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Influence of the ethical climate on workers’ health among healthcare professionals: a systematic review

Influencia del clima ético en la salud del trabajador entre los profesionales de la salud: una revisión sistemática

ABSTRACT

Objective:

To evaluate the influence of the ethical climate on workers’ health among healthcare professionals.

Method:

Systematic review and meta-analysis conducted in MEDLINE/PubMed, EMBASE, SciVerse Scopus (Elsevier), Cumulative Index to Nursing and Allied Health Literature and Web of Science. Trained reviewers performed the selection, data extraction, and assessment of methodological quality. Meta-analysis was applied for data synthesis.

Results:

Among the 2644 studies, 20 were included for analysis, in which three (15.0%) articles were classified as high quality (score ≥ 80%), while 17 (85.0%) were classified as regular (score 50-79%). There was a moderate negative correlation between the ethical climate and overall moral distress (r=-0.43; 95%CI -0.50; -0.36) and the frequency of moral distress (r=-0.36; 95%CI -0.45; -0.25), as well as the positive and strong correlation between ethical climate and job satisfaction (r=0.71; 95%CI 0.39-0.88).

Conclusion:

The negative and positive perception of the ethical climate among healthcare professionals, respectively, influenced the increase in moral distress and job satisfaction.

Descriptors:
Ethics; Health personnel; Occupational health; Nursing; Systematic review

RESUMEN

Objetivo:

Evaluar la influencia del clima ético en la salud de los trabajadores entre los profesionales de la salud.

Método:

Revisión sistemática y metanálisis utilizando MEDLINE/PubMed, EMBASE, SciVerse Scopus (Elsevier), Cumulative Index to Nursing and Allied Health Literature y Web of Science. La selección, la extracción de datos y la evaluación de la calidad metodológica fueron realizadas por revisores capacitados. Se aplicó metanálisis para la síntesis de datos.

Resultados:

Entre 2644 estudios, 20 fueron incluidos para el análisis, en el que tres (15,0%) artículos fueron clasificados como de alta calidad (puntuación ≥ 80%), mientras que 17 (85,0%) fueron clasificados como regulares (puntuación 50-79%). Ocurrió correlación negativa y moderada entre el clima ético y el sufrimiento moral general (r=-0,45; IC95% -0,52; -0,38) y la frecuencia del sufrimiento moral (r=- 0,32; IC 95% -0,45; -0,18), así como una correlación positiva y fuerte entre el clima ético y la satisfacción laboral (r=0,71; IC 95% 0,39-0, 88).

Conclusión:

La percepción negativa y positiva del clima ético entre los profesionales de la salud, respectivamente, influyeron en el aumento del malestar moral y la satisfacción laboral.

Descriptores:
Ética; Personal de salud; Salud laboral; Enfermería; Revisión sistemática

RESUMO

Objetivo:

Avaliar a influência do clima ético na saúde do trabalhador entre os profissionais de saúde.

Método:

Revisão sistemática nas bases MEDLINE/PubMed, EMBASE, SciVerse Scopus (Elsevier), Cumulative Index to Nursing and Allied Health Literature e Web of Science. A seleção, a extração dos dados e a avaliação da qualidade metodológica foram realizadas por revisores capacitados. Aplicou-se a meta-análise para a síntese dos dados.

Resultados:

Dentre os 2644 estudos, foram incluídos 20 para análise, em que três (15,0%) artigos foram classificados como de alta qualidade (pontuação ≥ 80%), enquanto 17 (85,0%) foram classificados como regulares (pontuação 50-79%). Houve correlação negativa e moderada entre o clima ético e o sofrimento moral geral (r=-0,43; IC95% -0,50; -0,36) e a frequência de sofrimento moral (r=-0,36; IC95% -0,45; -0,25), bem como a correlação positiva e forte entre o clima ético e a satisfação no trabalho (r=0,71; IC95% 0,39-0,88).

Conclusão:

A percepção negativa e positiva do clima ético entre os profissionais de saúde, respectivamente, influenciou no aumento do sofrimento moral e na satisfação no trabalho.

Descritores:
Ética; Pessoal de saúde; Saúde ocupacional; Enfermagem; Revisão sistemática

INTRODUCTION

The ethical climate is defined as the workers’ perception of how ethical issues are dealt within their daily work, or if there are organizational conditions that support them in ethical reflections during their practice, contemplating care, management, policies and deliberation of ethical problems in services11. Olson LL. Hospital nurses' perceptions of the ethical climate of their work setting. J Nurs Sch. 1998;30(4):345-9. doi: https://doi.org/10.1111/j.1547-5069.1998.tb01331.x
https://doi.org/10.1111/j.1547-5069.1998...
,22. Koskenvuori J, Numminen O, Suhonen R. Ethical climate in nursing environment: a scoping review. Nurs Ethics. 2019;26(2):327-45. doi: https://doi.org/10.1177/0969733017712081
https://doi.org/10.1177/0969733017712081...
. This perception can be negative or positive, according to the classification of the ethical climate through the Hospital Ethical Climate Survey (HECS)11. Olson LL. Hospital nurses' perceptions of the ethical climate of their work setting. J Nurs Sch. 1998;30(4):345-9. doi: https://doi.org/10.1111/j.1547-5069.1998.tb01331.x
https://doi.org/10.1111/j.1547-5069.1998...
.

A positive rating can be associated with sharing decisions, access to information needed for care and a friendly team relationship, with respect for opinions of people involved in patient care. The negative perception occurs when the professional does not have the institution’s support or openness to act according to its ethical values and difficulties in accessing information that can support in decision-making11. Olson LL. Hospital nurses' perceptions of the ethical climate of their work setting. J Nurs Sch. 1998;30(4):345-9. doi: https://doi.org/10.1111/j.1547-5069.1998.tb01331.x
https://doi.org/10.1111/j.1547-5069.1998...
.

Given this context, a positive ethical climate becomes necessary to provide qualified health care and with a lower risk of illness for the worker33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,44. Victor B, Cullen JB. The organizational bases of ethical work climates. Adm Sci Q. 1988;33(1):101-25. doi: http://doi.org/10.2307/2392857
http://doi.org/10.2307/2392857...
. Thus, studies have shown that a positive ethical climate in the organizational environment promotes professional satisfaction with their work, making a healthy and safe environment for quality health care33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
.

The negative perception of the ethical climate is a predictor for the risk of harm to workers’ health77. Lanes TC, Dalmolin GL, Silva AM, Ramos FRS, Olson LL. Cross-cultural adaptation of the hospital ethical climate survey to Brazil. J Nurs Meas. 2023;31(2):148-62. doi: http://doi.org/10.1891/JNM-2021-0036
http://doi.org/10.1891/JNM-2021-0036...
. Among the types of harm, moral distress stands out and its influence on turnover intention22. Koskenvuori J, Numminen O, Suhonen R. Ethical climate in nursing environment: a scoping review. Nurs Ethics. 2019;26(2):327-45. doi: https://doi.org/10.1177/0969733017712081
https://doi.org/10.1177/0969733017712081...
. Turnover intention refers to the change of work sector in the institution due to several reasons, such as: inadequate working conditions, interpersonal relationship problems between colleagues in the sector and problems with the unit’s management for example22. Koskenvuori J, Numminen O, Suhonen R. Ethical climate in nursing environment: a scoping review. Nurs Ethics. 2019;26(2):327-45. doi: https://doi.org/10.1177/0969733017712081
https://doi.org/10.1177/0969733017712081...
. The occurrence of these issues highlights the importance of a positive ethical climate to reduce illness and strengthen the worker through moral issues. The literature presents studies on the association and correlation between the ethical climate and moral distress, the turnover intention and job satisfaction44. Victor B, Cullen JB. The organizational bases of ethical work climates. Adm Sci Q. 1988;33(1):101-25. doi: http://doi.org/10.2307/2392857
http://doi.org/10.2307/2392857...
-88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
.

