Evaluation of ethical climate in health services: a systematic review

Lanes, Taís Carpes; Magnago, Ana Carolina de Souza; Schutz, Thais Costa; Carneiro, Alessandra Suptitz; Morais, Bruna Xavier; Dalmolin, Graziele de Lima

doi:10.1590/1983-80422020284436

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Research • Rev. Bioét. 28 (4) • Oct-Dec 2020 • https://doi.org/10.1590/1983-80422020284436 copy

Evaluation of ethical climate in health services: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Ethical climate refers to the perceptions shared by health professionals of how ethical issues should be handled in their organization. This study aimed to identify scientific evidence of studies that used the Hospital Ethical Climate Survey in ethical climate assessment. This is a systematic review of 33 articles selected from Scopus, PubMed and Medline databases. Ethical climate was associated with workers’ health issues and it was evaluated as moderate to positive by health professionals. The topic was classified as positive for the “peers,” “patients” and “managers” factors, and negative for “physicians” and “hospital” factors. The review concluded that assessing the ethical climate is important for improving the work environment and that the Hospital Ethical Climate Survey is a valid and reliable instrument for such evaluation.

Keywords:
Ethics; Health services; Nursing

Identification	Study design	Level of evidence	Variables associated with ethical climate	Main results
Olson; 1998 ¹1. Olson LL. Hospital nurses’ perceptions of the ethical climate of their work setting. J Nurs Scholarsh [Internet]. 1998 [acesso 17 abr 2018];30(4):345-9. DOI: 10.1111/j.1547-5069.1998.tb01331.x https://doi.org/10.1111/j.1547-5069.1998...	Methodological	6	None	Hecs proved to be a valid and reliable instrument for the assessment of ethical climate.
Bahcecik, Oztürk; 2003 ⁵5. Bahcecik N, Oztürk H. The hospital ethical climate survey in Turkey. Jonas Healthc Law Ethics Regul [Internet]. 2003 [acesso 15 maio 2018];5(4):94-9. Disponível: https://bit.ly/32QxeZU https://bit.ly/32QxeZU...	Cross-sectional	6	Sociodemographic data	Ethical climate was associated with time of experience and age of the professional.
Hart; 2005 ³3. Hart SE. Hospital ethical climates and registered nurses’ turnover intentions. J Nurs Scholarsh [Internet]. 2005 [acesso 12 maio 2018];37(2):173-7. DOI: 10.1111/j.1547-5069.2005.00030.x https://doi.org/10.1111/j.1547-5069.2005...	Cross-sectional	6	Turnover intention Intention to leave nursing	Nurses who perceived ethical climate as positive reported a greater intention to remain in the area. Relationship between ethical climate and intention to leave nursing.
Ulrich and collaborators; 2007 ¹⁰10. Ulrich C, O’Donnell P, Taylor C, Farrar A, Danis M, Grady C. Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Soc Sci Med [Internet]. 2007 [acesso 12 maio 2018];65(8):1708-19. DOI: 10.1016/j.socscimed.2007.05.050 https://doi.org/10.1016/j.socscimed.2007...	Cross-sectional	6	Job satisfaction Turnover intention Ethical stress	Participants less inclined to turnover and with a low level of ethical stress considered the ethical climate more positively. Positive ethical climate increased job satisfaction and reduced turnover intentions.
Hamric, Blackhall; 2007 ¹¹11. Hamric AB, Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med [Internet]. 2007 [acesso 12 maio 2018];35(2):422-9. DOI: 10.1097/01.CCM.0000254722.50608.2D https://doi.org/10.1097/01.CCM.000025472...	Cross-sectional	6	Moral distress Labor data	Nurses with a high level of moral distress rated the ethical climate more negatively. Nurses considered the ethical climate more negatively than physicians.
Pauly and collaborators; 2009 ²⁹29. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics [Internet]. 2009 [acesso 19 abr 2018];16(5):561-73. DOI: 10.1177/0969733009106649 https://doi.org/10.1177/0969733009106649...	Cross-sectional	6	Moral distress	The more positive the ethical climate, the lower the levels of moral distress.
Lützén and collaborators; 2010 ¹²12. Lützén K, Blom T, Ewalds-Kvist B, Winch S. Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nurs Ethics [Internet]. 2010 [acesso 6 maio 2018];17(2):213-24. DOI: 10.1177/0969733009351951 https://doi.org/10.1177/0969733009351951...	Cross-sectional	6	Ethical stress	Negative perception of the ethical climate increased moral stress.
