____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Original Article Volume 13 Number 17 November 2020 Copyright © 2020 Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. Nurses' perspectives regarding the relationship between professional ethics and organizational commitment in healthcare organizations *Corresponding Author Camellia Torabizadeh Community-based Psychiatric Care Research Center, 2nd Floor, Building No.3, Fatemeh PBUH School of Nursing and Midwifery, Namazi Teaching Hospital, Namazi Square, Shiraz, Iran. Postal Code : 71936-13119 Tel : (+98)71 36 47 42 55 : 221 Email : torabik@sums.ac.ir Received: 18 April 2020 Accepted: 1 Oct 2020 Published: 8 Nov 2020 Citation to this article: Torkaman M, Heydari N, Torabizadeh C. Nurses' perspectives regarding the relationship between professional ethics and organizational commitment in healthcare organizations. J Med Ethics Hist Med. 2020; 13: 17. Mahya Torkaman1, Naval Heydari1, Camellia Torabizadeh2* 1.PhD Candidate in Nursing, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran. 2.Associate professor, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Abstract Nurses' professional and ethical performances are influenced by the health organizations' environment, and high quality and holistic care can only be provided by observing the principles of professional ethics and organizational commitment. Therefore, this study aimed at investigating the relationship between professional ethics and organizational commitment in nurses. This descriptive-analytic study was conducted in hospitals affiliated to Shiraz University of Medical Sciences (SUMS) in 2019 in Iran. The study participants included 210 public ward nurses selected using the stratified random sampling method. Data were collected using Petty Professional Ethics and Allen-Meyer Organizational Commitment questionnaires, and then analyzed by SPSS V.25. Both the mean score of the nurses' professional ethics (102.21 ± 10.89) and the mean score of the nurses' organizational commitment (95.30 ± 16.54) were at high levels. Moreover, a direct and significant relationship was found between professional ethics and organizational commitment (P= 0.009, r = 0.179). In other words, a positive correlation was found between professional ethics and organizational commitment. Considering the relationship between professional ethics and organizational commitment in nurses, managers should enhance nurses' level of adherence to ethical principles, organizational commitment and organizational attachment. Additionally, training courses can help improve nurses' professional capabilities, and hence enhancing the quality of providing healthcare services. Keywords: Organizational culture; Ethics; Organizational commitment; Nursing. Nurses’ perspective regarding the relationship between professional ethics and … 2 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 Introduction Human resources are the most important asset of organizations. Nurses, the largest and most important human resources in healthcare organizations, play a major role in providing continuous high quality care (1). The current rapid developments in healthcare organizations have raised concerns about necessity of caring based on the professional ethics' principles. Professional ethics is a set of basic human principles and standards governing the individuals and groups' behavior. Moreover, professional ethics is a rational thinking process that targets at determining values of an organization (2), and disregarding it can question the organization's legitimacy and actions. Empowerment and adherence to principles and codes of ethics are among the concerns of human resource management in the healthcare organizations worldwide (3). According to the International Council of Nurses (ICN), nurses not only promote public health and well-being, but also protect themselves against ethical dilemmas in healthcare organizations by emphasizing on ethical planning and practicing (4). The healthcare organizations' negligence of the professional ethics and their failure in adhering to ethical principles can create problems for nurses that question their measures and reduce their teamwork, job satisfaction, and appropriate relationships with colleagues (5). However, results of various studies indicated that nurses' adherence to professional ethics was not high. Bah et al. (2018) showed that nurses' adherence to ethical values was at a low level, and they did not observe the codes of ethics (4). In other words, nurses encounter conflicts between their personal and professional values by ignoring ethical considerations, thereby resulting in their distance from patients and indifference to care provision (4). Professional ethics and adherence to its principles can influence individual's commitment to the organization. Organizations can rarely succeed without adhering to professional ethics and institutionalizing the organization's ideals and values (6). Organizational commitment is defined as believing in the organization's values and goals, feeling loyal to the organization, as well as feeling ethical requirements, heart desires, and needs to stay in the organization. Organizational commitment is a type of emotional dependence on the organization; highly committed employees take their identity from the organization, participate in the organization, and enjoy membership in the organization (7). Employees with organizational commitment can create an efficient atmosphere to improve organizational ethics, motivation, and efficiency (2). Organizational commitment, as an employee evaluation criterion, affects nurses' intention to change their occupation, leave their occupation, absenteeism, conflicts, job