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Original Article

Volume 13 Number 17 November 2020

Nurses' perspectives regarding the relationship between professional

ethics and organizational commitment in healthcare organizations

*Corresponding Author

Camellia Torabizadeh

Community-Based Psychiatric Care

Research Center, 2nd Floor, Building

No.3, Fatemeh PBUH School of Nursing

and Midwifery, Namazi Teaching

Hospital, Namazi Square, Shiraz, Iran.

Postal Code : 71936-13119

Tel : (+98)71 36 47 42 55 : 221

Email : [email protected]

Received: 18 April 2020

Accepted: 1 Oct 2020

Published: 8 Nov 2020

Citation to this article:

Torkaman M, Heydari N, Torabizadeh C.

Nurses' perspectives regarding the

relationship between professional ethics

and organizational commitment in

healthcare organizations. J Med Ethics

Hist Med. 2020; 13: 17.

Mahya Torkaman1, Naval Heydari1, Camellia Torabizadeh2* 1.PhD Candidate in Nursing, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences,

Shiraz, Iran.

2.Associate Professor, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz,

Iran.

Abstract Nurses' professional and ethical performances are influenced by the

health organizations' environment, and high quality and holistic care

can only be provided by observing the principles of professional

ethics and organizational commitment. Therefore, this study aimed at

investigating the relationship between professional ethics and

organizational commitment in nurses. This descriptive-analytic study

was conducted in hospitals affiliated to Shiraz University of Medical

Sciences (SUMS) in 2019 in Iran. The study participants included

210 public ward nurses selected using the stratified random sampling

method. Data were collected using Petty Professional Ethics and

Allen-Meyer Organizational Commitment questionnaires, and then

analyzed by SPSS V.25.

Both the mean score of the nurses' professional ethics (102.21 ±

10.89) and the mean score of the nurses' organizational commitment

(95.30 ± 16.54) were at high levels. Moreover, a direct and significant

relationship was found between professional ethics and organizational

commitment (P= 0.009, r = 0.179). In other words, a positive

correlation was found between professional ethics and organizational

commitment.

Considering the relationship between professional ethics and

organizational commitment in nurses, managers should enhance

nurses' level of adherence to ethical principles, organizational

commitment and organizational attachment. Additionally, training

courses can help improve nurses' professional capabilities, and hence

enhancing the quality of providing healthcare services.

Keywords: Organizational culture; Ethics; Organizational

commitment; Nursing.

Nurses’ perspective regarding the relationship between professional ethics and …

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Introduction

Human resources are the most important

asset of organizations. Nurses, the largest

and most important human resources in

healthcare organizations, play a major role in

providing continuous high quality care (1).

The current rapid developments in healthcare

organizations have raised concerns about

necessity of caring based on the professional

ethics' principles. Professional ethics is a set of

basic human principles and standards

governing the individuals and groups'

behavior. Moreover, professional ethics is a

rational thinking process that targets at

determining values of an organization (2), and

disregarding it can question the organization's

legitimacy and actions. Empowerment and

adherence to principles and codes of ethics are

among the concerns of human resource

management in the healthcare organizations

worldwide (3). According to the International

Council of Nurses (ICN), nurses not only

promote public health and well-being, but also

protect themselves against ethical dilemmas in

healthcare organizations by emphasizing on

ethical planning and practicing (4). The

healthcare organizations' negligence of the

professional ethics and their failure in adhering

to ethical principles can create problems for

nurses that question their measures and reduce

their teamwork, job satisfaction, and

appropriate relationships with colleagues (5).

However, results of various studies indicated

that nurses' adherence to professional ethics

was not high. Bah et al. (2018) showed that

nurses' adherence to ethical values was at a

low level, and they did not observe the codes

of ethics (4). In other words, nurses encounter

conflicts between their personal and

professional values by ignoring ethical

considerations, thereby resulting in their

distance from patients and indifference to care

provision (4).

Professional ethics and adherence to its

principles can influence individual's

commitment to the organization.

Organizations can rarely succeed without

adhering to professional ethics and

institutionalizing the organization's ideals and

values (6). Organizational commitment is

defined as believing in the organization's

values and goals, feeling loyal to the

organization, as well as feeling ethical

requirements, heart desires, and needs to stay

in the organization. Organizational

commitment is a type of emotional

dependence on the organization; highly

committed employees take their identity from

the organization, participate in the

organization, and enjoy membership in the

organization (7). Employees with

organizational commitment can create an

efficient atmosphere to improve organizational

ethics, motivation, and efficiency (2).

Organizational commitment, as an employee

evaluation criterion, affects nurses' intention to

change their occupation, leave their

occupation, absenteeism, conflicts, job stress,

and clinical performance (8). To have efficient

human resources in the health sector,

employing nursing staffs with high

organizational commitment is extremely

challenging as nurses' low organizational

commitment can decrease their performance

and quality of care (9, 10). Safari and

Yoosefpour in their study in Iran showed that

enhancing nurses ‘organizational commitment

improved their quality of care (11).