Silén and collaborators; 2011 ³³33. Silén M, Svantesson M, Kjellström S, Sidenvall B, Christensson L. Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability. J Clin Nurs [Internet]. 2011 [acesso 20 abr 2018];20(23-24):3483-93. DOI: 10.1111/j.1365-2702.2011.03753.x https://doi.org/10.1111/j.1365-2702.2011...	Cross-sectional	6	Moral distress	Positive ethical climate is associated with a lower frequency of moral distress.
Joolaee and collaborators; 2013 ³⁴34. Joolaee S, Jalili HR, Rafii F, Hajibabaee F, Haghani H. The relationship between ethical climate at work and job satisfaction among nurses in Tehran. Indian J Med Ethics [Internet]. 2013 [acesso 12 maio 2018];10(4):238-42. DOI: 10.20529/IJME.2013.072 https://doi.org/10.20529/IJME.2013.072...	Cross-sectional	6	Job satisfaction	The more positive the ethical climate perception, the higher the satisfaction level reported by nurses.
Claeys and collaborators; 2013 ³⁵35. Claeys M, Faelens A, Sabbe B, Schrijvers D, Casterlé BDD, Luyten P. Psychometric properties of the Hospital Ethical Climate Survey: a cross-sectional study in a large sample of Belgian psychiatric nurses. Eur J Pers Cent Healthc [Internet]. 2013 [acesso 12 maio 2018];1(1):202-8. DOI: 10.5750/ejpch.v1i1.652 https://doi.org/10.5750/ejpch.v1i1.652...	Methodological and cross-sectional	6	None	Ethical climate was positive in the units. The lowest score was for the “hospital” factor, and the highest was for the “peers” factor.
Han; 2014 ²¹21. Han SJ. Nurse turnover intention and influencing factors. Int Inf Institute [Internet]. 2014 [acesso 10 maio 2019];17(10A):5037-42. Disponível: https://bit.ly/3nsWEFa https://bit.ly/3nsWEFa...	Cross-sectional	6	Turnover intention	The more positive the ethical climate, the lower the turnover intention.
Hwang, Park; 2014 ¹³13. Hwang JI, Park HA. Nurses’ perception of ethical climate, medical error experience and intent-to-leave. Nurs Ethics [Internet]. 2014 [acesso 6 maio 2018];21(1):28-42. DOI: 10.1177/0969733013486797 https://doi.org/10.1177/0969733013486797...	Cross-sectional	6	Labor data Turnover intention Experience with medical error	Significant differences were found between ethical climate and years of nursing and teaching experience. Nurses with a positive perception of the ethical climate presented lower rate of turnover intention and were less likely to commit medical errors.
Suhonen and collaborators; 2014 ²²22. Suhonen R, Stolt M, Gustafsson ML, Katajisto J, Charalambous A. The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people. J Adv Nurs [Internet]. 2014 [acesso 14 maio 2018];70(6):1356-68. DOI: 10.1111/jan.12297 https://doi.org/10.1111/jan.12297...	Cross-sectional	6	Individualized nursing care	Nurses who rated the ethical climate more positively were more likely to realize care provided was more individualized.
Sauerland and collaborators; 2014 ¹⁶16. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs [Internet]. 2014 [acesso 20 abr 2018];33(4):234-45. DOI: 10.1097/DCC.0000000000000050 https://doi.org/10.1097/DCC.000000000000...	Mixed	6	Moral distress Moral residue	Nurses who reported higher levels of moral distress rated the ethical climate more negatively.
Khalesi and collaborators; 2014 ²³23. Khalesi N, Arabloo J, Khosravizadeh O, Taghizadeh S, Heyrani A, Ebrahimian A. Psychometric properties of the Persian version of the Hospital Ethical Climate Survey. J Med Ethics Hist Med [Internet]. 2014 [acesso 20 maio 2018];7:15. Disponível: https://bit.ly/3nyyvwJ https://bit.ly/3nyyvwJ...	Cross-sectional	6	None	The highest rate of ethical climate was for the “managers” factor, and the lowest for the “physicians” factor. Hecs proved to be a valid and reliable instrument for the assessment of ethical climate.
