Relationship between hospital ethical climate, critical thinking disposition, and nursing task performance

Hospital ethical climate refers to nurses’ perceptions of how ethical issues are handled in their work setting [7, 8]. Different researchers mention multiple constructs of hospital ethical climate [7, 9]; among them, our study adopted Olson’s conceptualization of hospital ethical climate with five dimensions related to colleagues, patients, managers, hospital/organization, and physicians [7]. Many studies on hospital ethical climate have focused on its association with work-related factors, such as job satisfaction, moral distress, and turnover intentions [4, 6]. In South Korea, the variables commonly found in jobs and organizations are job stress, supervisor trust, and organizational commitment rather than personal [6]. In particular, the hospital ethical climate reflects organizational practices and values in care issues and is an important factor that affects the professional performance and ethical practices of nurses in that organization [8]. However, most previous studies did not address nursing professional practices as a personal variable, such as nursing task performance, when investigating hospital ethical climate [4, 6, 10‐12]. In addition, Noh and Lee suggested expanding the research to evaluate the relationship between hospital ethical climate and various variables such as nursing tasks and nursing outcomes [6].

Nursing task performance refers to the ability to perform tasks that require the nursing process and provide effective patient care [13‐15]. Nursing task performance has a significant impact on the quality of nursing and nursing competency [15, 16]. Nursing competency—an integrated or effective performance required for nurses’ roles in the work setting [17, 18]—is positively affected by ethical climate [8]. Numminen et al.’s study of 318 newly graduated nurses showed that the hospital ethical climate is positively correlated with nurse competency [8]. However, some studies have reported that nurses with less than one year of work experience are susceptible to hospital ethical climates [8, 19]. Thus, this study included nursing task performance as a variable in our exploration of hospital ethical climate with nurses who had been working for more than one year to compare our work with previous findings.

Critical thinking disposition can be defined as a person’s consistent internal motivation to solve problems and make decisions by thinking critically [20], and a measure to a tendency towards critical thinking [20, 21]. Critical thinking disposition is an attitude to actively engage in critical thinking in situations that require critical thinking [21]. Nurses with a higher critical thinking disposition solve clinical problems to search for the cause and make decisions with careful consideration based on clinical evidence [22]. In particular, in rapidly changing clinical settings, nurses experience ethical dilemmas in the relationships with patients, colleagues, and organization, which are key elements of the hospital ethical climate, and this has been shown to be a factor that causes difficulties in nursing task performance and inhibiting nurse’s professional decision-making [1]. In addition, owing to the emergence of new infectious diseases such as COVID-19, nurses face more complex and high-level ethical challenges including fear of infection, disappointing results of treatment, and high mortality rate [23], and they are required to think critically to make decisions appropriate for these ethical situation. In Yuxiu Jia et al.’s qualitative study, nurses were reported to develop nursing strategies rooted in critical thinking to cope with ethical challenges [23], influenced by the hospital ethical climate [1, 8]. Furthermore, some studies reported that critical thinking disposition is significantly associated with nursing task performance [24, 25]. Choi & Cho's study targeting 419 nurses in a general hospital, critical thinking disposition and problem-solving processes were found to be factors that significantly affect nursing task performance [24]. In rapidly changing clinical setting, the study reported that critical thinking disposition of nurses is the one of the most important ability in resolving various ethical issues or dilemmas that arise during the process of nursing to patients from diverse cultural, social, and religious backgrounds [24]. Based on existing findings, we theorized that hospital ethical climate and nursing task performance may be related in a pathway through critical thinking disposition among nurses with one year of experience in a clinical setting.

Despite the need to consider hospital ethical climate, in a scoping review on ethical climate in the nursing environments, South Korea has the least amount of research compared to other countries [4], and interest in nurses’ perception of the ethical climate has not sufficiently spread in South Korea [6]. Moreover, the higher the critical thinking disposition, the higher the nurses’ decision making [22]. Therefore, to provide quality care to patients through accurate judgment in clinical settings, a disposition toward critical thinking and nursing task performance is important for nurses. However, to the best of our knowledge, no previous studies have examined the relationship between these three variables. Thus, we addressed this gap in the literature by investigating the relationship between hospital ethical climate, critical thinking disposition, and nursing task performance.

We conducted a cross-sectional survey. This study aimed to investigate the association between hospital ethical climate, critical thinking disposition, and nursing task performance, and confirm the mediating effect of critical thinking disposition on these relationships (Fig. 1).

Nurses working in cities in Ulsan, South Korea were recruited using convenience sampling. Based on prior studies, nurses with less than one year of work experience were susceptible to the hospital ethical climate [8, 19]; therefore, in this study, the inclusion criteria for the participants were nurses with more than one year of experience working in a general hospital. For regression analysis, the sample size was calculated using G*Power 3.1.9.7. The minimum number of participants needed for a statistical power of 0.95, a significance level of 0.05, and 12 predictors based on an effect size of 0.15, was 184. Considering an expected dropout rate of 20%, 220 printed questionnaires with consent forms were distributed and returned. A total of 200 valid questionnaires were used in the final analysis, after excluding 20 questionnaires with missing data.