Faced with this issue, in June 2020 a preliminary search was conducted in the International Prospective Register of Systematic Reviews (PROSPERO), Cochrane Database of Systematic Reviews and in the Joanna Briggs Institute (JBI): Database of Systematic Reviews and Implementation Reports in order to investigate the records of reviews on the themes of ethical climate and workers’ health. The search found two systematic reviews on ethical interventions99. Schildmann J, Nadolny S, Haltaufderheide J, Gysels M, Vollmann J, Bausewein C. Ethical case interventions for adult patients. Cochrane Database Syst Rev. 2019;2019(7):CD012636. doi: https://doi.org/10.1002/14651858.CD012636.pub2
https://doi.org/10.1002/14651858.CD01263...
and the ethical climate in the work context of frontline professionals in business organizations1010. Friend SB, Jaramillo F, Johnson JS. Ethical climate at the frontline: a meta-analytic evaluation. J Serv Res. 2020;23(2):116-38. doi: https://doi.org/10.1177/1094670519898261
https://doi.org/10.1177/1094670519898261...
, but none from the perspective of the influence of the ethical climate on workers’ health among healthcare professionals. Thus, there is a need for analysis and synthesis of this evidence, including the use of meta-analytical tests, to identify the variables that are essentially influenced by the negative and positive ethical climate in the work of healthcare professionals1111. Ventovaara P, Sandeberg M, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics. 2021;28(6):1061-72. doi: https://doi-org.ez47.periodicos.capes.gov.br/10.1177/0969733021994169
https://doi-org.ez47.periodicos.capes.go...
-1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
.

Based on the results and recognition of the variables involved in workers’ health regarding the ethical climate, the aim is in future studies, to direct and prospect interventions to promote the health of professionals and quality of patient care. The application of the results into practice will be in the form of planning and construction of strategies that promote an ethical climate and consequently reduce the risk to the worker’s health55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
-77. Lanes TC, Dalmolin GL, Silva AM, Ramos FRS, Olson LL. Cross-cultural adaptation of the hospital ethical climate survey to Brazil. J Nurs Meas. 2023;31(2):148-62. doi: http://doi.org/10.1891/JNM-2021-0036
http://doi.org/10.1891/JNM-2021-0036...
.

Thus, the objective was to evaluate the influence of the ethical climate on workers’ health among healthcare professionals.

METHOD

It consists of a systematic meta-analytical review reported based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and conducted according to the JBI methodology on etiological and risk evidence1414. Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (editors). JBI Manual for Evidence Synthesis. JBI; 2020. doi: https://doi.org/10.46658/JBIMES-20-08
https://doi.org/10.46658/JBIMES-20-08...
. The protocol for this review was registered in PROSPERO under the number: CRD42020199979. No changes were made after the review was finalized, with the same information provided in the protocol. The systematic review was conducted in the city of Santa Maria, RS, Brazil from August 2020 to April 2023.

The research question was developed according to the acronym PEO (P: population - health professionals; E: exposure - ethical climate; O: outcome - worker’s health). Thus, the research question was defined: “Does the ethical climate have an influence on workers’ health among healthcare professionals?”.

Original articles were included, of observational type, cross-sectional or longitudinal, descriptive or analytical, that presented the analysis of the correlation between the ethical climate and the workers’ health variables, such as moral distress, job satisfaction, abandonment of the profession, the turnover intention, burnout syndrome and among others. The inclusion of these variables occurred because the literature addresses the association between these variables of workers’ health and the ethical climate, showing significant correlations33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
. Articles written in English, Portuguese or Spanish, composed of a sample or population of healthcare professionals from any area and healthcare service were also included.

In addition, articles that used the HECS instrument to evaluate the ethical climate and validated instruments for measuring workers’ health variables were included. The use of the HECS was defined because it is the most used instrument to assess the ethical climate among health professionals in different health services, when compared to other instruments44. Victor B, Cullen JB. The organizational bases of ethical work climates. Adm Sci Q. 1988;33(1):101-25. doi: http://doi.org/10.2307/2392857
http://doi.org/10.2307/2392857...
. Additionally, the systematic review with meta-analysis recommends that the studies have homogeneity between the variables so that the tests can be performed. Among the variables are: instruments, population, research context, sample, statistical tests and analyses, for example1414. Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (editors). JBI Manual for Evidence Synthesis. JBI; 2020. doi: https://doi.org/10.46658/JBIMES-20-08
https://doi.org/10.46658/JBIMES-20-08...
. No restriction on the publication year and geographical location was set, as the goal was to access all studies that fit within the scope of the research.

The HECS instrument consists of 26 items divided into five factors: peers, physicians, hospital, management, and patients. The instrument was developed in 1998 by Linda Olson11. Olson LL. Hospital nurses' perceptions of the ethical climate of their work setting. J Nurs Sch. 1998;30(4):345-9. doi: https://doi.org/10.1111/j.1547-5069.1998.tb01331.x
https://doi.org/10.1111/j.1547-5069.1998...
in Chicago, United States and adapted and validated for Brazil in 202277. Lanes TC, Dalmolin GL, Silva AM, Ramos FRS, Olson LL. Cross-cultural adaptation of the hospital ethical climate survey to Brazil. J Nurs Meas. 2023;31(2):148-62. doi: http://doi.org/10.1891/JNM-2021-0036
http://doi.org/10.1891/JNM-2021-0036...
. The instrument analysis occurs through the mean and standard deviation, in which above 3.5 is considered the perception of a positive ethical climate and lower, as a negative ethical climate11. Olson LL. Hospital nurses' perceptions of the ethical climate of their work setting. J Nurs Sch. 1998;30(4):345-9. doi: https://doi.org/10.1111/j.1547-5069.1998.tb01331.x
https://doi.org/10.1111/j.1547-5069.1998...
,77. Lanes TC, Dalmolin GL, Silva AM, Ramos FRS, Olson LL. Cross-cultural adaptation of the hospital ethical climate survey to Brazil. J Nurs Meas. 2023;31(2):148-62. doi: http://doi.org/10.1891/JNM-2021-0036
http://doi.org/10.1891/JNM-2021-0036...
.

An initial search in the SciVerse Scopus (Elsevier) and MEDLINE/PubMed (via National Library of Medicine) databases was performed to identify articles on the subject and to assist in the development of search strategies. For this, 10 relevant articles were selected in which the words of the text in the titles, abstracts and descriptors were used to make the search strategies.

Data search sources were MEDLINE/PubMed (via National Library of Medicine), EMBASE (Elsevier), SciVerse Scopus (Elsevier), Cumulative Index to Nursing and Allied Health Literature (CINAHL) with Full Text (EBSCO) and Web of Science - Core Collection (Clarivate Analytics). The search strategies were composed of keywords, MeSH and Entry Terms with the selection of articles until the final date of the review (04/09/2023).