Ghorbani and collaborators; 2014 ²⁴24. Ghorbani AA, Hesamzadeh A, Khademloo M, Khalili S, Hesamzadeh S, Berger V. Public and private hospital nurses’ perceptions of the ethical climate in their work settings, Sari City, 2011. Nurs Midwifery Stud [Internet]. 2014 [acesso 20 maio 2018];3(1):e12867. DOI: 10.17795/nmsjournal12867 https://doi.org/10.17795/nmsjournal12867...	Cross-sectional	6	Sociodemographic data	Sociodemographic data did not influence the perceptions of nurses about the ethical climate.
Whitehead and collaborators; 2015 ¹⁷17. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh [Internet]. 2015 [acesso 18 abr 2018];47(2):117-25. DOI: 10.1111/jnu.12115 https://doi.org/10.1111/jnu.12115...	Cross-sectional	6	Moral distress Labor data	More positive perceptions of the ethical climate were associated with lower levels of moral distress. Physicians rated the ethical climate more positively than nurses.
Numminen and collaborators; 2015 ²⁵25. Numminen O, Leino-Kilpi H, Isoaho H, Meretoja R. Ethical climate and nurse competence: newly graduated nurses’ perceptions. Nurs Ethics [Internet]. 2015 [acesso 5 maio 2018];22(8):845-59. DOI: 10.1177/0969733014557137 https://doi.org/10.1177/0969733014557137...	Cross-sectional	6	Self-assessed professional competence Turnover intention Job satisfaction	Nurses with a higher level of competence, satisfied with their jobs and who never planned to change jobs, presented a more positive perception of the ethical climate.
Jahantigh and collaborators; 2015 ²⁶26. Jahantigh M, Arbabisarjou A, Zare S, Shahrakipour M, Ghoreishinia G. Hospital's ethical climate and nurse's desired ethical climate in Ali-ebn-Abitaleb and Khatam-al-Anbia hospital of Zahedan. Pharm Lett [Internet]. 2015 [acesso 20 maio 2018];7(12):427-31. Disponível: https://bit.ly/32VFF6f https://bit.ly/32VFF6f...	Cross-sectional	6	Sociodemographic data Desired ethical climate	A significant relationship was observed between age/work environment and the ethical climate. A significant difference was observed between the perceptions shared by nurses of the ethical climate and the desired mean score for ethical climate.
Suhonen and collaborators; 2015 ²⁷27. Suhonen R, Stolt M, Katajisto J, Charalambous A, Olson LL. Validation of the Hospital Ethical Climate Survey for older people care. Nurs Ethics [Internet]. 2015 [acesso 16 maio 2018];22(5):517-32. DOI: 10.1177/0969733014549878 https://doi.org/10.1177/0969733014549878...	Cross-sectional	6	None	The ethical climate was positive in general, with a higher score for the “peers” factor and a lower score for the “physicians” factor.
Sauerland and collaborators; 2015 ¹⁸18. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate part II: neonatal and pediatric perspectives. Dimens Crit Care Nurs [Internet]. 2015 [acesso 18 abr 2018];34(1):33-46. DOI: 10.1097/DCC.0000000000000083 https://doi.org/10.1097/DCC.000000000000...	Cross-sectional	6	Moral distress	Significant inverse relationship between moral distress and ethical climate.
Numminen and collaborators; 2015 ²⁸28. Numminen O, Leino-Kilpi H, Isoaho H, Meretoja R. Newly graduated nurses’ competence and individual and organizational factors: a multivariate analysis. J Nurs Scholarsh [Internet]. 2015 [acesso 4 maio 2018];47(5):446-57. DOI: 10.1111/jnu.12153 https://doi.org/10.1111/jnu.12153...	Cross-sectional	6	Practice environment Turnover intention	Nurses who were satisfied with the quality of care evaluated the ethical climate more positively. Nurses with turnover intention evaluated the practice environment and the ethical climate less positively.
Jahantigh, Zare, Shahrakipour; 2016 ³⁶36. Jahantigh M, Zare S, Shahrakipour M. The survey of the relationship between ethical climate and ethical behavior in nurses. Pharm Chem [Internet]. 2016 [acesso 20 maio 2018];8(3):189-93. Disponível: https://bit.ly/3lELjB2 https://bit.ly/3lELjB2...	Cross-sectional	6	Sociodemographic data Ethical behavior	The relationship between sociodemographic data/ethical behavior and the ethical climate was not significant.