Survey data were collected between November and December 2021. First, permission for the study was obtained from the chief nursing department of each hospital. Thereafter, one of the researchers contacted the nurses directly at each hospital and explained the study’s purpose, procedure, and questionnaire content. Moreover, nurses were informed that participation was voluntary and that they could withdraw at any time during the study without any negative consequences. The questionnaires were then distributed along with a consent form, and those who did not understand the items in the questionnaires could ask the researcher for help to fill them out. One of the researchers collected the completed questionnaires. In the case of another hospital, we provided the URL for the survey using Google Surveys owing to the risk of COVID-19. We uploaded the same questionnaires to a Google survey, and the first page of the survey contained the purpose, procedure, voluntary nature, and withdrawal from the study. In addition, at the bottom of the first page, a button (“I agree”) was created, and clicking it would denote that the participants has agreed to participate in the study. For those who did not understand the items in the questionnaire, the contact number and email were provided on the first page, and the researchers responded and explained the study whenever the participants requested.

Data were analyzed using SPSS (version 25.0; IBM Corp., Armonk, NY, USA) and the SPSS PROCESS macro v3.4. Skewness and kurtosis for each main variable (critical thinking disposition, hospital ethical climate, and nursing task performance) were checked to determine whether the data were normally distributed (skewness range of all main variables -0.121 to 0.347, kurtosis range of all main variables -0.357 to 0.330). The main variables and covariates were analyzed using descriptive statistics. Correlations between the study variables were analyzed using Pearson’s correlation coefficients. PROCESS macro for SPSS (Model 4) was used to evaluate the mediating effect of hospital ethical climate on the relationship between critical thinking disposition and nursing task performance [29, 30]. A 95% bias-corrected confidence interval from 5,000 resamples was generated using the bias-corrected bootstrapping method. The bootstrapping size was 5,000. Significant indirect effects were identified as p < 0.05 when the confidence interval (CI) did not include zero [29, 30]. For analysis of correlations and mediating effect, main study variables was used the item scores.

This study was approved by the Institutional Review Board of Dongguk University, to which the authors belong (DGU IRB 20210040). This study was conducted on human participants in accordance with the Declaration of Helsinki and its subsequent amendments. The purpose, procedures, and rules of the study were explained to all the participants. In addition, the voluntary nature and confidentiality of the study were highlighted, and participants’ personal information was not revealed. Informed consent was obtained from all the subjects.

Of the 200 participants, 92.0% (184) were female, and the mean age was 30.50 years (range 23–64). A total of 142 (71.0%) participants were unmarried and 27.5% (55) were religious. A total of 141 (70.5%) participants held a bachelor’s degree or higher. The mean total period of clinical experience was 7.38 years (range 1–32), about half of the participants had worked in a general ward (56%), and 163 participants responded that their positions were staff nurses. A total of 117 participants were aware of the Korean code of ethics for nurses (58.5%), and 69.5% of the participants responded that they had experience receiving nursing ethics education (Table 1).

The total score of hospital ethical climate was 91.86 ± 11.29. The mean scores of hospital ethical climate and critical thinking disposition were 3.53 ± 0.43 and 3.62 ± 0.40, respectively (Table 2). The mean nursing task performance score was 3.96 ± 0.43. The higher mean score for hospital ethical climate was peer and manager, 3.92 ± 0.47 and 3.80 ± 0.53, respectively. Hospital ethical climate was positively correlated with critical thinking disposition (r = 0.37, p < 0.001) and nursing task performance (r = 0.57, p < 0.001). In addition, nursing task performance was positively correlated with critical thinking disposition (r = 0.64, p < 0.001).

As shown in Table 3, the direct association between hospital ethical climate and nursing task performance was significant (ß = 0.34, p < 0.001). In the mediation analysis, hospital ethical climate was positively associated with critical thinking disposition (ß = 0.30, p < 0.001), and critical thinking disposition was positively associated with nursing task performance (ß = 0.54, p < 0.001). The indirect pathway of hospital ethical climate on nursing task performance through critical thinking disposition was significant (index = 0.16; Boot SE = 0.04; Boot CI:0.09, 0.25). Figure 2 shows the indirect pathway for critical thinking disposition on the relationship between hospital ethical climate and nursing task performance.

Participants in this study evaluated the hospital ethical climate positively and higher than neutral with a total sum of 91.86, which is in accordance with previous studies [8, 19, 31]. In addition, domains that were positively perceived in the hospital ethical climate were particularly related to peers and managers rather than patient, hospital/organization and physicians. The results of this study are consistent with earlier studies [24]. Nurse managers are commonly appointed from among the nursing staff in the hospital, and most have a long-term clinical background and a good understanding of the hospital’s ethical climate in the field [11]. This makes managers willing to listen and support staff nurses in decision-making when they face ethical dilemmas regarding a nursing situation. Through this process, staff nurses come to trust and respect their managers, which has a crucial impact on creating and maintaining positive perceptions of the hospital’s ethical climate. Moreover, their leadership and support to staff nurses are related to the hospital’s ethical climate and, consequently, how ethical issues are dealt with for the benefit of patients [8]. The previous study reported that access to knowledgeable peers for decision support on ethical issues is important resources for preventing and handling ethical conflicts [32]. In addition, it is reported that after particularly difficult events, when reflecting whit colleagues, action, feeling, and new perspectives on ethical conflicts are made visible, processed, and normalized [32]. Thus, the exchange of experience and judgements between peers contribute to self-confidence and the ability to act in ethical conflicts.