Torkaman M., et al.

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Volume 13 Number 17 November 2020

Researchers of the present study consisted of

clinical educators, and nurses who have

frequently observed the weaknesses of

healthcare organizations in adhering to ethical

principles and organizational commitment. In

addition, they have closely experienced the

consequences of ignoring professional ethics

and organizational commitment. Both

professional ethics and organizational

commitment can influence the quality of

healthcare staff’s work-life and nursing care,

and to the best of our knowledge, this is the

first study to investigate the relationship

between professional ethics and organizational

commitment on nurses.

Method

This descriptive-analytical study was

conducted from July to October 2019 in

hospitals affiliated to Shiraz University of

Medical Sciences (SUMS) in Shiraz, one of

the largest cities in the south of Iran.

Participants, selected using stratified random

sampling method, were 210 nurses working

in SUMS’ affiliated hospitals. The sample

size was calculated as 210 based on a similar

study (12), and the sample size formula

using r = 0.192, confidence level of 0.95,

and test power of 0.8 by Medcalc software.

Inclusion criteria were as follows: being

employed as a nurse, having at least a

bachelor's degree in nursing, and consenting

to participate in the study. Participants were

excluded if they refused to continue

attending or fully complete the

questionnaires.

The Ethics Committee affiliated with SUMS

approved this research (Medical Ethic No:

IR. SUMS. REC.1398.1086), and introduction

letters were sent to the hospitals' managers

for necessary coordination. Prior to the

study, all participants were provided with a

cover letter explaining the study’s purpose

and data collection procedure. Then,

informed written consent was obtained from

all participants, and they were guaranteed

the confidentiality of the data, anonymity as

well as their voluntary participation in the

study.

To collect data, Petty professional ethics and

Allen-Meyer organizational commitment

scales were administered along with the

demographic information questionnaire. The

professional ethics questionnaire, developed

by Petty in 1993, includes four dimensions:

interest in work, perseverance in work,

healthy human relationships at work, and

participation in work. Attainable scores on

this questionnaire ranged from 23 to 115

such that higher scores indicate higher

professional ethics. Scores within the range

of 23-46, 47-69, and 70-115 indicated low,

moderate, and good levels of the

professional ethics, respectively. Content

validity of this questionnaire was confirmed

by an expert panel of professionals, and its

construct validity was corroborated by factor

analysis method. Cronbach's alpha value to

measure the total internal consistency of this

tool was 0.96. Interest in work, perseverance

in work, healthy human relationships

at work, and participation in work had

Cronbach's alpha values of 0.85, 0.79, 0.87,

and 0.74, respectively (13, 14). Moreover,

Sheikhzakaryaie and Atashzadeh-Shoorideh

showed that the total reliability of this tool was

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Volume 13 Number 17 November 2020

85%. For the following four dimensions,

healthy human relationships at work,

perseverance in work, interest in work, and

participation in work, the reported reliability

indices were 79%, 91%, 84%, and 86%,

respectively (15).

The Allen-Meyer organizational commitment

questionnaire (1990) contains 24 items with

three main dimensions of affective (indicating

the individual's emotional dependence on the

organization), continuance (including costs of

leaving the job), and normative commitment

(showing the obligation and sense of duty to

stay in the organization). The respondents'

scores could range from 24 to 168.

Respectively, a score within the ranges of 120-

190, 60-90, and 0-60 showed high, moderate,

and low organizational commitment.

Reliability coefficients of the affective,

continuance, and normative commitment

dimensions were 0.86, 0.79, and 0.75,

respectively. Validity of this questionnaire was

also confirmed by 15 experts, and its structural

validity was verified by confirmatory factor

analysis (16, 17). In the study by Nabizadeh et

al., the internal consistency was assessed using

Cronbach's alpha coefficient (18). Based on

their findings, (α = 0.87) for the total tool, (α =

0.82) for the emotional commitment, (α =

0.89) for the continuous commitment, and (α =

0.75) for the normative commitment

dimension were obtained. The tool's stability

was evaluated using the retest method at 14-

day intervals for all the organizational

commitment tools (r = 0.89) as well as the

continuous commitment (r = 0.93), emotional

commitment (r = 0.93), and normative

commitment (r = 0.87) dimensions (18).

Using SPSS software version 25, descriptive

statistics (percentage, mean, and standard

deviation) and analytical statistics (t-test and

Pearson and Spearman correlation coefficient)

were used to analyze the data. According to

Kolmogorov-Smirnov test, data had a

normal distribution, and the level of

significance was considered at 5%.

