International Journal of Nursing and Health Care Research (ISSN: 2688-9501)

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The Ethical Organizational Culture of University Hospitals in Finland

Authors: Salonen Päivi1, Leino Kaija2, Lepistö Sari2, Kaunonen Marja3, Helminen Mika4, Mattila Elina5*

*Corresponding Author: Mattila Elina, Chief of Nursing, Tampere University Hospital, Tampere, Finland.

Received Date: 27 October, 2021

Accepted Date: 10 November, 2021

Published Date: 15 November, 2021

Citation: Salonen P, Leino K, Lepistö S, Kaunonen M, Helminen M, et al. (2021) The Ethical Organizational Culture of University Hospitals in Finland Int J Nurs Health Care Res 4: 1259. DOI: https://doi.org/10.29011/2688-9501.101259

Aims of the study

The main aim of this study was to investigate the perceived ethical organizational culture in five Finnish university hospitals, as evaluated by managers and health care employees. This study is part of a larger study, the purpose of which is to establish factors that predict a good organizational culture. Therefore, the research questions in this study include the following:

RQ1. How did the managers and health care workers of the five Finnish university hospitals describe the ethical organizational culture?

RQ2. Which of the explaining factors were associated with a stronger ethical organizational culture in the Finnish university hospitals?

RQ3. What were the factors predicting a stronger ethical organizational culture of the five Finnish university hospitals?

Abstract

The purpose of this paper is to describe the ethical organizational culture, and to identify factors predicting the ethical culture of Finnish university hospitals. In Finland, the restructuring of health and social services raise issues related to values and ethics as well as leadership. Data were collected using the 58-item Corporate Ethical Virtues (CEV) scale by Kaptein [1]. Data were analyzed using descriptive statistics, parametric tests, and logistic regression models with the enter method. Participants gave the highest ethical culture ratings for clarity, congruency of supervisors, and discuss ability, and the lowest for the congruency of senior management, supportability, and transparency. The strongest predictors of a stronger ethical organizational culture were age, profession, work experience, level of management, and the number of subordinates. Evidence generated by this study could be put to good use in identifying the strengths and weaknesses of the organizations and developing educational interventions for managers.

Keywords: Ethical organizational culture; Health; Nursing staff; Administrative staff; Parametric tests

Introduction

Increasing expenses, reduced resource allocation, and prioritization demands have increased the interest in the organizational culture of health care [2,5]. Great emphasis has been placed on the need to change the organizational culture in order to pursue effective improvement in health care performance [6]. Despite the pressure to increase efficiency, a value base must be cherished in health care in order to ensure the well-being of employees [7]. In Finland, the restructuring of health and social services is an ongoing process, extensively reforming the organization and operation of services [8-9]. Changes in organizational structures also raise issues related to values and ethics as well as leadership [10]. Globally, health care organizations operate ethically [11-14] although ethical activities in social services and health care have been found to be lower compared to other actors [13-15]. Employees of ethical organizations have been found to be satisfied with their work and to experience work engagement [16]. An organization committed to ethical values and norms strengthens the commitment of its staff [17], and an open, clear, and participatory management of change supports well-being [18].

According to previous research, an ethical organizational culture also has a positive effect on organizational results [1,4,12,19] and on ethical decision-making [21-23]. Patient safety and cost-effectiveness have been shown to be good in ethically high-level organizations [24].

Ethical organizational culture

Ethical culture is part of organizational culture [25]. The values, norms, and practices of the organization support or prevent ethical activities. An organizational ethical culture comprises existing experiences, attitudes, and expectations that manifest themselves as the employees’ views of good and evil as well as right and wrong. [26-27]. Organizational culture is formed communally, it changes slowly, and it is determined by how the organization is accustomed to functioning [28]. According to Kaptein [15], ethical culture describes behavior that affects an organization’s operations. It has been shown that the stronger the organizational ethical culture, the less unethical behavior there is [25] and the lower rates of sick leaves and employee turnover there are [22,29,30]. A strong ethical culture also had a significant positive association with the experienced person-organization fit, which in turn was related to higher work engagement. Person-organization fit and work engagement were both associated with higher affective commitment and lower rates of intentions to change jobs [29].