In this study, nurses with a positive perception of their hospital’s ethical climate showed increased nursing task performance. Although it is difficult to compare our results with those in currently published literature, few studies have examined the relationship between hospital ethical climate and nursing task performance. Numminen et al. showed that newly graduate nurses who had a positive perception of hospital ethical climate had significantly higher nursing competency [8]. In addition, nurses with a more positive perception of the “patient” dimension of hospital ethical climate were less likely to have made medical errors [26]. Considering job satisfaction and turnover as factors affecting nursing competency, including nursing task performance, a previous study reported that hospital ethical climate was positively correlated with job satisfaction [10]. Other studies found that nurses with more negative perceptions of hospital ethical climate were highly inclined to leave the hospital or their previous position [19, 33]. Moreover, a negative or poor ethical climate can contribute to burnout [12]. Job satisfaction, intent to leave, and burnout are associated with lower nursing task performance or nursing competency correlated with hospital ethical climate [8, 34, 35] and result in poor patient safety and quality of care [34]. Therefore, hospital administrators should pay attention to a more positive institutional ethical climate.

Critical thinking disposition was significantly positively associated with nursing task performance, and this is consistent with previous findings [24, 25]. In a study by Mohamed et al., critical thinking disposition was significantly correlated with nursing performance in patients undergoing hemodialysis [25]. Moreover, in Park et al.’s study of 188 nurses with more than 13 months of clinical experience, critical thinking disposition was a major factor influencing nurses’ competency as measured using the nursing performance appraisal tool [36]. Dispositions are the tendency to do something, and critical thinking disposition is included in the concept of critical thinking [37]. In addition, critical thinking does not occur or may be substandard without critical thinking disposition [38]. In nursing, nurses with higher critical thinking or critical thinking dispositions, are able to perform their professional work efficiently and provide effective nursing care [24, 36, 39]. Thus, helping nurses increase their critical thinking disposition enables them to engage proactively in job performance.

Critical thinking disposition mediated the relationship between hospital ethical climate and nursing task performance. It was confirmed that a more positive perception of the hospital’s ethical climate was associated with increased critical thinking disposition, which subsequently increased nursing task performance. In addition, nurses who perceived the hospital’s ethical climate as more negative decreased nursing task performance with decreasing critical thinking disposition. This suggests that critical thinking disposition is an important factor in the hospital ethical climate and nursing task performance, which can be explained by several factors. Given that the hospital ethical climate sets standards for how problems should be addressed, focusing on interactions with colleagues and patients [7], when nurses perceive a more positive hospital ethical climate, their communication self-efficacy increases [40], and when communication competency increases, critical thinking disposition increases [41]. In other words, nurses perceived the hospital’s ethical climate positively and actively communicated with other professionals, including managers or physicians, about patient care, treatment, or further treatment plans, and an increase in critical thinking disposition in the process of exchanging opinions. The higher the critical thinking disposition, the higher the nurse’s critical decision-making [22] and the nursing task performance [36, 39]. Therefore, in order to improve nurses’ task performance, the first step would be to improve the hospital ethical climate more positively. Organizations can improve their hospital ethical climate through ethics training, support, and information exchange within the nursing team [4]. Moreover, the code of ethics for nurses is to be built upon in combination with the laws, regulation and professional standards [42], and culture plays an important role in giving shape to nursing professional ethical values [43]. Therefore, to develop ethical training/education for nurses, there should be mandated and customized by the local law and culture. Together with this, critical thinking disposition is also an important factor to consider improving nurses’ task performance, and it is important to provide various training or education programs to improve critical thinking disposition. Hospital policymakers or administrators should identify the characteristics of the hospital ethical climate and create a positive hospital ethical climate, as well as increase nurses’ critical thinking disposition and improve task performance. It also enhances quality of care and patient safety.

This study had some limitations. First, the findings have limited generalizability because the nurses were conveniently sampled. Second, this was a cross-sectional study, which limits the interpretation of causality. Hence, future research can be improved through longitudinal studies. Third, as some responses were made through an online self-report questionnaire, participants may have exaggerated or reduced their performance and perceptions according to their understanding. Additionally, we did not consider the number of hospitals or universities involved in nursing ethics education. This may have affected nurses’ perceptions of the hospital’s ethical climate. Future research should test this hypothesis, including the number and places of nursing ethics education. Finally, numerous factors influenced nursing task performance, and only hospital ethical climate and critical thinking dispositions were included in this study. Hospital ethical climate and critical thinking disposition could explain a limited portion of nursing task performance. Hence, further research is recommended to explore various factors affecting nursing task performance.