Based on the PEO acronym, the following words were used to compose the strategies: Population: health personnel, nurses, nursing, physicians, physician assistants, physician-nurse relations, nursing supervisory, healthcare professionals, nursing staff, registered nurses, nurse- physician; Exposure of interest: ethics, ethical climate, hospital ethical climate survey, hecs, ethical climate positive, ethical climate negative, ethical climate positively, ethical climate negatively, ethical climate questionnaire; Outcome: workers health, occupational stress, job stress, moral distress, burnout, psychological exhaustion, turnover personnel, turnover intentions, job satisfaction, work satisfaction, moral distress scale-revised, occupational, turnovers, moral residue, personnel turnover. The complete composition of the strategies can be found in the supplementary material.

The selection of articles occurred in a double-independent way by two reviewers (A and B), who assessed the titles and abstracts of the articles for potential eligibility. For the selection, the record and reference managers Rayyan and EndNote were used. After identifying potential studies, the full text was assessed. Reviewers searched for other new studies in the reference list of articles included in the review.

Inconsistencies between reviewers A and B were resolved by consensus after the selection of articles was completed. Both reviewers met in person for discussion and final decision on the inclusion or exclusion of articles that showed discrepancies in their analysis based on the eligibility criteria.

The two reviewers (A and B) extracted the data using a Microsoft Excel spreadsheet prepared for this research. Before starting this stage, the data extraction spreadsheet was tested in five articles and discussed by both reviewers. One reviewer (A) extracted the data properly and the other reviewer (B) verified whether the extracted information was consistent, identifying errors and inconsistencies. The spreadsheet had the following data: General characteristics and methods: authors, study design, scenario and statistical correlation tests between the ethical climate and the workers’ health variables. Participants: sample or population, professional category, age or age group and gender. Results: descriptive data and correlation between ethical climate and the variable related to workers’ health.

The three reviewers (A, B and C) assessed the methodological quality and risk of bias of the studies in a double-independent manner, using the Joanna Briggs critical appraisal tools (Checklist for Analytical Cross Sectional Studies)1515. Joanna Briggs Institute. Checklist for analytical cross sectional studies [Internet]. JBI; 2017 [cited 2022 Jan 27]. Available from: https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf
https://jbi.global/sites/default/files/2...
. The reviewers were trained by a member of the review team, who applied a pilot test with the first five articles included in this study among the reviewers, to guarantee the quality and accuracy of the evaluation.

The Joanna Briggs critical appraisal tools (Checklist for Analytical Cross Sectional Studies) consists of eight evaluation criteria for analytical cross-sectional studies, classified on a scale of: “yes”, “no”, “nuclear” or “not applicable”. The three reviewers (A, B and C) used this instrument to evaluate the methodological quality of the articles included in the review. The quality of the information was considered excellent through the classification “yes” of all the listed criteria1515. Joanna Briggs Institute. Checklist for analytical cross sectional studies [Internet]. JBI; 2017 [cited 2022 Jan 27]. Available from: https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf
https://jbi.global/sites/default/files/2...
.

The score for the answers to each item ranged: 0 for the answer “no”; 1 for the answer “yes”; “unclear” for the answer that was not clear and “not applicable” for the answer that did not apply to the articles1515. Joanna Briggs Institute. Checklist for analytical cross sectional studies [Internet]. JBI; 2017 [cited 2022 Jan 27]. Available from: https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal-Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf
https://jbi.global/sites/default/files/2...
. Thus, the maximum score was eight points and calculated through percentages. The quality of each study was classified as high (80%-100%), regular (50%-79%) or low (<50%)1616. Poudel P, Griffiths R, Wong VW, Arora A, Flack JR, Khoo CL, et al. Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review. BMC Public Health. 2018;18(1):577. doi: https://doi.org/10.1186/s12889-018-5485-7
https://doi.org/10.1186/s12889-018-5485-...
. Differences in the assessment of methodological quality and study bias were resolved by consensus among the three reviewers, through an in-person meeting.

Also, to better evaluate the quality of the studies, the inter-researcher reliability was calculated based on the intra-class correlation coefficient: 0.40 = bad; 0.4 ≤ a ˂0.75 = satisfactory and ≥0.75 = excellent1717. Fleiss JL, Cohen J. The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability. Educ Psychol Meas. 1973;33(3):613-9. doi: http://doi.org/10.1177/001316447303300309
http://doi.org/10.1177/00131644730330030...
. This test is aimed to provide clarity and reliability in the evaluations of studies among research reviewers.

For the synthesis of results, meta-analysis was used, which is a technique for combining the results of studies providing another new estimate1818. Normand SL. Meta-analysis: formulating, evaluating, combining, and reporting. Stat Med. 1999;18(3):321-59. doi: https://doi.org/10.1002/(SICI)1097-0258(19990215)18:3<321::AID-SIM28>3.0.CO;2-P
https://doi.org/10.1002/(SICI)1097-0258(...
. The associations between the ethical climate and the worker’s health variables were evaluated using Pearson’s correlation coefficient (r value). The r values from the different studies were summarized using the “Fisher’s z transformation”. For this, the correlation coefficients were converted to the z variable, which has a normal distribution, using the following transformation formula: z = 0,5[ln(1+r) - ln(1-r)]1919. Kenny DA. Statistics for the social and behavioral sciences. London: Longman; 1987.. Additionally, the studies were weighted based on the magnitude of the standard error (SE) of each study, which was calculated according to the following formula: EP = 1/(√N−3), where N is the sample size of the corresponding study. For correlation classification, the following parameters were used: 0.1 to 0.29 weak correlation; from 0.3 to 0.49 moderate correlation and above 0.5 is considered a strong correlation1919. Kenny DA. Statistics for the social and behavioral sciences. London: Longman; 1987..

Thus, the meta-analytical approach employed calculated weighted Fisher's z coefficients, which were subsequently transformed back to r values with 95% confidence intervals (95%CI). A random effects model was used separately for the outcome and each variable of interest (Ethical climate and Overall moral distress; Ethical climate and Intensity of moral distress; Ethical climate and Frequency of moral distress; Ethical climate and turnover intention; Ethical climate and job satisfaction).

Heterogeneity between studies was assessed using the chi-square test, adopting a significance level of p<0.10, and by estimating the inconsistency between studies (I22. Koskenvuori J, Numminen O, Suhonen R. Ethical climate in nursing environment: a scoping review. Nurs Ethics. 2019;26(2):327-45. doi: https://doi.org/10.1177/0969733017712081
https://doi.org/10.1177/0969733017712081...
), with up to 25% being considered as low heterogeneity, close to to 50% of moderate heterogeneity and above 75% of high heterogeneity2020. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-60. doi: https://doi.org/10.1136/bmj.327.7414.557
https://doi.org/10.1136/bmj.327.7414.557...
,2121. Page MJ, Higgins JPT, Sterne JAC. Chapter 13: Assessing risk of bias due to missing results in a synthesis. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane handbook for systematic reviews of interventions version 6.2 [Internet]. Cochrane. 2021 [cited 2022 Jan 29]. Available from: https://www.training.cochrane.org/handbook
https://www.training.cochrane.org/handbo...
.

Statistical analyses were conducted using the Stata 14.2 software, and the meta-analysis results are presented in a forest plot. The results of the studies were summarized in a table, which included the citation, design, sample size, participants, variables associated with the ethical climate and its main results.

RESULTS

Study selection

A total of 2,644 articles were found, of which 355 were duplicated and were included only once, totaling 2289 studies for the analysis, as shown in Figure 1.