Ethical leadership

Ethical leadership is a normatively appropriate behavior manifested in an individual's actions and interactions that is conveyed to subordinates through communication and decision-making [14-15]. It is a prerequisite for the success of health care management and the achievement of organizational goals [15,31]. Leadership contributes to the emergence of an ethical organizational culture [32-34] and has been found to have a positive impact on employee engagement [21-35] and the professional well-being of managers [16]. Supervisors and management must behave in accordance with ethical expectations and rules in order to set an example for employees [1,35-36].

At the heart of leadership is influencing people-what matters is how leaders exercise power and what value choices they make [31,37]. Ethics in a leadership role is challenging due to the demanding nature of the work and the mental workload [31,38]. Constant changes in working life, economic pressures, and technological developments affect the ability of managers to maintain ethics in their managerial work [38]. Previous research has assessed the relationship between organizational ethical culture and background factors in management work. It has been shown that senior management rates an organization’s ethics as better than middle management [4]. According to O’Fallon and Butterfield [21], female leaders are more involved in ethical decision-making than male ones. Huhtala and colleagues [4] found a small gender-related difference in the assessments of the ethical behavior of directors in that women rated ethical leadership as better than did men. According to Trevino and colleagues [39], senior managers do not perceive ethical problems as often as lower-level managers. Of the managers, those aged 41-50 years rated their operations as highly ethical and those aged over 60 years gave the most negative assessments of their ethics [4]. However, Kaptein has found no link between the level of management and the director’s gender and age [12]. Leading different generations is also a challenge for ethical leadership [40], as the new generation differs from previous ones because of the expectations placed on work and leadership [41]. Baby boomers (aged over 50 years) and members of Generation X (aged 35-50 years) have higher expectations on leadership than other generations [42].

Identifying, evaluating, and addressing ethical issues is a key component of the professional competencies of different professional groups in health care [43]. Long work experience increases expertise and the ability to identify unethical activities [44], but as a result of routine, the identification of ethical problems may decrease [45]. Organizational size also has an impact on ethical performance and ethical decision-making, as decisions are not made ethically in large organizations [21]. Research on organizational ethical culture has increased in the 21st century [1], but there is an increasing need for empirical research as well as theoretical knowledge of the ethics of organizational culture [10,32]. According to recent evidence presented in the literature review of this article [10,14,32] we may assume that there will be statistical differences between both sociodemographic and managerial characteristics and the ethical culture of an organization. In this paper, we describe the ethical culture of university hospitals in Finland, as evaluated by managers and health care employees, in addition to identifying factors predicting the ethical culture of organizations.

Methods

Participants and the Procedure

The participants of this study consisted of managers and health care employees in five Finnish university hospitals (Tampere, Helsinki, Kuopio, Oulu, and Turku). Data were collected via the Webropol survey service from October to November 2015. Permission to conduct the research was obtained from the university hospitals’ directors. Managers included head physicians and head nurses as well as principal chiefs. The head nurses were requested to select the health care employees participating in this study-i.e., they were asked to select one ward with at least 25 staff members and to forward the questionnaire link to them. A total of 561 participants responded to the questionnaires. Sample size analyses were conducted to determine adequate sample size [46].

Corporate Ethical Virtues Scale (CEV)

Ethical organizational culture was measured using the 58-item Corporate Ethical Virtues questionnaire (CEV) [47]. Permission to use the questionnaire was obtained from Professor of Business Ethics and Integrity Management Muel Kaptein. The scale was first translated from Dutch to Finnish and later translated back again into Dutch by two independent authorized translators [10,32].

The CEV contains eight dimensions, which have been empirically validated [1,15]: clarity (10 items; e.g., “The organization makes it sufficiently clear to me how I should conduct myself appropriately toward others within the organization”); congruency of supervisors (6 items; e.g., ”My supervisor sets a good example in terms of ethical behavior”); congruency of senior management (4 items; e.g., “The conduct of the Board and (senior) management reflects a shared set of norms and values”); feasibility (6 items; e.g., “In my immediate working environment, I am sometimes asked to do things that conflict with my conscience”); supportability (6 items; e.g., “In my immediate working environment, everyone is totally committed to the (stipulated) norms and values of the organization”); transparency (7 items; e.g., “If a colleague does something which is not permitted, my manager will find out about it”); discuss ability (10 items; e.g., “In my immediate working environment, reports of unethical conduct are handled with caution”); and sanction ability (9 items;, e.g., “in my immediate working environment, people are accountable for their actions”). The stronger the presence of these virtues, the more ethical the organization12 and the less likely the occurrence of unethical behavior are19. Participants rated these items on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly agree).

