Barriers to ethical treatment of patients in clinical environments: A systematic narrative review
Abstract
Background and Aim
It is essential that healthcare providers display ethical behavior toward their patients. Despite development of codes of ethics for clinical practice, the occurrence of unethical behaviors toward patients is alarmingly high. The present study was conducted to identify the barriers to ethical treatment of patients in clinical environments.
Methods
Through systematic narrative review, the present study investigated the barriers to ethical treatment of patients. This study was carried out in line with Assessment of Multiple Systematic Reviews 2 and Preferred Reporting Items of Systematic reviews and Meta-Analyses guidelines.
Results
Ethical challenges in clinical environments can be classified into two categories: “organizational factors” and “personal factors.” Organizational factors consist of three domains: managers and regulations, organizational environment, and human resources. Personal factors consist of two domains: factors related to patients and their families and factors related to care providers.
Conclusion
Research shows that encouraging healthcare teams to adopt ethical behaviors through education and having them persistently observe ethics in their clinical practice will not completely bridge the gap between theory and practice: it seems that the clinical environment, the personal characteristics of healthcare team members and patients, and the organizational values of the healthcare system pose the greatest barrier to bridging this gap. Accordingly, in addition to raising healthcare providers’ awareness of the existing issues in clinical ethics, measures should be taken to improve organizational culture and atmosphere.
1 INTRODUCTION
Treating patients according to codes of ethics is a key characteristic of healthcare teams and a professional obligation in the healthcare system. In every stage of the healthcare team's practice, especially in clinical environments, conforming to codes of ethics is essential to maintaining patients’ ethical and legal rights.1
Respect for principles of ethics in clinical environments should address concerns about unethical behaviors and the contributory factors.2 Studies report that, despite healthcare teams' awareness of ethical issues, codes of ethics are not properly followed in practice, and the rate of unethical behaviors in clinical environments is increasing.3-5 Several studies report disrespect for patient privacy,6, 7 violation of patient dignity,8-11 disregard for patient autonomy,12 negligence of patients’ basic needs and inappropriate treatment of patients.13
Establishment of an effective ethical relationship between healthcare providers and patients is fundamental to clinical interventions; however, several studies report various instances of unethical behaviors in clinical environments, including hiding the truth, refusing to report errors, and forging patients' files.14-17 According to a report by Health Research and Quality Agency, 10.8% of patients believe that their care providers occasionally or generally ignore their words, fail to clearly explain patients’ treatment plans to them, and do not spend adequate time with the patients.18 Not providing them with enough information, doctors and nurses believe that they can ideally decide on behalf of their patients and act accordingly and that they do not deem it necessary to educate patients and seek their consent.19 Research shows that patients’ dignity and privacy are not respected in medical centers.20-24 Hospital staff does not treat patients with respect and 22.4% of doctors do not approve of the fact that they must not shout at patients under any circumstances.25
Following commercialization of healthcare by private practitioners, public health standards have been deteriorating. Advertising, hiring representatives to attract more patients, and overcharging patients have emerged as major ethical issues.26 A study in Sri Lanka found that several doctors committed unethical behaviors, including prescription bias and receiving gifts from patients.27 Sometimes, doctors get involved in unethical activities regarding prescription of medications 28 and accepting gifts from pharmaceutical companies to recognize their products, which can result in changes to their pattern of prescribing medications to their patients.27
In studies conducted in the United States and Australia, nurses referred to obstacles to following codes of ethics in their workplace which prevented them from treating their patients with dignity and compassion. They listed lack of nursing personnel, work overload, shortage of time, and financial and organizational limitations as major barriers to respecting professional ethics in clinical environments.29, 30 Another study in Greece attributed lack of support for patients to lack of personnel, time, and proper education about ethical behaviors.31
Disregard for ethical behaviors can put patients' safety and lives at risk and undermine the patients' relationship with the personnel, lower the quality of services, and increase the probability of personnel's violence and abuse against the patients.32 On the other hand, respect for codes of ethics can improve the process of caring for patients,33 enhance the quality of hospital services,34 increase patients’ satisfaction with treatment teams,35 and improve the hospital atmosphere and clinical interactions.36, 37
Many studies conducted in Iran report poor observance of ethical behaviors, which is surprising considering the common belief that in religious societies, individuals act ethically and benevolently, as religious principles dictate. Even though the majority of healthcare providers, especially nurses, are familiar with the ethical aspects of their profession and their significance, the major concern is their ability to use those ethical principles in their clinical practice. Of course, these concerns are not restricted to nurses in Iran: most nurses all over the world agree that there are barriers to acting ethically in clinical environments.38
Attention to care providers' compliance with codes of ethics in their interactions with patients has been increasing, as shown by the large number of articles published on the subject.38-40 However, the existing barriers to ethical treatment of patients have not been explored enough. To understand healthcare providers' ethical behaviors, it is important that the possible causes of their failure to adhere to these behaviors should be identified. Research shows that patients tend to be influenced by the quality of healthcare services and the behaviors which they associate with them.41-43 As healthcare providers constantly face ethical situations in their professional lives, it is not possible to promote their respect for codes of ethics without identifying the barriers to their ethical treatment of patients. Providing an overview of the available body of evidence in relation to obstacles to ethical treatment of patients in clinical environments can contribute to clarifying, summarizing, and concluding from the literature related to this concept.