Figure 1 -
Flowchart of the double-independent selection process of articles included in the review, according to PRISMA*. Santa Maria, Rio Grande do Sul, Brazil, 2023

The review corpus consisted of 20 articles33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
,2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
. A search was performed in the references of the included articles, however, no study that responded to the research objective was found.

Characteristics of the studies

Studies with a cross-sectional design prevailed (75%; n=15)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-2525. 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. 2013;10(4):238-42. doi: https://doi.org/10.20529/IJME.2013.072
https://doi.org/10.20529/IJME.2013.072...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
, conducted in the United States (n=5; 33.3%)11. Olson LL. Hospital nurses' perceptions of the ethical climate of their work setting. J Nurs Sch. 1998;30(4):345-9. doi: https://doi.org/10.1111/j.1547-5069.1998.tb01331.x
https://doi.org/10.1111/j.1547-5069.1998...
,2626. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs. 2014;33(4):234-45. doi: https://doi.org/10.1097/DCC.0000000000000050
https://doi.org/10.1097/DCC.000000000000...
-2828. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117-25. doi: https://doi.org/10.1111/jnu.12115
https://doi.org/10.1111/jnu.12115...
,3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
and in Iran (n=5; 25%)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,2525. 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. 2013;10(4):238-42. doi: https://doi.org/10.20529/IJME.2013.072
https://doi.org/10.20529/IJME.2013.072...
,3535. Rivaz M, Asadi F, Mansouri P. Assessment of the relationship between nurses’ perception of ethical climate and job burnout in intensive care units. Invest Educ Enferm. 2020;38(3):e12. doi: https://doi.org/10.17533/udea.iee.v38n3e12
https://doi.org/10.17533/udea.iee.v38n3e...
, published between 2005 and 2023, particularly in 2017 (n=4; 26.7%)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
, with a total of 4896 participants. Most of the participants were female, except for one study that did not present this information in its text, and another that had a male prevalence3232. Hou Y, Timmins F, Zhou Q, Wang J. A cross-sectional exploration of emergency department nurses’ moral distress, ethical climate and nursing practice environment. Int Emerg Nurs. 2021;55:100972. doi: https://doi.org/10.1016/j.ienj.2021.100972
https://doi.org/10.1016/j.ienj.2021.1009...
) (90%; n=18)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
,3333. Kim H, Kim H, Oh Y. Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BMC Nursing. 2023;22:55. doi: https://doi.org/10.1186/s12912-023-01212-0
https://doi.org/10.1186/s12912-023-01212...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
, aged between 21 and 60 years and working as nurses (90%; n=18)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
,2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-2727. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and Addressing Moral Distress and Ethical Climate Part II. Dimens Crit Care Nurs. 2015;34(1):33-46. doi: https://doi.org/10.1097/DCC.0000000000000083
https://doi.org/10.1097/DCC.000000000000...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
) and physicians (15%; n=3) in the hospital setting (100%, n=100)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
-66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
,2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
. In the strategies, the term “healthcare professional” was used to cover all professional categories, however, articles were found mostly with nurses and physicians.

Regarding the individual results for each variable, it was found that the ethical climate was evaluated individually in 17 studies33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
,2323. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses' perceptions of moral distress and ethical climate. Nurs Ethics. 2009;16(5):561-73. doi: https://doi.org/10.1177/096973300910664
https://doi.org/10.1177/096973300910664...
-3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
,3333. Kim H, Kim H, Oh Y. Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BMC Nursing. 2023;22:55. doi: https://doi.org/10.1186/s12912-023-01212-0
https://doi.org/10.1186/s12912-023-01212...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
, in which it was perceived as positive (70.6%; n=12)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,2424. 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. 2011;20(23-24):3483-93. doi: https://doi.org/10.1111/j.1365-2702.2011.03753.x
https://doi.org/10.1111/j.1365-2702.2011...
,2626. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs. 2014;33(4):234-45. doi: https://doi.org/10.1097/DCC.0000000000000050
https://doi.org/10.1097/DCC.000000000000...
,2727. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and Addressing Moral Distress and Ethical Climate Part II. Dimens Crit Care Nurs. 2015;34(1):33-46. doi: https://doi.org/10.1097/DCC.0000000000000083
https://doi.org/10.1097/DCC.000000000000...
,2929. de Boer JC, van Rosmalen J, Bakker AB, Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurement. Nurs Crit Care. 2015;21(3):e19-e27. doi: https://doi.org/10.1111/nicc.12206
https://doi.org/10.1111/nicc.12206...
-3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
,3333. Kim H, Kim H, Oh Y. Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BMC Nursing. 2023;22:55. doi: https://doi.org/10.1186/s12912-023-01212-0
https://doi.org/10.1186/s12912-023-01212...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
by varying its mean from (3.51 ± 0.53)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
to 3.93 (± 0.58)3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
, and the variation of the sum of their means from (94.39 ± 18.3)2626. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs. 2014;33(4):234-45. doi: https://doi.org/10.1097/DCC.0000000000000050
https://doi.org/10.1097/DCC.000000000000...
to (100.60 ± 14.41)3434. Küçükkelepçe GE, Özkan TK, Besirik SA. The relationship between moral distress levels and ethical climate perceptions of PICU nurses. J Nurs Manag. 2022;30(7):2416-23.doi: https://doi.org/10.1111/jonm.13871
https://doi.org/10.1111/jonm.13871...
.

The moral distress variable was evaluated in 11 studies88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,2323. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses' perceptions of moral distress and ethical climate. Nurs Ethics. 2009;16(5):561-73. doi: https://doi.org/10.1177/096973300910664
https://doi.org/10.1177/096973300910664...
-2424. 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. 2011;20(23-24):3483-93. doi: https://doi.org/10.1111/j.1365-2702.2011.03753.x
https://doi.org/10.1111/j.1365-2702.2011...
,2626. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs. 2014;33(4):234-45. doi: https://doi.org/10.1097/DCC.0000000000000050
https://doi.org/10.1097/DCC.000000000000...
-2727. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and Addressing Moral Distress and Ethical Climate Part II. Dimens Crit Care Nurs. 2015;34(1):33-46. doi: https://doi.org/10.1097/DCC.0000000000000083
https://doi.org/10.1097/DCC.000000000000...
,2929. de Boer JC, van Rosmalen J, Bakker AB, Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurement. Nurs Crit Care. 2015;21(3):e19-e27. doi: https://doi.org/10.1111/nicc.12206
https://doi.org/10.1111/nicc.12206...
,3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
-3434. Küçükkelepçe GE, Özkan TK, Besirik SA. The relationship between moral distress levels and ethical climate perceptions of PICU nurses. J Nurs Manag. 2022;30(7):2416-23.doi: https://doi.org/10.1111/jonm.13871
https://doi.org/10.1111/jonm.13871...
,3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
in general, by intensity and frequency. The intensity and frequency of moral distress ranged from low, being Intensity: (0.11 ± 0.38) to (2.09 ± 1.68) and Frequency: (0.21 ± 0.69) to (1. 45 ± 1.34) the lowest values among the studies2727. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and Addressing Moral Distress and Ethical Climate Part II. Dimens Crit Care Nurs. 2015;34(1):33-46. doi: https://doi.org/10.1097/DCC.0000000000000083
https://doi.org/10.1097/DCC.000000000000...
to moderate, being Intensity: (3.79 ± 2.21) to (2.14±2.42) and Frequency: (0.23±0. 93) to (2.86±1.88) the highest values among the studies2626. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs. 2014;33(4):234-45. doi: https://doi.org/10.1097/DCC.0000000000000050
https://doi.org/10.1097/DCC.000000000000...
.