Background information of the participants

A structured instrument was used to assess sociodemographic (4 items) and managerial characteristics (4 items). Sociodemographic data included gender, age, educational level, and profession. Data on managerial characteristics included work experience, having or not having managerial or leadership duties, having a senior management, middle management, or immediate superior position, and the number of immediate subordinates for the managers.

Data Analyses

Statistical analysis was carried out using SPSS for windows 22 (SPSS Inc., Chicago, IL, USA). Statistical differences with a p-value of < 0.05 were considered significant [48]. Descriptive statistics were used to characterize the sample’s sociodemographic and managerial profile. For testing the statistical significance between background variables and CEV dimensions, cross-tabulation with the Chi squared or Fisher’s exact test was used. For analyzing age, education, the number of immediate subordinates, and management duties on a weekly basis were categorized. Age was categorized into three categories: Generation Y (35 years or under), Generation X (35-50 years), and baby boomers (more than 50 years).

To examine the strongest predictors of a strong ethical organizational culture, the following categorization was used: poor organizational culture < 3.5, and strong ethical culture > 4.5. Factors predicting a strong organizational ethical culture were investigated using logistic regression models with the enter method. The results were reported as odds ratios (OR) with 95% confidence intervals (95% CI).

The validity and reliability of CEV have been widely tested [4,10,14,16,32]. Cronbach’s alpha test was used for evaluating the internal consistency of the subscales. In this study, the Cronbach alpha values for CEV subscales ranged from 0.82 to 0.95. According to Nunnally and Bernstein [49], the lowest acceptable Cronbach alpha value is 0.60, and on this basis the internal consistencies were satisfactory. Several studies have reported a satisfactory internal consistency of over 0.70 for CEV; for example, Kaptein [1] found that the item reliabilities ranged between 0.93 and 0.96, and in the inclusive sample (n = 4,359) of social and health care workers in the study by Kangas and colleagues [14], the Cronbach alpha varied between 0.80 and 0.97.

Results

Description of participants

The distributions of the participants’ characteristics are shown in Table 1. Descriptive statistics showed that most of the participants were female and over 50 years of age. The mean age was 48 years, ranging from 22 to 67 years, with a standard deviation of 10.0. The educational level was rather high, since 39% had an academic education. The majority of the participants comprised nursing staff (73%) with over 15 years of hospital work experience (52%), and 61% reported having managerial and leadership duties. The proportions of female and male participants who reported having managerial and leadership duties were 59% (n = 282) and 71% (n = 53), respectively. Only those who reported having managerial duties answered the questions entailing the level of management, and the number of subordinates. Most of the respondents held an immediate superior position (66%) and most of the managers had 20-39 (36%) subordinates. (Table 1).

The ethical organizational culture in five university hospitals

The overall ratings of the organizational ethical culture in the Finnish university hospitals were rather high, as shown in Table 2. Clarity (M 4.90; Md 5.00; SD 0.77), congruency of supervisors (M 5.05;Md 5.20; SD 0.98), and discuss ability (M 4.75; Md 4.90; SD 0.93) were evaluated the most positively, whereas the scores for the congruency of senior management (M 4.28; Md 4.25; SD 1.03), transparency (M 4.11; Md 4.17; SD 0.91), and supportability (M 4.05; Md 4.17; SD 0.92) were the lowest.

Factors related to stronger organizational ethical culture

Several significant associations were found between demographic variables and a stronger self-evaluated organizational ethical culture. However, for the most part, significant associations were found between demographic variables and clarity, congruency of senior management, supportability, as well as sanction ability.