stress, and clinical performance (8). To have efficient human resources in the health sector, employing nursing staffs with high organizational commitment is extremely challenging as nurses' low organizational commitment can decrease their performance and quality of care (9, 10). Safari and Yoosefpour in their study in Iran showed that enhancing nurses ‘organizational commitment improved their quality of care (11). Torkaman M., et al. 3 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 Researchers of the present study consisted of clinical educators, and nurses who have frequently observed the weaknesses of healthcare organizations in adhering to ethical principles and organizational commitment. In addition, they have closely experienced the consequences of ignoring professional ethics and organizational commitment. Both professional ethics and organizational commitment can influence the quality of healthcare staff’s work-life and nursing care, and to the best of our knowledge, this is the first study to investigate the relationship between professional ethics and organizational commitment on nurses. Method This descriptive-analytical study was conducted from July to October 2019 in hospitals affiliated to Shiraz University of Medical Sciences (SUMS) in Shiraz, one of the largest cities in the south of Iran. Participants, selected using stratified random sampling method, were 210 nurses working in SUMS’ affiliated hospitals. The sample size was calculated as 210 based on a similar study (12), and the sample size formula using r = 0.192, confidence level of 0.95, and test power of 0.8 by Medcalc software. Inclusion criteria were as follows: being employed as a nurse, having at least a bachelor's degree in nursing, and consenting to participate in the study. Participants were excluded if they refused to continue attending or fully complete the questionnaires. The Ethics Committee affiliated with SUMS approved this research (Medical Ethic No: IR. SUMS. REC.1398.1086), and introduction letters were sent to the hospitals' managers for necessary coordination. Prior to the study, all participants were provided with a cover letter explaining the study’s purpose and data collection procedure. Then, informed written consent was obtained from all participants, and they were guaranteed the confidentiality of the data, anonymity as well as their voluntary participation in the study. To collect data, Petty professional ethics and Allen-Meyer organizational commitment scales were administered along with the demographic information questionnaire. The professional ethics questionnaire, developed by Petty in 1993, includes four dimensions: interest in work, perseverance in work, healthy human relationships at work, and participation in work. Attainable scores on this questionnaire ranged from 23 to 115 such that higher scores indicate higher professional ethics. Scores within the range of 23-46, 47-69, and 70-115 indicated low, moderate, and good levels of the professional ethics, respectively. Content validity of this questionnaire was confirmed by an expert panel of professionals, and its construct validity was corroborated by factor analysis method. Cronbach's alpha value to measure the total internal consistency of this tool was 0.96. Interest in work, perseverance in work, healthy human relationships at work, and participation in work had Cronbach's alpha values of 0.85, 0.79, 0.87, and 0.74, respectively (13, 14). Moreover, Sheikhzakaryaie and Atashzadeh-Shoorideh showed that the total reliability of this tool was Nurses’ perspective regarding the relationship between professional ethics and … 4 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 85%. For the following four dimensions, healthy human relationships at work, perseverance in work, interest in work, and participation in work, the reported reliability indices were 79%, 91%, 84%, and 86%, respectively (15). The Allen-Meyer organizational commitment questionnaire (1990) contains 24 items with three main dimensions of affective (indicating the individual's emotional dependence on the organization), continuance (including costs of leaving the job), and normative commitment (showing the obligation and sense of duty to stay in the organization). The respondents' scores could range from 24 to 168. Respectively, a score within the ranges of 120- 190, 60-90, and 0-60 showed high, moderate, and low organizational commitment. Reliability coefficients of the affective, continuance, and normative commitment dimensions were 0.86, 0.79, and 0.75, respectively. Validity of this questionnaire was also confirmed by 15 experts, and its structural validity was verified by confirmatory factor analysis (16, 17). In the study by Nabizadeh et al., the internal consistency was assessed using Cronbach's alpha coefficient (18). Based on their findings, (α = 0.87) for the total tool, (α = 0.82) for the emotional commitment, (α = 0.89) for the continuous commitment, and (α = 0.75) for the normative commitment dimension were obtained. The tool's stability was evaluated using the retest method at 14- day intervals for all the organizational commitment tools (r = 0.89) as well as the continuous commitment (r = 0.93), emotional commitment (r = 0.93), and normative commitment (r = 0.87) dimensions (18). Using SPSS software version 25, descriptive statistics (percentage, mean, and standard deviation) and analytical statistics (t-test and Pearson and Spearman correlation coefficient) were used to analyze the data. According to Kolmogorov-Smirnov test, data had a normal distribution, and the level of significance was considered at 5%. Results Demographic characteristics From 210 nurse participants, 156 were female (74.3%), 129 were married (61.4%), and 189 had a bachelor's degree (90%). The mean age of nurses was 31.11 ± 6.74 years, and their mean work experience was 7.46 ± 5.89 years (Table 1). Table 1- Participant’s demographic information Variable Number (Percentage %) Marital status Single Married 81 (38.6) 129 (61.4) Gender Male Female 54 (25.7) 156 (74.3) Education level Bachelor's degree Master’s degree 189 (90) 21 (10) Type of employment Permanent employment Contractual employment Temporary to permanent employment Conscription law's employment Corporate employment 60 (28.6) 40 (19) 29 (13.8) 72 (34.3) 9 (4.3) Based on the independent t-test results, mean scores of the professional ethics and Torkaman M., et al. 5 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 organizational commitment were not significantly diverse in different gender and marital status groups. However, a significant difference was found between the participants' organizational commitment and level of education, and organizational commitment was higher in nurses with a bachelor's degree (Table 2). Table 2- Nurses' demographic information as well as its relationship with organizational commitment and professional ethics (n = 210) Variables Organizational commitment Professional ethics *Age r = 0.129 P = 0.062 r = 0.047 P = 0.501 *Years of working r = - 0.051 P = 0.459 r = - 0.02 P = 0.777 **Gender Male 96.51±16.00 r= -0.001 P=0.988 102.61±12.34 r = - 0.055 P =0.425 Female 94.89±16.75 102.07±10.38 P-value 0.535 0.757 **Marital status Single 93.50±17.89 r = 0.56 P=0.451 101.91±13.01 r = - 0.043 P = 0.538 Married 96.44±15.59 102.40±9.37 P-value 0.211 0.752 **Academic level Bachelor 96.37±15.60 r = - 0.125 P =0.071 102.31±10.60 r = - 0.003 P =0.965 Master 85.76±21.54 101.28±13.48 P-value 0.005* ** 0.682 *Pearson correlation coefficient was used, and significance level was considered at 0.01. **Spearman correlation coefficient was used, and significance level was considered at 0.01. ***Independent t-test was used, and significance level was considered at 0.05. Participants' professional ethics and organizational commitment The professional ethics' total mean score was high (102.21 ± 10.89) in nurses. The highest and lowest scores were attributed to the perseverance in work (27.41 ± 3.11) and relations in work (23.00 ± 2.30) dimensions, respectively. The participants' mean scores in dimensions of interest in work and participation in work were )24.46 ± 5.32 ( and )27.32 ± 3.03(, respectively. Mean score of the total organizational commitment was high (95.30 ± 16.54). The highest mean score was related to continuance commitment dimension (37.76 ± 9.80), while the lowest mean score was attributed to the normative (30.61 ± 6.63) and affective commitment (31.92 ± 6.49) dimensions. Correlation between professional ethics and organizational commitment Professional ethics had a direct correlation with interest in work. In addition, organizational commitment had a very weak Nurses’ perspective regarding the relationship between professional ethics and … 6 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 correlation and weak correlation with affective and normative dimensions, respectively. Organizational commitment also had a direct and very weak relationship with professional ethics and normative dimension, respectively (Table 3). Table 3. Correlation between professional ethics and organizational commitment in nurses Variable Professional ethics Interest in Work Perseverance in work Human relations at work Participation in work Total Organizational Commitment r=0.179 P=0.009* r=0.304 P<0.001* r=0.123 P=0.076 r= -0.028 P=0.681 r=0.006 P=0.926 Affective Commitment r=0.228 P=0.001* r=0.413 P<0.001* r=0.071 P=0.308 r= - 0.025 P=0.724 r=0.038 P=0.583 Continuance Commitment r=0.047 P=0.497 r=0.065 P=0.352 r=0.056 P=0.420 r= - 0.007 P=0.918 r=0.004 P=0.954 Normative Commitment r=0.154 P=0.025* r=0.257 P<0.001* r=0.154 P=0.026* r= - 0.036 P=0.600 r= -0.027 P=0.695 Pearson correlation coefficient was used, and significance level was considered at 0.01. Discussion This study aimed to investigate the relationship between professional ethics and organizational commitment in nurses. According to the findings of this work, which are consistent with those of a study by Dehghani et al. (19) in Iran, the mean score of nurses' total professional ethics was at a high level, showing that observing professional ethics was a part of the nursing profession's intrinsic nature. However, a study in Uganda indicated that nurses had a poor knowledge of basic ethical concepts (20). Another study in Iran showed that nurses' knowledge and attitudes were at a moderate level towards ethical codes, implying that nurses did not use various and available related resources appropriately (e.g., international and national codes of ethics in the nursing profession) (21). The discrepancy between our findings and other studies can be due to the differences in participants' characteristics and tools used for measuring professional ethics. In addition, professional ethics is a multi- dimensional phenomenon influenced by nursing education system, system's views and attitudes toward nurses, as well as social and cultural factors. In professional ethics, the highest and lowest mean scores were related to the perseverance in work and human relations dimensions, respectively. The nurses' high level of perseverance in work can be justified by nursing profession nature, in which nurses should render high quality services to patients despite all shortcomings, many overtime hours, and shortage of the healthcare staff. The low scores in the human relations Torkaman M., et al. 7 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 