The overall mean of moral distress ranged from moderate, with (1.94 ± 0.66) being the lowest value among the studies88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
) to high, with (96.5 ± 55.8) being the highest value among the studies3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
. In the individual analysis, the ethical climate and moral distress were calculated using the median, interquartile range, mean and/or sum of means.

Turnover was evaluated using the mean of two studies, which was classified as low turnover intention (100%; n=2) (5.28 ± Does not show the standard deviation)1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
and (3.63 ±1.03)3333. Kim H, Kim H, Oh Y. Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BMC Nursing. 2023;22:55. doi: https://doi.org/10.1186/s12912-023-01212-0
https://doi.org/10.1186/s12912-023-01212...
. Job satisfaction was evaluated in five studies, with health professionals satisfied with their work (100%; n=5)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,2525. 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. 2013;10(4):238-42. doi: https://doi.org/10.20529/IJME.2013.072
https://doi.org/10.20529/IJME.2013.072...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
, through means that varied between (3.08 ± 0.45)3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
to (3.17 ± 0.63)2525. 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. 2013;10(4):238-42. doi: https://doi.org/10.20529/IJME.2013.072
https://doi.org/10.20529/IJME.2013.072...
) and the variation of the sum of the means between (62.15 ± 13.46)66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
) to (62.64 ± 9.39)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
. Only in a single study job satisfaction was evaluated through frequency and percentage (n=138; 74.2%)55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
.

Only one study evaluated the intensity of burnout (32.23 ± 12.36) and the frequency of burnout (25.54 ± 12.36), that is, showing high levels for burnout syndrome3535. Rivaz M, Asadi F, Mansouri P. Assessment of the relationship between nurses’ perception of ethical climate and job burnout in intensive care units. Invest Educ Enferm. 2020;38(3):e12. doi: https://doi.org/10.17533/udea.iee.v38n3e12
https://doi.org/10.17533/udea.iee.v38n3e...
.

Quality assessment

From the 20 included studies, three (15,0%)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,2828. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117-25. doi: https://doi.org/10.1111/jnu.12115
https://doi.org/10.1111/jnu.12115...
,2929. de Boer JC, van Rosmalen J, Bakker AB, Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurement. Nurs Crit Care. 2015;21(3):e19-e27. doi: https://doi.org/10.1111/nicc.12206
https://doi.org/10.1111/nicc.12206...
were classified as high quality (score ≥ 80%), while 17 (85.0%) were classified as regular (score 50-79%)55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
,2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-2727. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and Addressing Moral Distress and Ethical Climate Part II. Dimens Crit Care Nurs. 2015;34(1):33-46. doi: https://doi.org/10.1097/DCC.0000000000000083
https://doi.org/10.1097/DCC.000000000000...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
. None of the studies were classified as low quality (score <50%) nor rejected based on quality assessments.

The classification of quality assessment for each study can be seen in Figure 2, with the sign (+) referring to positive responses, the sign (-) to negative responses and n/a referring to not applicable.

Figure 2 -
Quality assessment using the Critical Appraisal Checklist for Analytical Cross‐Sectional Studies. Santa Maria, Rio Grande do Sul, Brazil, 2023

Among the intraclass correlation coefficients, 90% (n=18)33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
,1313. Han SJ. Nurse turnover intention and influencing factors. Int Inf Inst. 2014 [cited 2022 Jan 25];17(10A):5037-42. Available from: https://search.proquest.com/docview/1648990988/fulltextPDF/F3446782B0EF45E4PQ/1?accountid=26643
https://search.proquest.com/docview/1648...
,2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-2727. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and Addressing Moral Distress and Ethical Climate Part II. Dimens Crit Care Nurs. 2015;34(1):33-46. doi: https://doi.org/10.1097/DCC.0000000000000083
https://doi.org/10.1097/DCC.000000000000...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
of the studies had excellent to satisfactory agreement in the classification of methodological quality between the three reviewers.

Meta-analysis between ethical climate and workers’ health variables

The meta-analysis is presented in a forest plot, according to the subgroups: Ethical climate and Overall moral distress; Ethical climate and Intensity of Moral Distress; Ethical Climate and Frequency of Moral Distress; Ethical climate and turnover intention; Ethical climate and job satisfaction. It was not possible to perform a meta-analysis between the ethical climate and the profession abandonment and the burnout syndrome, as they were analyzed only in a single study2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
,3535. Rivaz M, Asadi F, Mansouri P. Assessment of the relationship between nurses’ perception of ethical climate and job burnout in intensive care units. Invest Educ Enferm. 2020;38(3):e12. doi: https://doi.org/10.17533/udea.iee.v38n3e12
https://doi.org/10.17533/udea.iee.v38n3e...
.

The three studies33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,2929. de Boer JC, van Rosmalen J, Bakker AB, Dijk M. Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurement. Nurs Crit Care. 2015;21(3):e19-e27. doi: https://doi.org/10.1111/nicc.12206
https://doi.org/10.1111/nicc.12206...
,3232. Hou Y, Timmins F, Zhou Q, Wang J. A cross-sectional exploration of emergency department nurses’ moral distress, ethical climate and nursing practice environment. Int Emerg Nurs. 2021;55:100972. doi: https://doi.org/10.1016/j.ienj.2021.100972
https://doi.org/10.1016/j.ienj.2021.1009...
) were excluded from the meta-analysis, as they performed correlation through univariate and multivariate general linear models and Tobit regression, calculating the beta values, in which it was not possible to convert them to the Z-Fischer values.

Ethical climate and Moral distress

Figure 3 shows the forest plot of the subgroup ethical climate and moral distress.

Figure 3
Forest plot of the relationship between ethical climate and moral distress. Santa Maria, Rio Grande do Sul, Brazil, 2023

The transformations from Fisher’s z coefficients to r values indicated a negative, significant and moderate correlation between ethical climate and overall moral distress: r=-0.43 (95%CI -0.50; -0.36); negative, significant and moderate correlation between the ethical climate and the frequency of moral distress: r=-0.36 (95%CI -0.45; -0.25) and non-significant correlation between the ethical climate and the intensity of moral distress: r=0.00(95%CI -0.31; 0.32).

Heterogeneity was considered moderate for overall moral distress (I2=63.1%; p=0.019), high for frequency (I2=78.6%; p=0.001) and intensity (I2=94.4%; p=0.000) of moral distress.

Ethical climate and Job satisfaction

Figure 4 shows the relationship between ethical climate and job satisfaction.

Figure 4 -
Forest plot of the relationship between ethical climate and job satisfaction. Santa Maria, Rio Grande do Sul, Brazil, 2023

The transformations from Fisher’s z coefficients to r values indicated a positive, significant, and strong correlation between ethical climate and job satisfaction: r=0.71 (95%CI 0.39; 0.88). The heterogeneity between studies was considered high (I2=98.2%; p<0.001).

Ethical climate and Turnover intention

Figure 5 shows the relationship between ethical climate and turnover intention.

Figure 5 -
Forest plot of the relationship between ethical climate and turnover intention. Santa Maria, Rio Grande do Sul, Brazil, 2023

Transformations from Fisher’s z coefficients to r values indicated a non-significant correlation between ethical climate and turnover intention: r=-0.22 (95%CI -0.62; 0.28). Heterogeneity between studies was also considered high (I2=97.9%; p=0.000).