The strongest statistical associations were found between respondent age and clarity (p < 0.001), congruency of supervisors (p < 0.001), congruency of senior management (p < 0.001), feasibility (p = 0.045), discuss ability (p < 0.001), as well as sanction ability (p = 0.005). Older employees evaluated the organizational culture as a whole to be more ethical than younger employees. Significant associations were also found between work experience in the university hospital and clarity (p < 0.001), congruency of supervisors (p = 0.005), congruency of senior management (p < 0.001), discuss ability (p < 0.001), and sanction ability (p = 0.024). Profession was associated with strong clarity in that administrative staff evaluated the ethical organizational culture the strongest (p = 0.008). Statistically significant associations were found between level of management and congruency to supervisors (p = 0.029), congruency of senior management (p < 0.001), discuss ability (p < 0.001) and sanction ability (p < 0.001). When only those who reported having subordinates were selected into analysis, the less number of subordinates indicated stronger clarity (p = 0.014). Gender did not explain the rating of a stronger ethical culture. However, significant associations were found between level of education and clarity (p < 0.001), congruency of supervisors (p = 0.024), congruency of senior management (p = 0.026), feasibility (p = 0.039), discuss ability (p < 0.001) and sanction ability (p = 0.024).

Factors predicting stronger ethical organizational culture

Logistic regression analysis with the enter method was used to identify factors predicting a stronger ethical organizational culture (Table 3). The most important predictors were age, profession, work experience, level of management, and the number of subordinates. Stronger clarity was explained by profession, work experience, and the level of management. Nursing staff reported stronger clarity compared to physicians. In addition, participants with over 15 years of work experience and also top managers reported strongest clarity. Furthermore, the level of management explained stronger clarity in that middle managers and top managers reported stronger clarity compared to managers with an immediate superior position. The managers with 1-19 subordinates reported strongest clarity.

Stronger congruence of senior management was explained only with age. Participants over 50 years reported stronger congruence of senior management than younger participants. Stronger supportability was explained by profession and the number of subordinates. Administrative staff reported strongest supportability and physicians the weakest. The number of subordinates helped to explain stronger supportability in that managers with 1-19 subordinates reported strongest supportability and more than 80 subordinates the weakest.

Age was only sociodemographic associated with stronger sanction ability. Younger participants reported strongest sanction ability.

Background variables did not explain stronger congruency of supervisors, feasibility, transparency, or discuss ability, and these findings are therefore not reported in Table 3.

Discussion

This study provided valuable information about the organizational ethical culture in Finnish university hospitals and highlighted the factors that should be taken into account when developing interventions and updating the education and training of managers in order to decrease unethical behavior by improving work engagement. As Kaptein [15] argued, in order to improve the ethical culture of an organization, the dimensions of the ethical culture that are to be improved should be first identified. It is also known that ethical problems should be made visible and that there is a need to discuss ethical issues in an organization openly [50].

The ratings of the organizational ethical culture in the five university hospitals in Finland were rather high. This is an important result because an organization’s ethical climate correlates with organizational behavior [51]. Hospital employees have traditionally been ethically oriented. However, the culture in health care is constantly changing, and patients’ rights and roles, for example, are affecting the culture and the employees’ work [50]. Therefore, it is important to observe the development of the culture. Ethical questions are present every day in a hospital, and hospital workers are used to evaluating their hospital’s ethical culture. However, the results indicated that employees’ background factors, such as age, long work experience, and a high position in the organization, tended to affect positive views on the organization’s ethics. Older employees evaluated the congruency of senior management to be less ethical than younger employees. Older employees have more expertise identifying how senior management maintain ethics in their management and how ethical dilemmas are solved as reported also by Larkin [44]. Younger employees may have less work experience and different expectations on the norms, rules, congruency of supervisors, and ethics in general. A recent study indicated that, for Generation Y (born 1981-1995), work is less important than for Generation X (born 1966-1980) and baby boomers (born 1956–1965). To Generation Y, personal ambition is a much greater value than for those from other generations [52]. This may indicate that the expectations placed on work, management, and the ethics of organizational culture are changing.