Results

Demographic characteristics

From 210 nurse participants, 156 were

female (74.3%), 129 were married (61.4%),

and 189 had a bachelor's degree (90%). The

mean age of nurses was 31.11 ± 6.74 years,

and their mean work experience was 7.46 ±

5.89 years (Table 1).

Table 1- Participant’s demographic

information

Variable Number

(Percentage %)

Marital status

Single

Married

81 (38.6)

129 (61.4)

Gender

Male

Female

54 (25.7)

156 (74.3)

Education level Bachelor's degree

Master’s degree

189 (90)

21 (10)

Type of employment

Permanent employment Contractual employment Temporary to

permanent employment

Conscription law's employment

Corporate employment

60 (28.6)

40 (19)

29 (13.8)

72 (34.3)

9 (4.3)

Based on the independent t-test results,

mean scores of the professional ethics and

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organizational commitment were not

significantly diverse in different gender and

marital status groups. However, a significant

difference was found between the

participants' organizational commitment and

level of education, and organizational

commitment was higher in nurses with a

bachelor's degree (Table 2).

Table 2- Nurses' demographic information as well as its relationship with organizational commitment

and professional ethics (n = 210) Variables Organizational commitment Professional ethics

*Age r = 0.129

P = 0.062

r = 0.047

P = 0.501

*Years of working r = - 0.051

P = 0.459

r = - 0.02

P = 0.777

**Gender

Male 96.51±16.00 r= -0.001

P=0.988

102.61±12.34 r = - 0.055

P =0.425 Female 94.89±16.75 102.07±10.38

P-value 0.535 0.757

**Marital status

Single 93.50±17.89 r = 0.56

P=0.451

101.91±13.01 r = - 0.043

P = 0.538 Married 96.44±15.59 102.40±9.37

P-value 0.211 0.752

**Academic level

Bachelor 96.37±15.60 r = - 0.125

P =0.071

102.31±10.60 r = - 0.003

P =0.965 Master 85.76±21.54 101.28±13.48

P-value 0.005* ** 0.682

*Pearson correlation coefficient was used, and significance level was considered at 0.01.

**Spearman correlation coefficient was used, and significance level was considered at 0.01. ***Independent t-test was used, and significance level was considered at 0.05.

Participants' professional ethics and

organizational commitment

The professional ethics' total mean score was

high (102.21 ± 10.89) in nurses. The highest

and lowest scores were attributed to the

perseverance in work (27.41 ± 3.11) and

relations in work (23.00 ± 2.30) dimensions,

respectively. The participants' mean scores

in dimensions of interest in work and

participation in work were )24.46 ± 5.32 (

and )27.32 ± 3.03(, respectively.

Mean score of the total organizational

commitment was high (95.30 ± 16.54). The

highest mean score was related to

continuance commitment dimension (37.76

± 9.80), while the lowest mean score was

attributed to the normative (30.61 ± 6.63)

and affective commitment (31.92 ± 6.49)

dimensions.

Correlation between professional ethics

and organizational commitment

Professional ethics had a direct correlation

with interest in work. In addition,

organizational commitment had a very weak

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correlation and weak correlation with

affective and normative dimensions,

respectively. Organizational commitment

also had a direct and very weak relationship

with professional ethics and normative

dimension, respectively (Table 3).

Table 3. Correlation between professional ethics and organizational commitment in nurses

Variable Professional

ethics

Interest

in Work

Perseverance

in work

Human relations

at work

Participation

in work

Total

Organizational

Commitment

r=0.179

P=0.009*

r=0.304

P<0.001*

r=0.123 P=0.076

r= -0.028 P=0.681

r=0.006 P=0.926

Affective

Commitment

r=0.228

P=0.001*

r=0.413

P<0.001*

r=0.071

P=0.308 r= - 0.025

P=0.724

r=0.038 P=0.583

Continuance Commitment

r=0.047 P=0.497

r=0.065 P=0.352

r=0.056 P=0.420

r= - 0.007

P=0.918

r=0.004

P=0.954

Normative

Commitment

r=0.154

P=0.025*

r=0.257

P<0.001*

r=0.154

P=0.026* r= - 0.036

P=0.600

r= -0.027 P=0.695

Pearson correlation coefficient was used, and significance level was considered at 0.01.

Discussion

This study aimed to investigate the

relationship between professional ethics and

organizational commitment in nurses.

According to the findings of this work,

which are consistent with those of a study by

Dehghani et al. (19) in Iran, the mean score

of nurses' total professional ethics was at a

high level, showing that observing

professional ethics was a part of the nursing

profession's intrinsic nature. However, a

study in Uganda indicated that nurses had a

poor knowledge of basic ethical concepts

(20). Another study in Iran showed that

nurses' knowledge and attitudes were at a

moderate level towards ethical codes,

implying that nurses did not use various and

available related resources appropriately

(e.g., international and national codes of

ethics in the nursing profession) (21). The

discrepancy between our findings and other

studies can be due to the differences in

participants' characteristics and tools used

for measuring professional ethics. In

addition, professional ethics is a multi-

dimensional phenomenon influenced by

nursing education system, system's views

and attitudes toward nurses, as well as social

and cultural factors.