DISCUSSION

The relationship between the ethical climate and the workers’ health variables was identified, especially among nurses working in the hospital setting2222. Hart SE. Hospital ethical climates and registered nurses' turnover intentions. J Nurs Scholarsh. 2005;37(2):173-7. doi: https://doi.org/10.1111/j.1547-5069.2005.00030.x
https://doi.org/10.1111/j.1547-5069.2005...
-3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
https://doi.org/10.1002/nop2.1221...
. The focus of studies with this population is because the nurses’ greater proximity to daily work issues, being one of the mediators in the relationship between patients, the health team and managers3737. Constantina C, Papastavrou E, Charalambous A. Cancer nurses' perceptions of ethical climate in Greece and Cyprus. Nurs Ethics. 2019;26(6):1805-21. doi: https://doi.org/10.1177/0969733018769358
https://doi.org/10.1177/0969733018769358...
,3838. Liu Y, Cui N, Zhang Y, Wang X, Zhang H, Chen D, et al. Psychometric properties of the ethical conflict in nursing questionnaire critical care version among Chinese nurses: a cross-sectional study. BMC Nurs. 2021;20:133. doi: https://doi.org/10.1186/s12912-021-00651-x
https://doi.org/10.1186/s12912-021-00651...
.

Regarding the descriptive results of each variable, that is, ethical climate, moral distress, job satisfaction and turnover intention, it was found that the perception of the ethical climate was evaluated as positive among health professionals, as mentioned in the literature3333. Kim H, Kim H, Oh Y. Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BMC Nursing. 2023;22:55. doi: https://doi.org/10.1186/s12912-023-01212-0
https://doi.org/10.1186/s12912-023-01212...
-3737. Constantina C, Papastavrou E, Charalambous A. Cancer nurses' perceptions of ethical climate in Greece and Cyprus. Nurs Ethics. 2019;26(6):1805-21. doi: https://doi.org/10.1177/0969733018769358
https://doi.org/10.1177/0969733018769358...
,3939. Kumar BA, Pragnesh BP, Prerna P, Reekee P, Pankaj HB, Ebbie T. Ethical climate and its effect in teaching hospital: A vision from 3rd eye. J Indian Acad Forensic Med. 2019;41(1):45-9. doi: https://doi.org/10.5958/0974-0848.2019.00011.3
https://doi.org/10.5958/0974-0848.2019.0...
,4040. Lemmenes D, Valentine P, Gwizdalski P, Vincent C, Liao C. Nurses' perception of ethical climate at a large academic medical center. Nurs Ethics. 2018;25(6):724-33. doi: https://doi.org/10.1177/0969733016664980
https://doi.org/10.1177/0969733016664980...
. The evaluation of the positive ethical climate occurs through support for professional practice by managers, being a potential tool to measure collaboration between colleagues and facilitate the resolution of ethical issues3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
,4040. Lemmenes D, Valentine P, Gwizdalski P, Vincent C, Liao C. Nurses' perception of ethical climate at a large academic medical center. Nurs Ethics. 2018;25(6):724-33. doi: https://doi.org/10.1177/0969733016664980
https://doi.org/10.1177/0969733016664980...
,4141. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578). doi: https://doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802...
.

The result of the moral distress overall scale ranged from moderate to high, being a prominent problem for workers’ health. Moreover, professionals showed job satisfaction and low turnover intention. According to previous research, the importance of promoting the growth of workers and their recognition in the workplace is highlighted, with the aim of reducing turnover and promoting job satisfaction3333. Kim H, Kim H, Oh Y. Impact of ethical climate, moral distress, and moral sensitivity on turnover intention among haemodialysis nurses: a cross-sectional study. BMC Nursing. 2023;22:55. doi: https://doi.org/10.1186/s12912-023-01212-0
https://doi.org/10.1186/s12912-023-01212...
,4242. Faramarzpour M, Farokhzadianb J, Tirgari B, Mangolian SP, Borhani F, Rafati F. Nurses’ perceptions of hospital ethical climate and their job satisfaction. Ethic Med Public Health. 2021;18:100664. doi: https://doi.org/10.1016/j.jemep.2021.100664
https://doi.org/10.1016/j.jemep.2021.100...
,4343. Yang T, Jin X, Shi H, Liu Y, Guo Y, Gao Y, et al. Occupational stress, distributive justice and turnover intention among public hospital nurses in China: a cross-sectional study. Appl Nurs Res. 2021;61:151481. doi: https://doi.org/10.1016/j.apnr.2021.151481
https://doi.org/10.1016/j.apnr.2021.1514...
.

In the context of the studies analyzed in the present review, all of them presented regular to high methodological quality, with an excellent to satisfactory degree of inter-observer agreement. Additionally, study heterogeneity ranged from moderate to high. It is suggested that in all studies the analyzes were adequate, although they could have been described more clearly in three studies2525. 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. 2013;10(4):238-42. doi: https://doi.org/10.20529/IJME.2013.072
https://doi.org/10.20529/IJME.2013.072...
-2727. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and Addressing Moral Distress and Ethical Climate Part II. Dimens Crit Care Nurs. 2015;34(1):33-46. doi: https://doi.org/10.1097/DCC.0000000000000083
https://doi.org/10.1097/DCC.000000000000...
.

Furthermore, the quality was lower in the identification of confounding factors and strategies to deal with these factors, and some studies were conducted in different settings, populations and countries, resulting in heterogeneity55. Asl ZE, Abdollahzadeh F, Lotfi M, Attari AMA, Asghari E. The relationship of ethical climate and nurses' job satisfaction in the operating room: a cross-sectional study. Nurs Midwifery Stud. 2017 [cited 2022 Jan 20];6(3):137-9. Available from: https://journals.lww.com/nams/Fulltext/2017/06030/The_Relationship_of_Ethical_Climate_and_Nurses_.7.aspx
https://journals.lww.com/nams/Fulltext/2...
,2828. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117-25. doi: https://doi.org/10.1111/jnu.12115
https://doi.org/10.1111/jnu.12115...
. Despite this analysis, the results of the studies were considered reliable and of good quality, corresponding to current clinical practice.

From the meta-analysis, it was found that the ethical climate had a negative and moderate correlation with overall moral distress2323. Pauly B, Varcoe C, Storch J, Newton L. Registered nurses' perceptions of moral distress and ethical climate. Nurs Ethics. 2009;16(5):561-73. doi: https://doi.org/10.1177/096973300910664
https://doi.org/10.1177/096973300910664...
,2626. Sauerland J, Marotta K, Peinemann MA, Berndt A, Robichaux C. Assessing and addressing moral distress and ethical climate, part I. Dimens Crit Care Nurs. 2014;33(4):234-45. doi: https://doi.org/10.1097/DCC.0000000000000050
https://doi.org/10.1097/DCC.000000000000...
-2828. Whitehead PB, Herbertson RK, Hamric AB, Epstein EG, Fisher JM. Moral distress among healthcare professionals: report of an institution-wide survey. J Nurs Scholarsh. 2015;47(2):117-25. doi: https://doi.org/10.1111/jnu.12115
https://doi.org/10.1111/jnu.12115...
,3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
,3434. Küçükkelepçe GE, Özkan TK, Besirik SA. The relationship between moral distress levels and ethical climate perceptions of PICU nurses. J Nurs Manag. 2022;30(7):2416-23.doi: https://doi.org/10.1111/jonm.13871
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,2424. 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. 2011;20(23-24):3483-93. doi: https://doi.org/10.1111/j.1365-2702.2011.03753.x
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,3636. Ventovaara P, Sandeberg M, Petersen G, Bolgren K, Pergert P. A cross-sectional survey of moral distress and ethical climate - situations in paediatric oncology care that involve children’s voices. Nurs Open. 2022;9(4):2108-16. doi: https://doi.org/10.1002/nop2.1221
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, the more negative the ethical climate is perceived, the greater the moral distress and the frequency of experiencing distressing situations. Likewise, the correlation between the ethical climate and job satisfaction was positive and strong, that is, the more positive the ethical climate is perceived, the more satisfied are the healthcare professionals66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
.