The participants in the present study gave the highest organizational ethical culture ratings for clarity, congruency of supervisors, and discuss ability. These results suggest that ethical expectations are made concrete and understandable in the organization, supervisors act as role models in the organizations, and there is a possibility to discuss ethical issues within the organization. These findings are in agreement with those of Kangas and colleagues [14] in a sample of social services and health care workers. The results of the present study demonstrate that it is possible to build shared rules in large organizations as regards what is right or wrong. Regulations and changes in health care culture may not only cause new ethical problems but also provide assistance in attempting to solve problems [50].

The participants of the present study gave the lowest organizational ethical culture ratings for congruency of senior management, transparency, and supportability. Interestingly, the participants perceived strategic managers as less ethical than operative managers. Employees are not familiar with the senior managers’ work, nor with how ethically they conduct their work. Senior management can seem distant from the perspective of the subordinates, especially in larger organizations [30]. Operative managers are present in the employees’ daily work, which makes it easier to evaluate their work. Aloustani et al. [51] also stated that the ethicality of nursing managers’ leadership was high from the nursing perspective.

Strategic managers tended to evaluate the ethicality of their work as higher than did mid-level managers [10,14,39]. These different views can lead to conflicts, which can also be reflected onto the workers. It is known that organizational ethical culture plays a significant role in enhancing employee wellbeing, which is concretely demonstrated by, for example, sickness absences [30]. It is worrying that transparency seems to be a difficult issue in organizational culture. We concluded that employees were unable to clearly predict how the organization would react to inappropriate behavior. The transparency of actions and decisions is important because it protects staff from exhaustion, for example [53].

Profession was associated with strong clarity in that nursing staff evaluated stronger clarity and supportability than did physicians. However, administrative staff evaluated supportability stronger than did nursing staff. This result is unexpected because presumably physicians receive collegial support from their own superiors, whereas support for nursing staff may be weaker. However, physicians and nurses may have a different ethical climate. The ethical climate was particularly associated with patient care, inadequate staffing, and the attitude of managers towards nursing staff [54].

Research Limitations

The study design was cross-sectional, demonstrating the hospital workers’ experiences of organizational ethical culture at the time of participating in the study. Therefore, future follow-up studies are needed. Responding to the survey was voluntary, which has led to selection bias. The sample size was adequate, but the generalizability of the results is limited by the high non-response rate. The number of managers was over-represented, and because they gave higher scores than other participants, the organizational ethical culture may have been evaluated more positively. The age and sex distribution in our study was comparable to that of Finnish health care employees in general [55], and the participants represented all five Finnish university hospitals.

Practical Implications

Health care organizations are changing in many ways globally. For example, labor shortage is a pressing issue that can threaten the ethicality of the organizations and the quality of patient care in many ways. Therefore, it is important to continue to develop an open discussion culture as well as shared values and norms. Top-level managers need to develop a new communication culture with the employees. On the operative level, managers must reduce unnecessary hierarchy between professionals. By evaluating the organizational culture, managers may identify the strengths and weaknesses of the organization and thus prevent conflicts. It is also necessary to discuss how generation-specific attitudes affect the organization’s ethical culture.

Tables

Variable

 n

 %

Age

     
 

≤ 35 years

87

16

 

36-50 years

192

34

 

 > 50 years

274

50

Gender

   
 

Female

478

86

 

Male

75

14

Level of education

   
 

Vocational education

187

33

 

University of Applied Sciences (Bachelor)

157

28

 

Academic

217

39

Profession

   
 

Physicians

87

16

 

Nursing staff

404

73

 

Administrative staff

63

11

Work experience

   
 

< 4 years

58

11

 

4-9 years

80

14

 

10-15 years

128

23

 

 > 15 years

289

52

Managerial or leadership duties

   
 

Yes

341

61

 

No

213

39

Level of management

   
 

Immediate superior position

227

66

 

Middle management

93

27

 

Top management

22

6

Number of subordinates

   
 

None

19

6

 

1-19 subordinates

82

23

 

20-39 subordinates

124

35

 

40-79 subordinates

64

18

 

 ≥ 80 subordinates

62

18

       

Table 1: Sociodemographic and management characteristics of participants (n = 561) Sample size for the characteristics of participants varied because of missing data.

