprofessional interaction with physicians.
In the present study, the present authors examined the relationship between nurses’ view of the hospital ethical climate and the demographic variables such as age, sex, the marital status of participants, the work experience, the type of work area, the work experience in the current ward, the type of work shift and the experience of attendance at ethics workshop and there was no statistically significant relationship. The finding showed that despite the different views and origins of the mind, nurses’ judgments were very similar to the different contextual variables. Some other studies also confirm this result [9,13,14]. In the present study, there was a statistically significant relationship between the level of education with the nurses’ view of the ethical climate of the hospital. It seems that people with a master’s and doctoral degree received a lower mean score than those with a bachelor’s degree in understanding the ethical climate of the hospital. This result can be due to the professional attitudes of the individuals with higher education, which may lead to changes in the expectations of people with education. The supplement is higher than the health system. Highly educated people want a more ethically sound system and are always looking to improve their work ethic and resolve ethical challenges.
As a result, they seek an idealistic ethical climate, express dissatisfaction with the unfavourable state of the ethical climate, and want all areas of the ethical climate to be transcendent and desirable [12].
In this study, nurses’ perceptions of the ethical climate of their workplace were significantly correlated with the type of employment, so that for the contractual nurses, the ethical climate was less favourable. The nurses with a projected employment status had a desirable score than the contractual ones. This result could be due to the fact that almost all of the job rights and benefits of a nurse with a projected employment status are the same as those of a formal nurse, and since formal nurses have greater job security and higher rights than informal (contractual) nurses, they can criticise and complain with more confident, express more easily their opposition to policies and decisions that they do not consider the ethical, and possibly for the mentioned reasons, they have a better understanding of the ethical climate that governs their organisation. A study by Borhani F et al., also found that the nurses non-formal workforce employment status reported an undesirable ethical climate, which is consistent with the current study [12]. In the present study, there was no statistically significant relationship between the variables of age, sex, the level of education, the type of employment, the marital status, the work experience, the type of work shift, and the work experience in the current ward of the nurses participating in the study with their attitude to physician-nurse collaboration. There was only a statistical relationship between the variable of the experience of attendance at ethics workshop and nurses’ attitudes to physician-nurse collaboration. The nurses who did not attend the ethics workshop had a lower mean score of collaboration with the physicians than those who attended the ethics workshop.
Limitation
Limitation of the study is the self-reported data which may be subject to recall and social desirability bias.
Conclusion
Since a favourable ethical climate affects the ethical performance of nurses, any factor that disrupts nurses’ comfort while performing their duties lead to a decline in the proper performance of the nurses. Therefore, there is a need for a coherent planning in each of the areas influencing the creation of an ethical climate. It is important for managers to be aware of the fact that a favourable ethical climate encourages the nurses in relation to the organisation. Managers play an important role in promoting a desirable ethical climate. Also, it can be concluded that there is a need for creating a culture of collaboration between physicians and nurses.