dimension can be due to nurses' lack of sufficient motivation, burnout, job dissatisfaction, and lack of professional interest as well as low nurse-patient ratio. In this regard, nursing managers can significantly help improve the relationships in workplace and serve as role models for other healthcare system personnel by adhering to the ethics' principles and appropriate human relationships (22). The mean score of total organizational commitment was high among the participants; this finding was also confirmed by many studies in Iran and other countries (23-25). Staff with higher levels of organizational commitment usually have better performance with less absenteeism and delay to work, which are significantly important in sensitive occupations such as nursing (26). Organizational commitment enables the employees to interact emotionally with the organization, feel satisfied to work for the organization, and make endeavor to reach the organization's goals (24). The results of other heterogeneous studies reported an average level of organizational commitment among nurses (27, 28). In our study, the highest mean score of commitment was related to continuance commitment dimension as individual’s continuance commitment can be enhanced by increasing the number and length of training programs (e.g., in-service courses) (27). Continuous commitment appears when an individual analyzes positive and negative aspects of leaving the organization. With high levels of continuance commitment, the employees remain loyal to the occupation because they think that starting a new job would destroy the experiences gained in the organization. However, such thought may put the organization in a position facing employees who are not motivated, creative and innovative (6). The present study’s participants seemed to adapt to the current situation to avoid financial costs of leaving the organization, possibly due to low nurses' salaries and economic problems in Iran. The lowest mean score of organizational commitment was related to normative commitment dimension, which was confirmed by another study in Iran on nurses (18). In normative commitment, employees are faced with the situation of staying in the organization because they think it is a right and proper action. The following approaches can be effective in improving employees' normative commitment: in-service training, labor division based on the individuals' abilities and competences, as well as continuous evaluation of the personnel's performance, abilities, and capabilities (26). This study’s results showed a significant relationship between professional ethics and organizational commitment. Many studies also confirmed the relationship of professional and ethical empowerment with nurses' organizational commitment (25, 29). Inconsistent with the present study, a research in Iran on nurses showed no significant relationship between professional ethics and organizational commitment (2). Based on the literature, ethical work environment can be considered to be a main factor affecting the performance and Nurses’ perspective regarding the relationship between professional ethics and … 8 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 competence of the staff (4, 30). In this regard, Karami et al. stated that hospital managers need to extensively plan to improve nurses' professional performance and organizational quality (7). The present study showed a significant relationship between the nurses' organizational commitment and the bachelor's degree. This finding was in line with the results of a study by Nabizadeh et al. (18), but contradicted those of a study by Sheikhzakaryaie and Atashzadeh-Shoorideh (15). Usually, nurses with master's and doctoral degrees are employed in universities and research centers in Iran. Moreover, nurses with a bachelor's degree have fewer job opportunities, and hence they have to work in clinical settings and are more dependent on the healthcare organizations. Given that various factors affect nurses' professional ethics and organizational commitment, managers should consider factors such as delegating authority, clarifying responsibilities, and evaluating staff performance properly. The authorities should enhance nurses' commitment to ethics and organizational attachment through training courses to empower the nurses, thereby improving their quality of health care services. A limitation of this study was administration of the self-report questionnaires, and hence future work can use other data collection methods such as interview and observation to increase data validity. Conclusion According to the study findings, nurses had high levels of professional ethics and organizational commitment, and a significant relationship was observed between these two factors. Considering the priority of high-quality care provision by nurses, nursing managers should seriously consider the effect of nurses' professional ethics and organizational commitment on organization's development. Moreover, providing a precise definition of ethical codes as well as in-service training courses for nurses can encourage them to practice on ethical principles and improve their organizational commitment. Acknowledgments This study was derived from an approved research project in Shiraz University of Medical Sciences, Iran with registration number: 19773. The authors thank and appreciate all nurses who participated in this research. Conflict of Interests The authors declare that they have not competing interest. Torkaman M., et al. 9 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 17 November 2020 References 1. Esmaelzadeh F, Abbaszadeh A, Borhani F, Peyrovi H. 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