Bartholdson and collaborators; 2016 ³⁰30. Bartholdson C, Sandeberg M, Lützén K, Blomgren K, Pergert P. Healthcare professionals’ perceptions of the ethical climate in paediatric cancer care. Nurs Ethics [Internet]. 2016 [acesso 20 maio 2018];23(8):877-88. DOI: 10.1177/0969733015587778 https://doi.org/10.1177/0969733015587778...	Cross-sectional	6	Labor data	Nurses rated the ethical climate positively less frequently than physicians.
Boer and collaborators; 2016 ³⁷37. Boer JC, Rosmalen J, Bakker AB, Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurement. Nurs Crit Care [Internet]. 2016 [acesso 13 maio 2018];21(3):e19-27. DOI: 10.1111/nicc.12206 https://doi.org/10.1111/nicc.12206...	Longitudinal	4	Labor data Moral distress	Nurses rated the ethical climate more negatively than physicians. The positive ethical climate helps nurses and physicians cope with moral distress.
Jang, Oh; 2019 ³¹31. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics [Internet]. 2019 [acesso 10 maio 2019];26(4):1186-98. DOI: 10.1177/0969733017742959 https://doi.org/10.1177/0969733017742959...	Cross-sectional	6	Job satisfaction Ethical leadership	Job satisfaction was positively correlated with the ethical climate. No significant association was found between ethical climate and ethical leadership.
Özden and collaborators; 2019 ⁹9. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics [Internet]. 2019 [acesso 15 maio 2020];26(4):1211-25. DOI: 10.1177/0969733017736924 https://doi.org/10.1177/0969733017736924...	Cross-sectional	6	Ethical leadership Job satisfaction Sociodemographic and labor data	Significant positive correlation was found among ethical leadership, ethical climate and job satisfaction. A statistically significant difference was found between ethical climate and working hours, work type, work conditions and job satisfaction. Nurses who had been longer in the institution presented higher scores for leadership and ethical climate. Nurses who were more satisfied with the profession and relationships with their colleagues rated the ethical climate more positively.
Asgari and collaborators; 2019 ³²32. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics [Internet]. 2019 [acesso 20 abr 2019];26(2):346-56. DOI: 10.1177/0969733017712083 https://doi.org/10.1177/0969733017712083...	Cross-sectional	6	Job satisfaction	A significant relationship was found between ethical climate and job satisfaction.
Lemmenes and collaborators; 2018 ¹⁹19. Lemmenes D, Valentine P, Gwizdalski P, Vincent C, Liao C. Nurses’ perception of ethical climate at a large academic medical center. Nurs Ethics [Internet]. 2018 [acesso 9 maio 2018];25(6):724-33. DOI: 10.1177/0969733016664980 https://doi.org/10.1177/0969733016664980...	Cross-sectional	6	Sociodemographic and labor data	Nurses under 30 years of age rated the ethical climate more positively than nurses over 30 years of age. Significant relationship between ethical climate and specialties: adult critical care nurses presented higher total mean scores.
Constantina, Papastavrou, Charalambous; 2019 ⁸8. Constantina C, Papastavrou E, Charalambous A. Cancer nurses’ perceptions of ethical climate in Greece and Cyprus. Nurs Ethics [Internet]. 2019 [acesso 15 maio 2018];26(6):1805-21. DOI: 10.1177/0969733018769358 https://doi.org/10.1177/0969733018769358...	Cross-sectional	6	Labor data	Nurses with an undergraduate degree rated the ethical climate more positively than nurses with a graduate degree.
Altaker, Howie-Esquivel, Cataldo; 2018 ²⁰20. Altaker KW, Howie-Esquivel J, Cataldo JK. Relationships among palliative care, ethical climate, empowerment, and moral distress in intensive care unit nurses. Am J Crit Care [Internet]. 2018 [acesso 10 maio 2019];27(4):295-302. DOI: 10.4037/ajcc2018252 https://doi.org/10.4037/ajcc2018252...	Cross-sectional	6	Moral distress Psychological empowerment	Nurses who rated the ethical climate more positively had lower levels of moral distress. A positive correlation was found between HECS and Psychological Empowerment Instrument.