Moral distress is an emotional imbalance that occurs when healthcare professionals recognize the correct actions to be taken. However, because of barriers from different aspects of the organization, healthcare professionals are unable to define a morally correct action4141. Ramos FRS, Barth PO, Brehmer LCF, Dalmolin GL, Vargas MA, Schneider DG. Intensity and frequency of moral distress in Brazilian nurses. Rev Esc Enferm USP. 2020;54:e035578). doi: https://doi.org/10.1590/s1980-220x2018020703578
https://doi.org/10.1590/s1980-220x201802...
. This reality is in hospital units, as observed in a Finnish study that identified a negative correlation between ethical climate and moral distress (r = −0.435, n = 86, p <0.001)1111. Ventovaara P, Sandeberg M, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics. 2021;28(6):1061-72. doi: https://doi-org.ez47.periodicos.capes.gov.br/10.1177/0969733021994169
https://doi-org.ez47.periodicos.capes.go...
.

The conflicting situations that trigger moral distress are related to the practice of futile and inadequate care. This care is low quality, with cost savings, use of more invasive treatments, as well as less time and number of health professionals working in each shift33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
,1111. Ventovaara P, Sandeberg M, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics. 2021;28(6):1061-72. doi: https://doi-org.ez47.periodicos.capes.gov.br/10.1177/0969733021994169
https://doi-org.ez47.periodicos.capes.go...
.

Upon these challenging ethical issues, healthcare professionals require institutional support to resolve these problems. Based on institutional support, the intention is to maintain the proper functioning of hospital units and reduce the risk of illness33. Asgari S, Shafipour V, Taraghi Z, Yazdani-Charati J. Relationship between moral distress and ethical climate with job satisfaction in nurses. Nurs Ethics. 2019;26(2):346-56. doi: http://doi.org/10.1177/0969733017712083
http://doi.org/10.1177/0969733017712083...
.

A study conducted in Turkey with nurses identified that the perception of the ethical climate of critical care nurses explained 12.5% of moral distress, significant for the “physicians” factor of the HECS instrument. The same study pointed out that nurses experience moral distress in situations of work overload due to overcrowding of hospitalized patients and little cooperation between the team and physicians, which is also identified in studies in Sweden2424. 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. 2011;20(23-24):3483-93. doi: https://doi.org/10.1111/j.1365-2702.2011.03753.x
https://doi.org/10.1111/j.1365-2702.2011...
, Finland1111. Ventovaara P, Sandeberg M, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics. 2021;28(6):1061-72. doi: https://doi-org.ez47.periodicos.capes.gov.br/10.1177/0969733021994169
https://doi-org.ez47.periodicos.capes.go...
, Iran88. Bayat M, Shahriyari M, Keshvari M. The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. J Med Ethics Hist Med. 2019;12(8):1-16. doi: https://doi.org/10.18502/jmehm.v12i8.1339
https://doi.org/10.18502/jmehm.v12i8.133...
and Netherlands4444. Donkers MA, Gilissen VJHS, Candel MJJM, Dijk NMV, Kling H, Heijnen-Panis R, et al. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics. 2021;22:73. doi: https://doi.org/10.1186/s12910-021-00641-3
https://doi.org/10.1186/s12910-021-00641...
.

Meanwhile, a Dutch study found no significant association between ethical climate and moral distress in intensive care nurses4444. Donkers MA, Gilissen VJHS, Candel MJJM, Dijk NMV, Kling H, Heijnen-Panis R, et al. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics. 2021;22:73. doi: https://doi.org/10.1186/s12910-021-00641-3
https://doi.org/10.1186/s12910-021-00641...
. The investigation recommends that nurses, because they are working in intensive care units, experience a feeling of solidarity among colleagues, patients and family members4444. Donkers MA, Gilissen VJHS, Candel MJJM, Dijk NMV, Kling H, Heijnen-Panis R, et al. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics. 2021;22:73. doi: https://doi.org/10.1186/s12910-021-00641-3
https://doi.org/10.1186/s12910-021-00641...
, understanding that this type of unit is a place of self-reflective and empowering care practice, even if through reports of fatigue4444. Donkers MA, Gilissen VJHS, Candel MJJM, Dijk NMV, Kling H, Heijnen-Panis R, et al. Moral distress and ethical climate in intensive care medicine during COVID-19: a nationwide study. BMC Med Ethics. 2021;22:73. doi: https://doi.org/10.1186/s12910-021-00641-3
https://doi.org/10.1186/s12910-021-00641...
.

Planning and ethical discussion in care practices create opportunities for sharing information, enhancing the perception of the ethical climate and reducing moral distress, which, in turn, promotes teamwork4545. Pavlish CL, Brown-Saltzman K, Robinson EM, Henriksen J, Warda US, Farra C, et al. An ethics early action protocol to promote teamwork and ethics efficacy. Dimens Crit Care Nurs. 2021;40(4):226-36. doi: https://doi.org/10.1097/DCC.0000000000000482
https://doi.org/10.1097/DCC.000000000000...
. The effect of the negative ethical climate on moral distress is perceived in the work environment as lower quality of care, job dissatisfaction and turnover1111. Ventovaara P, Sandeberg M, Räsänen J, Pergert P. Ethical climate and moral distress in paediatric oncology nursing. Nurs Ethics. 2021;28(6):1061-72. doi: https://doi-org.ez47.periodicos.capes.gov.br/10.1177/0969733021994169
https://doi-org.ez47.periodicos.capes.go...
,4646. Ulrich B, Barden C, Cassidy L, Varn-Davis N. Critical care nurse work environments 2018: findings and implications. Crit Care Nurse. 2019;39(2):67-84. doi: https://doi.org/10.4037/ccn2019605
https://doi.org/10.4037/ccn2019605...
.

Regarding job satisfaction, it is important to investigate the effect of the ethical climate on it, which is understood as the degree of positive emotion that professionals feel towards their work environment. Additionally, it refers to an individual’s state of mind, being a tool for measuring organizational effectiveness66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
,4242. Faramarzpour M, Farokhzadianb J, Tirgari B, Mangolian SP, Borhani F, Rafati F. Nurses’ perceptions of hospital ethical climate and their job satisfaction. Ethic Med Public Health. 2021;18:100664. doi: https://doi.org/10.1016/j.jemep.2021.100664
https://doi.org/10.1016/j.jemep.2021.100...
.