Narrative synthesis allows researchers to investigate similarities and differences between studies, explore relationships within data and assess the validity of evidence, and results in a summary of knowledge about a certain review question which can be used to improve practice or policy.44 Narrative systematic reviews are used to synthesize both quantitative and qualitative studies 45 and are an especially useful means of linking various studies for reinterpretation or interconnection to generate or assess a new piece of evidence.46
According to previous research, healthcare providers' ethical behaviors are influenced by a variety of factors. Investigating the barriers to ethical treatment of patients and exploring the literature related to this concept can help planning and decision-making toward removing the existing obstacles.
2 METHOD
In the present study, barriers to ethical treatment of patients were investigated in a systematic review using narrative synthesis. This Systematic Narrative synthesis consists of five elements: (1) Identifying a research question, (2) Searching, (3) Screening, (4) Sampling, and (5) Analysis.47 The study has been carried out in line with Assessment of Multiple Systematic Reviews 2 guideline and Preferred Reporting Items of Systematic reviews and Meta-Analyses tool.
3 RESEARCH QUESTIONS
What are the barriers to ethical treatment of patients in clinical environments?
4 RESEARCH STRATEGY
4.1 Searching
In the present study, all the articles published in English from 1990 to 2022 in the databases of PubMed, Google Scholar, Web of Science, Scopus, medRxiv, Cochrane library, CINAHL, and Embase were examined by one of the authors. Also, the gray literature on organizational websites, for example, the supreme board of medical ethics for ethical treatment of patients and WHO, was examined.
To ensure exhaustive coverage of the subject, the initial search addressed titles, keywords, and abstracts using different combinations of the keywords and Boolean Operators (AND and OR). A broad range of relevant search keywords, such as ethics, codes of ethics, health personnel, systematic narrative review, unethical behavior, ethics, ethical issues, ethical challenges, ethical behavior, ethical codes, codes of ethics, professional ethics, medical ethics, patient dignity, patient privacy, disrespectful behavior, healthcare providers, nurse, medicine, physician, patients, client, caregiver, practice, bioethics, narrative synthesis, systematic review, rapid review, and barriers were used. The keywords extracted from MeSH and related articles were used for appropriate syntax search in each database. In addition to electronic search, the researchers executed a manual search of lists of references in articles to identify more related articles.
4.2 Screening and sampling
Most of the articles used qualitative and review approaches to study ethical behaviors in clinical environments. A few studies used quantitative approaches to explore factors related to ethical behaviors in clinical environments. Subsequently, the titles and abstracts of the articles which met the inclusion criteria were selected and the full texts were acquired and studied. The initial screening of titles and abstracts from the retrieved studies was carried out by the first two authors. Subsequently, each abstract and title was screened by two other members of the research team independently. Because the analysis was an iterative process, the team met regularly to discuss their views of the articles and analyze how the findings were related to the subject under study. For studies that passed this initial screening, the full texts were assessed by two other members of the research team. If there was disagreement between the two authors, all the researchers met and engaged in a comprehensive discussion to obtain consensus. This systematic and collaborative method was used to increase the rigor and reliability of the study selection process.
The methodological quality of the included studies was assessed with the Mixed-Methods Appraisal Tool (MMAT) (v. 2018),48 independently by two of the authors. The articles which acquired higher scores were selected for review.
4.3 The inclusion criteria
- 1.
The article has been published in English.
- 2.
The subject of the article is relevant to the research question.
- 3.
Articles that address inpatients care settings.