Charalambous and collaborators; 2018 ⁷7. Charalambous A, Cloconi C, Papastavrou E, Theodoula A. Psychometric properties of the Hospital Ethical Climate Survey: a cross-sectional study in Greek and Cypriot cancer care settings. J Nurs Meas [Internet]. 2018 [acesso 20 maio 2018];26(2):237-48. DOI: 10.1891/1061-3749.26.2.237 https://doi.org/10.1891/1061-3749.26.2.2...	Methodological	6	None	Hecs proved to be a valid and reliable instrument for the assessment of ethical climate.
Pergert, Bartholdson, Sandeberg; 2019 ⁶6. Pergert P, Bartholdson C, Sandeberg M. The ethical climate in paediatric oncology: a national cross-sectional survey of health-care personnel. Psychooncology [Internet]. 2019 [acesso 10 maio 2019];28(4):735-41. DOI: 10.1002/pon.5009 https://doi.org/10.1002/pon.5009...	Cross-sectional	6	Labor data	Physicians rated the ethical climate more positively than nurses and nursing assistants.

Identification^* * Nine articles1,3,5–7,11,12,28,30have no mean and standard deviation values in the overall classification of ethical climate;	Ethical climate classification by HECS factors					Overall classification of ethical climate/HECS
	Patients	Peers	Physicians	Managers	Hospital
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Ulrich and collaborators; 2007 ¹⁰10. Ulrich C, O’Donnell P, Taylor C, Farrar A, Danis M, Grady C. Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Soc Sci Med [Internet]. 2007 [acesso 12 maio 2018];65(8):1708-19. DOI: 10.1016/j.socscimed.2007.05.050 https://doi.org/10.1016/j.socscimed.2007...	–	–	–	–	–	97.3 (14.4)
Pauly and collaborators; 2009 ²⁹29. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics [Internet]. 2009 [acesso 19 abr 2018];16(5):561-73. DOI: 10.1177/0969733009106649 https://doi.org/10.1177/0969733009106649...	3.71 (0.573)	4.12 (0.617)	3.35 (0.741)	3.40 (1.071)	3.11 (0.747)	3.48 (0.612)
Silén and collaborators; 2011 ³³33. Silén M, Svantesson M, Kjellström S, Sidenvall B, Christensson L. Moral distress and ethical climate in a Swedish nursing context: perceptions and instrument usability. J Clin Nurs [Internet]. 2011 [acesso 20 abr 2018];20(23-24):3483-93. DOI: 10.1111/j.1365-2702.2011.03753.x https://doi.org/10.1111/j.1365-2702.2011...	–	–	–	–	–	95.00 (^ has no standard deviation; )
Joolaee and collaborators; 2013 ³⁴34. Joolaee S, Jalili HR, Rafii F, Hajibabaee F, Haghani H. The relationship between ethical climate at work and job satisfaction among nurses in Tehran. Indian J Med Ethics [Internet]. 2013 [acesso 12 maio 2018];10(4):238-42. DOI: 10.20529/IJME.2013.072 https://doi.org/10.20529/IJME.2013.072...	–	–	–	–	–	3.36 (0.69)
Claeys and collaborators; 2013 ³⁵35. Claeys M, Faelens A, Sabbe B, Schrijvers D, Casterlé BDD, Luyten P. Psychometric properties of the Hospital Ethical Climate Survey: a cross-sectional study in a large sample of Belgian psychiatric nurses. Eur J Pers Cent Healthc [Internet]. 2013 [acesso 12 maio 2018];1(1):202-8. DOI: 10.5750/ejpch.v1i1.652 https://doi.org/10.5750/ejpch.v1i1.652...	3.90 (0.49)	4.15 (0.49)	3.75 (0.59)	3.85 (0.77)	3.64 (0.59)	3.85 (0.46)
Han; 2014 ²¹21. Han SJ. Nurse turnover intention and influencing factors. Int Inf Institute [Internet]. 2014 [acesso 10 maio 2019];17(10A):5037-42. Disponível: https://bit.ly/3nsWEFa https://bit.ly/3nsWEFa...	3.35 (0.40)	3.61 (0.50)	2.76 (0.60)	3.28 (0.60)	2.78 (0.50)	3.11 (^ has no standard deviation; )
