Psychometric properties of instruments measuring ethical climate among healthcare professionals in care settings pre-pandemic: a systematic review.

Background: The ethical climate in healthcare is part of the work environment and a basis for professional nursing practice. The ethical climate is crucial as it is closely associated with staff job satisfaction, the quality-of-care provision, and nurses' intention to stay in their current occupation and position. Even though several instruments assessing ethical climate in healthcare have been developed over the years, their psychometric properties have not been systematically reviewed.

Objectives: This study was conducted to identify and critically appraise the psychometric properties of instruments used to measure the ethical climate among healthcare professionals in care settings prior to the COVID-19 pandemic.

Methods: A systematic review was performed, covering papers published between 1994 and 2019, excluding grey literature sources. The literature search was performed in October 2019 in Cinahl, PsychINFO, PubMed, and SocIndex. Empirical studies were included describing the psychometric properties of instruments measuring the ethical climate among healthcare professionals in healthcare settings. Data on psychometric properties were extracted and a quality assessment was performed following the quality criteria for measurement properties proposed by Terwee et al. criteria 2007.

Result: Our search yielded 15,150 publications. After title and abstract screening, 611 studies were retained for full-text analysis, of which eight studies describing five instruments were included (five instrument development studies and three translation studies). Four studies concerned the Hospital Environment Climate Scale (HECS). All instruments had been assessed for content validity and internal consistency. Information concerning criterion validity, construct validity, and reproducibility was lacking or intermediate. No information concerning floor/ceiling effect or interpretability was reported in most cases. One study reported having performed a test-retest analysis. None of the included studies fulfilled all the Terwee et al. criteria.

Conclusion: Five instruments were identified as having undergone psychometric testing; however, none fulfilled all the criteria outlined by Terwee et al. Also, only one of the instruments had been subjected to the well-established test-retest analysis. This highlights a need for further well-structured validation studies of instruments assessing the ethical climate among healthcare professionals in care settings.