- 4.
All peer-reviewed articles.
4.4 The exclusion criteria
- 1.
The full text of the article is not available.
- 2.
The article is repeated or is irrelevant.
- 3.
Articles that are about theory rather than actual practice.
- 4.
Articles that address outpatients, long-term and psychiatric care settings.
- 5.
Conference proceedings and publications which are not data-driven, such as editorials, commentaries, and discussion documents.
- 6.
Articles published before 1990.
4.5 Sampling
After the process of quality appraisal of the selected studies, data extraction was conducted. For a preliminary synthesis of findings of included studies, the review team developed textual descriptions of the selected articles. The extracted data were classified into themes. Figure 1 shows a flowchart of the manner of selecting articles. 3359 articles were identified in the initial search. The articles were screened in terms of the relevance of their titles and abstracts to the research question and 137 articles were found to potentially meet the inclusion criteria of the study. After a close reading of the texts of the articles, 93 works which did not meet the criteria of the study or were irrelevant to the research question were excluded. Ultimately, 44 articles (two systematic reviews, 12 qualitative studies, and 30 quantitative descriptive-analytical studies) were selected for final synthesis.
5 RESULT
Research shows that encouraging healthcare teams to adopt ethical behaviors through education and having them persistently observe ethics in their clinical practice will not completely bridge the gap between theory and practice: it seems that the clinical environment, the personal characteristics of healthcare team members and patients, and the organizational values of the healthcare system pose the greatest barrier to bridging this gap. Accordingly, in addition to raising healthcare providers' awareness of the existing issues in clinical ethics, measures should be taken to improve organizational culture and atmosphere.
Review of the articles showed that healthcare providers’ ethical behavior is a multi-dimensional concept which is influenced by a variety of organizational and personal factors.49, 50
5.1 Organizational factors with an impact on care providers' ethical behavior
These factors fall into three domains: (1) managers and regulations, (2) organizational environment, and (3) human resources.
5.2 Managers and regulations
Care providers' ethical challenges in this domain consist of managers' ineffective supervision, defects in staff training, and managers' inadequate support of healthcare providers and poor responsiveness. With regard to regulations, ethical challenges concern procedures for evaluation of care providers' performance, recruitment procedures, and lack of supervision over observance of ethical principles.
Nurse administrators' ethical behaviors can affect nurses' performance and have positive outcomes for their organizations 50, 51 Support systems include positive support plans, flexibility, and effective reward and punishment policies. Managers' inadequate support of healthcare providers and poor responsiveness are among major barriers to ethical behaviors with regard to patient rights.52 A study by Korsah (2011) in Ghana showed that managers' negligence of nurses' needs lead to negative interactions between nurses and patients.53 Job security, one of the indexes of compensation, reduces stress in the personnel and can be employed by managers to improve the ethical climate in hospitals.54
The findings of a study indicate that if, in the evaluation of the performance of healthcare personnel, practical objectives are clearly set up and the personnel are informed about them, the evaluation process can prevent unethical behaviors by nurses in the workplace and facilitate ethical behaviors.55 Education has been suggested as an incentive for ethical behavior.51, 56-60 Unfortunately, there is a lack of an effective administrative system in Iran to evaluate nurses' skills and their professional competence. Also, on-the-job-training courses are mostly theoretical and do not address principles of ethical behavior.51 The ineffectiveness of the on-the-job training programs is one of the consequences of managers' unsatisfactory performance.61
Educating nurses in ethical principles can encourage nurses to behave ethically by affecting the manner of their decision-making in the face of ethical dilemmas and empowering them in coping with ethical issues in the workplace.62 Furthermore, educating nurses in ethical principles will familiarize nurses with the available organizational resources which they can refer to in case of ethical conflicts, which will reduce the rate of deviant behaviors in nurses and incline them to perform ethical acts.53, 63, 64 Educational programs and promotion of ethical counseling can improve healthcare providers' attitudes and behaviors and increase their sensitivity to patient privacy and patient confidentiality.65 A study by Ranasinghe (2002) showed that training in medical ethics is essential to improving doctors' knowledge and perception of and, by extension, adherence to ethical behaviors.27
Another dimension of managers and regulations which has an impact on adherence to ethical principles is the procedure for recruiting healthcare providers. Recruitment policies which result in the employment of honest and moral individuals can significantly reduce the occurrence of unethical behaviors in clinical environments and promote ethical behaviors.53, 66
Nurses' experiences show that frustration is a major impediment to ethical behaviors. Encouragement creates a sense of satisfaction and is a source of motivation.67 Research shows that punishment or lack of acknowledgment or reward by managers and administrators for ethical acts undermine nurses' inclination toward ethical behavior.68, 69
5.3 Organizational environment
Another influential factor in care providers' adherence to professional ethics is the organizational environment, which consists of the internal organizational environment and the external organizational environment. The internal environment encompasses such factors as organizational commitment, organizational culture, ethical climate, inadequate income, and an unsafe work environment. The external environment encompasses socio-cultural factors, including social support systems and underlying factors, such as the public opinions and attitudes on the image of health professionals, and expectations of other nurses, doctors, and patients' families.