Hwang, Park; 2014 ¹³13. Hwang JI, Park HA. Nurses’ perception of ethical climate, medical error experience and intent-to-leave. Nurs Ethics [Internet]. 2014 [acesso 6 maio 2018];21(1):28-42. DOI: 10.1177/0969733013486797 https://doi.org/10.1177/0969733013486797...	3.60 (0.60)	3.7 (0.70)	3.0 (0.80)	3.8 (0.80)	3.3 (0.60)	3.5 (0.60)
Suhonen and collaborators; 2014 ²²22. Suhonen R, Stolt M, Gustafsson ML, Katajisto J, Charalambous A. The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people. J Adv Nurs [Internet]. 2014 [acesso 14 maio 2018];70(6):1356-68. DOI: 10.1111/jan.12297 https://doi.org/10.1111/jan.12297...	–	–	–	–	–	3.85 (0.56)
Sauerland et al.; 2014 ¹⁶16. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs [Internet]. 2014 [acesso 20 abr 2018];33(4):234-45. DOI: 10.1097/DCC.0000000000000050 https://doi.org/10.1097/DCC.000000000000...	–	–	–	–	–	94.39 (18.3)
Khalesi and collaborators; 2014 ²³23. Khalesi N, Arabloo J, Khosravizadeh O, Taghizadeh S, Heyrani A, Ebrahimian A. Psychometric properties of the Persian version of the Hospital Ethical Climate Survey. J Med Ethics Hist Med [Internet]. 2014 [acesso 20 maio 2018];7:15. Disponível: https://bit.ly/3nyyvwJ https://bit.ly/3nyyvwJ...	2.80 (0.64)	2.90 (0.65)	2.46 (0.69)	3.04 (0.66)	2.61 (0.72)	2.75 (0.58)
Ghorbani and collaborators; 2014 ²⁴24. Ghorbani AA, Hesamzadeh A, Khademloo M, Khalili S, Hesamzadeh S, Berger V. Public and private hospital nurses’ perceptions of the ethical climate in their work settings, Sari City, 2011. Nurs Midwifery Stud [Internet]. 2014 [acesso 20 maio 2018];3(1):e12867. DOI: 10.17795/nmsjournal12867 https://doi.org/10.17795/nmsjournal12867...	3.94 (0.64)⁺ + hospital A; 4.01 (0.65)⁺⁺ ++ hospital B; – means no classification by factors;	4.12 (0.5)⁺ + hospital A; 4.05 (0.64)⁺⁺ ++ hospital B; – means no classification by factors;	3.31 (0.76)⁺ + hospital A; 3.46 (0.73)⁺⁺ ++ hospital B; – means no classification by factors;	4.23 (0.77)⁺ + hospital A; 4.24 (0.76)⁺⁺ ++ hospital B; – means no classification by factors;	3.37 (0.81)⁺ + hospital A; 3.48 (0.88)⁺⁺ ++ hospital B; – means no classification by factors;	3.76 (0.54)⁺ + hospital A; 3.82 (0.61)⁺⁺ ++ hospital B; – means no classification by factors;
Whitehead and collaborators; 2015 ¹⁷17. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh [Internet]. 2015 [acesso 18 abr 2018];47(2):117-25. DOI: 10.1111/jnu.12115 https://doi.org/10.1111/jnu.12115...	–	–	–	–	–	58.2 (11.1)
Numminen and collaborators; 2015 ²⁵25. Numminen O, Leino-Kilpi H, Isoaho H, Meretoja R. Ethical climate and nurse competence: newly graduated nurses’ perceptions. Nurs Ethics [Internet]. 2015 [acesso 5 maio 2018];22(8):845-59. DOI: 10.1177/0969733014557137 https://doi.org/10.1177/0969733014557137...	4.10 (0.52)	4.33 (0.54)	3.74 (0.58)	3.50 (0.91)	3.54 (0.64)	3.84 (0.45)
Jahantigh and collaborators; 2015 ²⁶26. Jahantigh M, Arbabisarjou A, Zare S, Shahrakipour M, Ghoreishinia G. Hospital's ethical climate and nurse's desired ethical climate in Ali-ebn-Abitaleb and Khatam-al-Anbia hospital of Zahedan. Pharm Lett [Internet]. 2015 [acesso 20 maio 2018];7(12):427-31. Disponível: https://bit.ly/32VFF6f https://bit.ly/32VFF6f...	14.70 (2.76)	15.42 (2.66)	20.98 (4.40)	22.07 (3.93)	21.6 (4.15)	94.78 (15.35)