Some studies were conducted on the evaluation of the ethical climate and job satisfaction, due to the impact on the clinical care of patients, as well as on workers’ health1212. Abadiga M, Nemera G, Hailu E, Mosisa G. Relationship between nurses’ perception of ethical climates and job satisfaction in Jimma University Specialized Hospital, Oromia region, south west Ethiopia. BMC Nursing. 2019;18:39.doi: https://doi.org/10.1186/s12912-019-0365-8
https://doi.org/10.1186/s12912-019-0365-...
,3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
. The aspects that lead to a positive correlation between the ethical climate and job satisfaction refer to the relationship between the healthcare team and management, as well as adequate working conditions, professional recognition and good relationships66. Özden D, Arslan GG, Ertuğrul B, Karakaya S. The effect of nurses’ ethical leadership and ethical climate perceptions on job satisfaction. Nurs Ethics. 2019;26(4):1211-25. doi: https://doi.org/10.1177/0969733017736924
https://doi.org/10.1177/0969733017736924...
. The understanding and attention of management towards healthcare professionals upon difficult situations influence job satisfaction3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
.

Studies point out that job satisfaction is related to the productivity and self-confidence of professionals upon decision-making in conflict situations, such as a care plan for patients in palliative care3030. Jang Y, Oh Y. Impact of ethical factors on job satisfaction among Korean nurses. Nurs Ethics. 2019;26(4):1186-98. doi: https://doi.org/10.1177/0969733017742959
https://doi.org/10.1177/0969733017742959...
,4242. Faramarzpour M, Farokhzadianb J, Tirgari B, Mangolian SP, Borhani F, Rafati F. Nurses’ perceptions of hospital ethical climate and their job satisfaction. Ethic Med Public Health. 2021;18:100664. doi: https://doi.org/10.1016/j.jemep.2021.100664
https://doi.org/10.1016/j.jemep.2021.100...
. Productivity and self-confidence come from variables recommended by the ethical climate, among which are management support and partnership during care, offering tools for ethical performance in their work4242. Faramarzpour M, Farokhzadianb J, Tirgari B, Mangolian SP, Borhani F, Rafati F. Nurses’ perceptions of hospital ethical climate and their job satisfaction. Ethic Med Public Health. 2021;18:100664. doi: https://doi.org/10.1016/j.jemep.2021.100664
https://doi.org/10.1016/j.jemep.2021.100...
.

Comparing the outcomes of this review with the literature, it is understood that job satisfaction indicates the need to provide clear norms and guidelines to employees for the resolution of ethical problems4242. Faramarzpour M, Farokhzadianb J, Tirgari B, Mangolian SP, Borhani F, Rafati F. Nurses’ perceptions of hospital ethical climate and their job satisfaction. Ethic Med Public Health. 2021;18:100664. doi: https://doi.org/10.1016/j.jemep.2021.100664
https://doi.org/10.1016/j.jemep.2021.100...
. Researchers explain that the perception of a positive ethical climate motivates healthcare professionals to maintain a fair relationship with their colleagues, promoting a feeling of satisfaction with their work4242. Faramarzpour M, Farokhzadianb J, Tirgari B, Mangolian SP, Borhani F, Rafati F. Nurses’ perceptions of hospital ethical climate and their job satisfaction. Ethic Med Public Health. 2021;18:100664. doi: https://doi.org/10.1016/j.jemep.2021.100664
https://doi.org/10.1016/j.jemep.2021.100...
.

The primary outcome of this review was the identification of the influence of the ethical climate on the workers’ health from the moral distress and job satisfaction variables, according to the meta-analytical analysis. When the ethical climate is perceived positively, on the contrary, it is associated with lower reports of moral distress and higher job satisfaction2525. 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. 2013;10(4):238-42. doi: https://doi.org/10.20529/IJME.2013.072
https://doi.org/10.20529/IJME.2013.072...
,3131. 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. 2018;27(4):295-302. doi: https://doi.org/10.4037/ajcc2018252
https://doi.org/10.4037/ajcc2018252...
.

It is essential that managers of these services understand the importance of a work environment evaluated with a positive ethical climate in the health of their employees, which will result in quality and safe care for patients. Based on these results, researchers and healthcare professionals will be able to visualize the influence of the ethical climate on the workers’ health and thus seek strategies to improve the work environment.

All studies showed moderate to high heterogeneity, which is a limitation of the study, as the research was conducted in different countries with various settings, populations, and social contexts. To reduce heterogeneity among the studies, random effects meta-analysis was calculated, and only studies that evaluated the ethical climate using the HECS instrument were included. Furthermore, despite the use of an appropriate search strategy for each database, some studies may have been missed, and others excluded by the decision to limit the review to documents written in English, Portuguese or Spanish.

CONCLUSION

The ethical climate has shown an influence on workers’ health, in which the negative and positive perception of healthcare professionals, respectively, influenced the increase in moral distress and job satisfaction. That is, the negative perception of the ethical climate was correlated with moral distress and the frequency of experiencing distressing situations. While the positive perception of the ethical climate was correlated with job satisfaction among healthcare professionals.

Despite different populations such as healthcare professionals, especially nurses working in hospitals in different countries, with prevalence in the United States and Iran, the results of studies on moral distress and job satisfaction when related to the ethical climate are similar. This is justified by the difficulty of making morally correct decisions and unhealthy relationships between professionals and management. In addition to professional recognition that has an impact on the perception of the ethical climate in organizations across different countries.

It is important to invest in studies that develop strategies to reduce the harm to workers’ health, improve job satisfaction and the perception of the ethical climate. Among the strategies, the following stand out: implementation of protocols and ethical guidelines, ethical consultant in each institutional unit, discussion meetings on conflicting cases within the team, making joint deliberation and interactive lectures for ethical education.

Further investigation should consider studies using other instruments for evaluating the ethical climate with worker health variables, however, attention should be given to heterogeneity, reliability, and data generalization.

Acknowledgments:

We would like to thank the Technological Initiation Program of HUSM-UFSM - PIT/EBSERH 2023/2024.

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  • Funding:

    This review received no funding.
  • Authorship contribution:

    Project administration: Taís Carpes Lanes, Graziele de Lima Dalmolin. Formal analysis: Taís Carpes Lanes, Graziele de Lima Dalmolin, Augusto Maciel da Silva, Gustavo Magno Baldin Tiguman. Conceptualization: Taís Carpes Lanes, Graziele de Lima Dalmolin. Data curation: Taís Carpes Lanes, Graziele de Lima Dalmolin, Augusto Maciel da Silva, Camila Milene Soares Bernardi, Thaís Costa Schutz, Gustavo Magno Baldin Tiguman. Writing-original draft: Taís Carpes Lanes, Graziele de Lima Dalmolin, Augusto Maciel da Silva, Camila Milene Soares Bernardi, Thaís Costa Schutz, Gustavo Magno Baldin Tiguman. Writing-review & editing: Taís Carpes Lanes, Graziele de Lima Dalmolin, Augusto Maciel da Silva, Camila Milene Soares Bernardi, Thaís Costa Schutz, Gustavo Magno Baldin Tiguman. Investigation: Taís Carpes Lanes, Graziele de Lima Dalmolin, Gustavo Magno Baldin Tiguman. Methodology: Taís Carpes Lanes, Graziele de Lima Dalmolin, Augusto Maciel da Silva, Gustavo Magno Baldin Tiguman. Funding acquisition: Graziele de Lima Dalmolin. Supervision: Taís Carpes Lanes, Graziele de Lima Dalmolin.

Edited by

Associate editor:

Dagmar Elaine Kaiser

Editor-in-chief:

João Lucas Campos de Oliveira

Publication Dates

  • Publication in this collection
    27 Oct 2023
  • Date of issue
    2023

History

  • Received
    31 July 2022
  • Accepted
    30 May 2023
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