Occasionally, lack of equipment in clinical environments including space limitation has an adverse effect on nurses' professional and ethical performance.57 Standard hospital facilities and equipment play an important role in fulfilling professional ethics.67 Shortage of facilities and equipment interfere with maintaining patients' dignity and made them feel unvalued.22
The studies showed that nurses' organizational commitment,70 and social orientation correlated with their ethical behavior.71 Developing and promoting an ethical climate contributes to healthcare providers’ ethical behavior in the domains of patient privacy and patient satisfaction.65 Organizational culture plays a crucial part in healthcare providers' accomplishment of their missions, which, in turn, influences the personnel's perceptions and behaviors in the process of care giving.58 A study by Larson (1999) showed that lack of cooperation, coordination, and collaborative decision-making between physicians and nurses results in an unsatisfactory work environment and an adverse effect on the ethical behaviors of healthcare providers.72
Social factors fall into two categories: support systems and respect for interpersonal ethical values, for example, social orientation and internal and external religious orientation. Some work therapists maintain that lack of financial and social support systems has an adverse effect on therapists' ethical behavior.57 Professional inequalities in clinical environments affect the ethical care provided by nurses. Among the major causes of workplace discrimination are healthcare systems' unequal treatmentof doctors and nurses, doctor's superiority, and significant differences between doctors' and nurses' salaries and social status.73
Some clinical procedures are not covered by insurance. Ineffective support systems are responsible for occasional errors made by healthcare personnel. “A short time ago, if a patient could not afford the cost of his or her treatment, ethics dictated that we should provide care just the same. Yet, today, we are told that if patients can't afford healthcare services, they should not come to medical centers at all.” Dominant social values influence individuals' behaviors.57 In a study in South Korea, the dominant cultural attitudes were found to be a major contributing factor in nurses' ethical behaviors.74 Georges and Grypdonck (2002) stressed the role of nurses' spiritual beliefsin improving their observance of ethics.75
Underlying factors include the opinions and expectations of other nurses, doctors, and patients' families. A variety of factors can prevent nurses from making appropriate ethical decisions and acting according to ethical principles in clinical practice, among them a stressful work environment, limited resources, confrontation with opposing values and norms, tendency to live up to others' expectations, and, in particular, difficult working conditions.67 Iranian people's generally negative perception of nurses' performance results in nurses' dissatisfaction with their career, with an adverse effect on their respect for patients' dignity.23
Social orientation refers to one's effective interpersonal relationships with others and respect for social norms. An individual's social orientation regarding sociability, willingness to communicate with others, being responsible, and showing respect for others' rights has an impact on his/her ethical behavior in interpersonal relationships.76 In intrinsic religious orientation, belief is deemed as a high virtue in its own right and a universal motive for commitment. However, external religious orientation is an external tool used by individuals to meet their personal needs, including safety and status.77 To an intrinsically religious individual, personal beliefs are more important than the social aspects of a religion. On the other hand, individuals with external religious motives rely on external social values and beliefs.78 Different ethical situations and religious attitudes can change ethical behavior in nurses and other members of healthcare teams. Intrinsic religious orientation has the greatest impact on ethical behavior and can predict it. While universal ethical principles contribute to ethical behavior, self-centeredness, personal ethical principles, greed for status, and external religious orientation have an adverse effect on ethical behavior.79
The variables of perception of the ethical climate, status-related selfishness, and external religious orientation have an adverse effect on ethical behavior. However, stronger intrinsic religious orientation, personal ethical principles, and perception of universal ethical principles result in an increase in nurses' ethical behavior scores.80, 81
5.4 Human resources
In the domain of human resources, factors which have an impact on care providers' ethical behavior include lack of workforce, job satisfaction, affinity between colleagues, positive role models, inappropriate modeling, and informal experimental learning. Organizational preconditions, which include the actual proportion of nurses to patients, work overload and lack of workforce, and nurses' right to select their unit, are among influential factors in professional ethics.52 Inadequate workforce can prevent nurses from performing many of their primary duties, including respecting the rights of all patients and their families, alleviating patients’ pains, and maintaining uniformity.1, 52, 57, 82