Suhonen and collaborators; 2015 ²⁷27. Suhonen R, Stolt M, Katajisto J, Charalambous A, Olson LL. Validation of the Hospital Ethical Climate Survey for older people care. Nurs Ethics [Internet]. 2015 [acesso 16 maio 2018];22(5):517-32. DOI: 10.1177/0969733014549878 https://doi.org/10.1177/0969733014549878...	3.96 (0.54)	4.29 (0.55)	3.58 (0.71)	3.94 (0.87)	3.64 (0.67)	3.85 (0.56)
Sauerland and collaborators; 2015 ¹⁸18. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate part II: neonatal and pediatric perspectives. Dimens Crit Care Nurs [Internet]. 2015 [acesso 18 abr 2018];34(1):33-46. DOI: 10.1097/DCC.0000000000000083 https://doi.org/10.1097/DCC.000000000000...	–	–	–	–	–	96.6 (17.77)
Jahantigh, Zare, Shahrakipour; 2016 ³⁶36. Jahantigh M, Zare S, Shahrakipour M. The survey of the relationship between ethical climate and ethical behavior in nurses. Pharm Chem [Internet]. 2016 [acesso 20 maio 2018];8(3):189-93. Disponível: https://bit.ly/3lELjB2 https://bit.ly/3lELjB2...	–	–	–	–	–	94.78 (15.35)
Boer and collaborators; 2016 ³⁷37. Boer JC, Rosmalen J, Bakker AB, Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurement. Nurs Crit Care [Internet]. 2016 [acesso 13 maio 2018];21(3):e19-27. DOI: 10.1111/nicc.12206 https://doi.org/10.1111/nicc.12206...	–	–	–	–	–	3.86 (0.46)
Jang, Oh; 2019 ³¹31. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics [Internet]. 2019 [acesso 10 maio 2019];26(4):1186-98. DOI: 10.1177/0969733017742959 https://doi.org/10.1177/0969733017742959...	3.69 (0.40)	4.01 (0.48)	3.61 (0.57)	3.98 (0.56)	3.46 (0.47)	3.59 (0.41)
Özden and collaborators; 2019 ⁹9. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics [Internet]. 2019 [acesso 15 maio 2020];26(4):1211-25. DOI: 10.1177/0969733017736924 https://doi.org/10.1177/0969733017736924...	–	–	–	–	–	92.62 (17.0)
Asgari and collaborators; 2019 ³²32. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics [Internet]. 2019 [acesso 20 abr 2019];26(2):346-56. DOI: 10.1177/0969733017712083 https://doi.org/10.1177/0969733017712083...	3.29 (^ has no standard deviation; )	3.72 (^ has no standard deviation; )	1.58 (^ has no standard deviation; )	3.8 (^ has no standard deviation; )	2.61 (^ has no standard deviation; )	3.51 (0.53)
Lemmenes and collaborators; 2018 ¹⁹19. Lemmenes D, Valentine P, Gwizdalski P, Vincent C, Liao C. Nurses’ perception of ethical climate at a large academic medical center. Nurs Ethics [Internet]. 2018 [acesso 9 maio 2018];25(6):724-33. DOI: 10.1177/0969733016664980 https://doi.org/10.1177/0969733016664980...	3.60 (0.60)	3.94 (0.65)	2.93 (0.81)	3.04 (1.06)	2.97 (0.74)	3.22 (0.65)
Constantina, Papastavrou, Charalambous; 2019 ⁸8. Constantina C, Papastavrou E, Charalambous A. Cancer nurses’ perceptions of ethical climate in Greece and Cyprus. Nurs Ethics [Internet]. 2019 [acesso 15 maio 2018];26(6):1805-21. DOI: 10.1177/0969733018769358 https://doi.org/10.1177/0969733018769358...	3.74 (0.69)	3.99 (0.64)	3.06 (0.79)	3.88 (0.92)	3.4 (0.72)	3.58 (0.62)
Altaker, Howie-Esquivel, Cataldo; 2018 ²⁰20. Altaker KW, Howie-Esquivel J, Cataldo JK. Relationships among palliative care, ethical climate, empowerment, and moral distress in intensive care unit nurses. Am J Crit Care [Internet]. 2018 [acesso 10 maio 2019];27(4):295-302. DOI: 10.4037/ajcc2018252 https://doi.org/10.4037/ajcc2018252...	–	–	–	–	–	3.9 (0.5)

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[1] Correspondence Taís Carpes Lanes – Rua João Goulart, 401, casa 2, fundos, Camobi CEP 97105-220. Santa Maria/RS, Brasil.