Sum variables of organizational ethical culture

Number of items

n

M

Md

Q1-Q3

SD

Minimum - maximum

Clarity

10

560

4.90

5.00

4.50-5.44

0.77

1.67-6.00

Congruency of supervisors

6

560

5.05

5.20

4.67-5.83

0.98

1.17-6.00

Congruency of senior management

4

555

4.28

4.25

3.75-5.00

1.03

1.00-6.00

Feasibility*

5

559

4.37

4.50

3.67-5.17

1.02

1.00-6.00

Supportability

5

561

4.05

4.17

3.50-4.67

0.92

1.00-6.00

Transparency

7

558

4.11

4.17

3.57-4.71

0.91

1.20-6.00

Discuss-ability

10

557

4.75

4.90

4.30-5.42

0.93

1.60-6.00

Sanction-ability

9

555

4.32

4.40

3.78-4.89

0.80

1.56-6.00

Table 2: Distributions of sum variables for CEV expressed by means (M), median (Md), kvartals (Q1-Q3) with standard deviations (SD)* Negatively worded items were scored for the purpose of the analyses.

N = 522

N = 517

N = 523

N = 517

Clarity

Congruency of senior management

Supportability

Sanction ability

OR

[95% CI]

OR

[95% CI]

OR

[95% CI]

OR

[95% CI]

Age

?35 years

1.00

1.00

1.00

1.00

36-50 years

2.10

[1.01-4.36]

3.33

[1.58-7.03]

1.07

[0.54-2.15]

0.41

[0.20-0.88]

>50 years

2.14

[0.90-5.09]

2.97

[1.29-6.86]

1.51

[0.69-3.31]

0.62

[0.28-1.38]

Gender

Male

1.00

1.00

1.00

1.00

Female

1.20

[0.63-2.28]

1.13

[0.63-2.03]

1.03

[0.58-1.85]

0.98

[0.55-1.75]

Level of education

Vocational

1.00

1.00

1.00

1.00

Univ. of Applied Sciences

0.58

[0.30-1.11]

0.61

[0.91-2.85]

0.84

[0.48-1.47]

0.67

[0.38-1.20]

Academic

0.98

[0.49-1.97]

1.03

[0.60-1.79]

1.02

[0.58-1.77]

0.61

[0.35-1.05]

Profession

Physician

1.00

1.00

1.00

1.00

Nursing staff

5.48

[2.32-12.95]

0.99

[0.49-2.02]

1.69

[0.79-3.59]

0.99

[0.47-2.05]

Administrative staff

4.12

[1.53-11.09]

0.97

[0.44-2.12]

2.97

[1.30-6.97]

0.98

[0.44-2.16]

Work experience

15 years

1.19

[0.48-2.94]

1.42

[0.64-3.17]

0.83

[0.38-1.79]

0.69

[0.32-1.51]

Level of management

No management level

1.00

1.00

1.00

1.00

Immediate superior position

0.25

[0.05-1.25]

4.49

[0.81-24.95]

1.03

[0.22-4.74]

1.92

[0.43-8.61]

Middle management

0.50

[0.12-3.04]

5.16

[0.92-29.00]

1.25

[0.27-5.88]

2.53

[0.55-11.63]

Top management

2.27

[0.22-23.15]

12.65

[1.64-97.43]

1.22

[0.18-8.19]

7.09

[1.06-47.58]

Number of subordinates

None

1.00

1.00

1.00

1.00

1?19 subordinates

4.72

[1.00-22.30]

0.31

[0.06-1.67]

1.13

[0.26-4.92]

1.02

[0.24-4.34]

20?39 subordinates

3.09

[0.63-15.18]

0.34

[0.06-1.88]

0.60

[0.13-2.73]

1.33

[0.30-5.82]

40?79 subordinates

3.47

[0.66-18.22]

0.20

[0.03-1.12]

0.83

[0.18-3.91]

1.84

[0.40-8.41]

?80 subordinates

1.64

[0.32-8.34]

0.30

[0.05-1.66]

0.24

[0.05-1.17]

1.77

[0.39-8.08]

Table 3: Predictors of stronger organizational ethical culture Abbreviations: CI, confidence interval; OR, odds ratio.

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