In a study by Hyeoun-Ae Park (2003), the nurses referred to ethical indifference as one of the main causes of unethical behavior. In this study, the nurses mentioned that because of work overload and lack of time, they could not provide enough patient-centered care.83 Bennett et al. (2003) found that lack of time and shortage of personnel are the major barriers to nurses’ use of research evidence and observance of professional ethics in practice.84 A study by Hansson (2007) showed that provision of ethical care requires time: for time-consuming activities, having enough time increases the likelihood of ethical behaviors.85 Klitzman found that being pressed for time is a barrier to doctor's empathy.86 The results of a study of the ethical dimension of care rationing showed that their inability to provide all the care required by patients cause certain professional problems or ethical issues for nurses. Nurses feel that care is given based on “time” rather than the patients' individual needs. Accordingly, they pay less heed to their patients' communication, social, psychological, and relational needs and attach more importance to the patients’ immediate medical and physiological needs.87
Research shows that there is a significant positive correlation between job satisfaction and ethical behavior.57, 71, 88 Empathetic treatment of patients can suffer as a result of care providers' emotional fatigue, job burnout, sleep deprivation, workload, and physical exhaustion.89-91 The main barrier to observance of professional ethics in the personal domain is failure to meet nurses' basic needs, including income adequacy and getting enough time-off.92
Role modeling is one of the methods employed by healthcare experts to teach empathetic interaction with patients.27, 86, 90, 91 Instructors with theoretical and specialized knowledge of ethics can act as role models and help improve adherence to professional ethics in students. According to Woods, as role models, instructors play a significant role in inculcation of ethical behavior in students.93
5.5 Personal factors which have an impact on care providers' ethical behavior
Personal factors which influence care providers’ ethical behavior fall into two categories:
(1) Factors related to care providers, including job burnout, patients' behaviors, and the values, beliefs, experiences, knowledge and skills of the treatment team, and (2) factors related to patients and their families, including awareness and beliefs of families and patient-related factors.
5.6 Factors related to care providers
These factors fall into three subcategories: care providers' personal characteristics, concerns, and capacities. According to some experts, care providers' personal characteristics (spirituality, materialism, self-esteem, and professional commitment) influence their ethical behaviors.57, 94 The results of a study by Dehghani et al. showed that internal factors include personality and personal responsibility includes positive energy in communicating with others, self-control, and communication challenges in interactions between doctors and nurses, among the personnel, and between nurses and patients.67
Some care providers believe that care providers' self-esteem influences their ethical behavior. It appears that new graduate care providers may neglect certain of their ethical duties, including pointing out doctors' errors, due to low self-esteem. Another factor which can affect care providers' professional behaviors is their concerns, which include financial difficulties, family issues, and job dissatisfaction.57
Such personal factors as values, beliefs, experience, knowledge, and skills, and such underlying factors as ethical awareness can influence healthcare providers' ethical decisions and behaviors.95-97 When nurses' dignity is neglected or abused, their self-respect may be undermined and their ability to respect patients and their families diminishes.63
According to a study by Hordern (2016), the religion and culture of the medical personnel play a crucial part in improving their professional performance and behavior.88 In their study conducted in Iran, Borhani et al. (2016) reported that personal and spiritual characteristics, education, mutual understanding, internal and external control, and experience of an unethical act are influential factors in the ethical sensitivity of nurses.66
Another contributing factor in ethical behavior is competence. One study lists the following as some of the aspects of care providers' competence which determine their observance of professional ethics: personality, values, lack of ethical knowledge, lack of sensitivity to patient rights, dissatisfaction with working conditions, and limited authority at work.94 Lack of ethical knowledge, skill and experience adversely affects care providers' ethical behavior.57
Killen's study (2002) showed that the variables of motivation and personality correlate significantly with perioperative nurses' ethical behavior.98 Having a negative attitude toward patients' family caregiversis another major ethical issue among nurses, especially pediatric nurses, indicating that pediatric nurses' ethical behavior is adversely affected by their negative attitude toward family caregivers.99
Significant differences in healthcare provider's empathy have been attributed to differences in their personal demographic characteristics, namely gender, experience, and field of practice.58, 100, 101 It has been found that female care providers are more empathetic toward patients than male care providers.51, 58, 90, 102-104 However, Venkatesh (2020) reported that, compared to women, men perform better in certain ethical areas, including mental health, chronic pain, and cancer.92
Some studies found that males are more likely to act unethically or regard dubious behavior as ethical.105, 106 However, the studies by Dalvand et al. (2017) and Hakimi (2020) showed that an increase in nurses' age correlates with a decrease in their respect for patient autonomy.103, 104 On the other hand, in a study by Borhani et al. (2021), gender, marital status, education level, and position were influential in nurses' ethical judgment and behavior.102
In a study by Taheri et al. (2015), nurses were found to hold the view that, among personal factors, critical thinking or the ability to make the right decision and judgment in the face of challenging ethical issues is the most important facilitator in observance of professional ethics in nursing.91
5.7 Factors related to patients and their families