In professional ethics, the highest and lowest

mean scores were related to the perseverance

in work and human relations dimensions,

respectively. The nurses' high level of

perseverance in work can be justified by

nursing profession nature, in which nurses

should render high quality services to

patients despite all shortcomings, many

overtime hours, and shortage of the

healthcare staff.

The low scores in the human relations

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dimension can be due to nurses' lack of

sufficient motivation, burnout, job

dissatisfaction, and lack of professional

interest as well as low nurse-patient ratio. In

this regard, nursing managers can

significantly help improve the relationships

in workplace and serve as role models for

other healthcare system personnel by

adhering to the ethics' principles and

appropriate human relationships (22).

The mean score of total organizational

commitment was high among the

participants; this finding was also confirmed

by many studies in Iran and other countries

(23-25). Staff with higher levels of

organizational commitment usually have

better performance with less absenteeism

and delay to work, which are significantly

important in sensitive occupations such as

nursing (26).

Organizational commitment enables the

employees to interact emotionally with the

organization, feel satisfied to work for the

organization, and make endeavor to reach

the organization's goals (24). The results of

other heterogeneous studies reported an

average level of organizational commitment

among nurses (27, 28). In our study, the

highest mean score of commitment was related

to continuance commitment dimension as

individual’s continuance commitment can be

enhanced by increasing the number and length

of training programs (e.g., in-service courses)

(27). Continuous commitment appears when

an individual analyzes positive and negative

aspects of leaving the organization. With

high levels of continuance commitment, the

employees remain loyal to the occupation

because they think that starting a new job

would destroy the experiences gained in the

organization. However, such thought may

put the organization in a position facing

employees who are not motivated, creative

and innovative (6).

The present study’s participants seemed to

adapt to the current situation to avoid

financial costs of leaving the organization,

possibly due to low nurses' salaries and

economic problems in Iran.

The lowest mean score of organizational

commitment was related to normative

commitment dimension, which was

confirmed by another study in Iran on nurses

(18). In normative commitment, employees

are faced with the situation of staying in the

organization because they think it is a right

and proper action. The following approaches

can be effective in improving employees'

normative commitment: in-service training,

labor division based on the individuals'

abilities and competences, as well as

continuous evaluation of the personnel's

performance, abilities, and capabilities (26).

This study’s results showed a significant

relationship between professional ethics and

organizational commitment. Many studies

also confirmed the relationship of

professional and ethical empowerment with

nurses' organizational commitment (25, 29).

Inconsistent with the present study, a

research in Iran on nurses showed no

significant relationship between professional

ethics and organizational commitment (2).

Based on the literature, ethical work

environment can be considered to be a main

factor affecting the performance and

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competence of the staff (4, 30). In this

regard, Karami et al. stated that hospital

managers need to extensively plan to

improve nurses' professional performance

and organizational quality (7).

The present study showed a significant

relationship between the nurses'

organizational commitment and the

bachelor's degree. This finding was in line

with the results of a study by Nabizadeh et

al. (18), but contradicted those of a study by

Sheikhzakaryaie and Atashzadeh-Shoorideh

(15). Usually, nurses with master's and

doctoral degrees are employed in

universities and research centers in Iran.

Moreover, nurses with a bachelor's degree

have fewer job opportunities, and hence they

have to work in clinical settings and are

more dependent on the healthcare

organizations.

Given that various factors affect nurses'

professional ethics and organizational

commitment, managers should consider

factors such as delegating authority,

clarifying responsibilities, and evaluating

staff performance properly. The authorities

should enhance nurses' commitment to

ethics and organizational attachment through

training courses to empower the nurses,

thereby improving their quality of health

care services.

A limitation of this study was administration

of the self-report questionnaires, and hence

future work can use other data collection

methods such as interview and observation

to increase data validity.

Conclusion

According to the study findings, nurses had

high levels of professional ethics and

organizational commitment, and a

significant relationship was observed

between these two factors. Considering the

priority of high-quality care provision by

nurses, nursing managers should seriously

consider the effect of nurses' professional

ethics and organizational commitment on

organization's development. Moreover,

providing a precise definition of ethical

codes as well as in-service training courses

for nurses can encourage them to practice on

ethical principles and improve their

organizational commitment.

Acknowledgments

This study was derived from an approved

research project in Shiraz University of

Medical Sciences, Iran with registration

number: 19773. The authors thank and

appreciate all nurses who participated in this

research.

Conflict of Interests

The authors declare that they have not

competing interest.

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