factors related to patients and their families fall into two categories: patient family-related factors, including family awareness and families' views, beliefs, and attitudes and patient-related factors.57 Diversity of culture, ethnicity, and the existence of different dialects between patients and the medical staff can create a barrier to an efficient communication that made patients feel undignified.23
Some families are not aware of their rights. Families are not familiar with clinical procedures and think that what is provided is what there should be. Some families only care about outcomes and methods of treatment do not matter to them. For example, when a child cries, some parents ask the care provider not to end the therapy session and some parents even allow therapists to punish their child.57 Patients' companions' awareness of nurses' duties and their reasonable expectations of the nursing staff can make a major contribution to ethical behavior and observance of ethical principles by nurses and other care providers.92 In addition, patients’ characteristics have an impact on nurses' ethical decision-making.95 Difficult patients are dependent, demanding, unreasonable, unadaptable, passive-aggressive, stubborn, and antisocial individuals who may display a combination of traits and behaviors and demand unacceptable amounts of commitment and time from their doctors and other caregivers, which will adversely affect care providers' ethical behaviors. Research shows that care providers' responses vary according to feelings expressed by patients.107-109 According to Hsu et al. (2012), expression of annoyance and tension by patients' families can generate empathetic reactions by care providers to angry or untrusting patients' responses to doctors.106 Hojat et al. found that medical students were less empathetic to patients who were difficult, hostile, rude, or ungrateful.70 In addition, Lawless (2009) reported that when nurses' dignity is not maintained by patients or their companions, nurses feel less inclined to respect patients and the consequences of tension at work have a direct impact on nurses' treatment of patients.63 The Figure 2 shows the influential factors in ethical treatment of patients in clinical environments.
6 DISCUSSION
In the present study, to answer the research question, the researchers conducted a review of literature on barriers to ethical treatment of patients in healthcare systems. The majority of the available studies concern students' and nurses' perceptions and care providers' experiences of ethical behaviors and associated factors. The present study addressed the barriers to ethical behavior in clinical environments. The first category of barriers consisted of organizational factors, indicating that professional ethics are not restricted to internal factors. Such external factors as instructors, managers, other care providers, education, and culture can contribute to the ethical growth of healthcare teams. Acquisition of professional ethics can be facilitated by a combination of internal and external factors. These factors promote respect for norms and regulations in nurses' professional behaviors in their relationships with patients. Furthermore, effective communication between the members of healthcare teams, improvement to organizational pre-conditions, effective support systems, and educational and cultural development can elevate adherence to professional ethics in clinical practice.67 Studies conducted in different clinical environments have shown that there are many differences in the ethical issues which the personnel encounter and that social, cultural, and economic factors have an impact on these issues.110, 111
An extensive review of the literature revealed that a combination of internal and external personal and organizational factors facilitates or impede ethical behavior by healthcare providers in clinical environments. Ethical climate reflects ethical values and behavioral expectations. People's attitude toward religion is both an intrinsic and an adventitious attribute. One practical strategy to reintroduce religion into nursing ethics is establishment of ethical codes and theories which reflect the effect of religion on nursing activities.112 Strong religious beliefs in nurses which encourage their adherence to their professional and human responsibilities can increase compliance with professional ethics.92 Though time may not be important by itself, ethical behaviors require time: more time increases opportunities for more positive behaviors.85
The second category of barriers to ethical treatment of patients concerns personal factors related to patients and their families and healthcare providers. Healthcare providers differ in terms of both their cultural attitudes and interaction. There are also differences between patients in nationality and culture. Therefore, the education of healthcare professionals should focus on nonverbal communication skills to enable care providers to respect cultural differences between patients. Organizational education and support are not enough without proper modeling.57
Some nurses are indifferent to the ethical aspects of clinical care and do not make an effort to provide ethical care. Frustration is an external factor which adversely affects nurses' ethical performance. Work overload can normalize unethical behaviors for nurses who will try to soothe their conscience by justifying their acts.104 Abbaszadeh et al. stress that students who are willing to enter nursing programs should be evaluated in terms of their metacognitive characteristics, for example, personality, to ascertain whether they are compatible with the nursing profession.113
As nurses' personalities have an impact on their ethical sensitivity or behavior, it is essential that nurses' personality traits should be evaluated as well.114 Finally, the results of the present systematic review showed that a considerable number of studies have reported that female healthcare providers are more empathetic to patients than male ones. This finding can be used in a highly selective way.
Healthcare providers should make an effort to eliminate unethical behaviors in their workplace. This important task should be initiated by the managers and leaders of healthcare teams in clinical environments and sustained by healthcare system.115 Prevention of unethical treatment of patients in clinical environments requires not only commitment from healthcare teams, but dissemination of a professional culture in the system.10 Respect for professional ethics can create a safe environment for treating and caring for patients and pave the way for the psychological and social growth of the healthcare team.115
7 LIMITATIONS
One of the limitations of the study is that only a few studies were found which explored ethics in different groups of healthcare professionals, especially doctors; therefore, many of the studies which were ultimately selected to be reviewed were related to nursing and nurses’ behaviors.
8 SUGGESTIONS
As patients and family caregivers have high expectations of healthcare professionals with regard to ethical behavior, there is a need for more research into patients' experiences of observance of professional ethics by all the members of healthcare teams, as well as experimental literature in this area. Recent research shows that healthcare providers' ethical treatment of patients is partly a function of the intrinsic characteristics of the members of healthcare teams. Accordingly, in addition to employing new learning approaches to promote ethics and ethical behaviors in healthcare systems, authorities should evaluate the intrinsic characteristics of candidates for medical and related professions at the beginning of their education.
With regard to improving organizational culture, organizational guidelines and protocols and clear governmental policies about providing care to patients can help prevent unethical behaviors by care providers in clinical environments. In addition, affinities between healthcare providers and managers and promotion of interdisciplinary collaboration and professional solidarity can help eliminate ethical challenges and barriers. Educating care providers about ethics can improve their perception of providing care to inpatients, resulting in better clinical performance. Revising the educational content and inclusion of subjects on professional ethics in academic environments and continuing training of the members of healthcare teams can enhance care providers' knowledge and awareness. By identifying barriers and applying the suggested solutions, managers can promote professional ethics and improve the quality of healthcare provided to inpatients.
9 CONCLUSION
Barriers to ethical behaviors in clinical environments fall into two categories: organizational factors (management, environment, and human resources), personal factors (items related to patients and their families (awareness and perceptions of families and issues related to patients) and items related to caregivers.
Identification of factors and investing in improving care providers' ethical competence are the ways to increase the quality of healthcare services. Thus, the promotion of ethics in professional performance should not be regarded as a secondary policy because it is essential to professional improvement and better services. The promotion of ethical behaviors through education and persistent observance of ethics in clinical practice will not completely bridge the gap between theory and practice: it seems that clinical environments and organizational values in healthcare systems are the greatest facilitators or inhibitors in bridging this gap. Thus, measures should be taken to improve organizational culture.
AUTHOR CONTRIBUTIONS
Fatemeh Ghani Dehkordi: Conceptualization; writing–original draft; investigation; resources. Camellia Torabizadeh: Conceptualization; writing–original draft; supervision; validation. Mahnaz Rakhshan: Data curation; investigation; writing–review and editing. Fatemeh Vizeshfar: Formal analysis; methodology; visualization.
ACKNOWLEDGMENTS
The authors have nothing to report.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ETHICS STATEMENT
The study was approved by the Ethics Committee of Shiraz University of Medical Sciences and assigned the ethical number IR. SUMS. REC.1399.1318.
TRANSPARENCY STATEMENT
The lead author Camellia Torabizadeh affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
