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Effect of Ethical Leadership on Moral Sensitivity in Chinese Nurses

A Multilevel Structural Equation Model

Zhang, Na PhD; Bu, Xing MBA; Xu, Zhen PhD; Gong, Zhenxing PhD; Gilal, Faheem Gul PhD

Author Information
doi: 10.1097/ANS.0000000000000357
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WORLDWIDE advanced scientific and technological developments in the health care field have increased the complexity of health service provision, and the increasing demands for care coupled with the inherent shortages of resources have raised various challenges and ethical problems.1 In China, along with changes in the rapport between nurses and patients and the severe shortage of nurses, nurses who have been under high workload and pressure for a long time experience a sense of moral numbness to the clinical ethical dilemma.2 Being aware of ethical issues in the clinical setting is the first step in successfully making and implementing ethical decisions.3,4 If one fails to recognize the ethical aspects in the environment, they are unaware of its existence; therefore, any ethical issues cannot be resolved in such a situation.5,6

In the process of ethical decision-making, moral sensitivity is defined as an “attention to the ethical values involved in a conflict-laden situation and a self-awareness of one's own role and responsibility in a situation,”7 it enables nurses to recognize the ethical nature of every practice action, and then they will be able to make the ethically appropriate decision.8 Specifically, moral sensitivity helps determine relative importance of different ethical issues for any given situation, promote contextual and intuitive understanding of the patient's vulnerability, and derive insight into the ethical consequences of any decision made on behalf of the patient.9 Thus, development of moral sensitivity creates an attitude and ethical response in nurses,10 which enables providing effective and ethical care for patients.3 In this sense, moral sensitivity is the core of nursing ethics and also a prerequisite for ethical nursing practice.

Existing research on nurses' moral sensitivity focuses on the individual influence factors, such as gender, age, spiritual values, culture, religion, education, and life experience.11,12 Although one of the most important issues in ethical decision-making is a morally sensitive environment, few studies have investigated the factors within the work environment that can affect a nurse's moral sensitivity.13 It has been suggested that nurses' individual perception of their work environment can influence the identification of ethical issues and their subsequent actions to resolve them.14 For several decades, the ethical climate has traditionally been conceptualized as “the shared perceptions of what ethically correct behavior is and how ethical issues should be handled.”15,16 In the field of nursing, the ethical climate was defined as the nurses' perceptions of how ethical concerns were handled in their work environment.17 The ethical climate of a workplace not only influenced the recognition of an ethical problem, but also established the ethical code that employees followed to process and rectify these types of problems.18,19 From this point, ethical climate is perceived as an organizational variable that can be manipulated to improve the health care environment11 and provide the context for nurses' ethical decision-making. For example, Silén et al20 found that a positive ethical climate included successfully addressing the requirements of patients and their family members, sharing support and data among the team of caregivers, and exercising clear standards of workplace conduct. The results of a study by VanSandt et al21 indicated that the ethical climate in the workplace is a primary predictor of individual moral consciousness.

Brown et al22 conceptualized ethical leadership as “the demonstration of normatively appropriate conduct through personal actions and interpersonal relationships, and the promotion of such conduct to followers through 2-way communication, reinforcement, and decision-making.” In this regard, ethical leaders set high ethical standards and use positive and negative incentives to affect the ethical behavior of their followers.22,23 For example, nurses demonstrate sincere promise and practice to ethical behavior on a daily basis at work, which can serve as a model for other nurses. It is the responsibility of the management-level staff, including matrons, supervisors, and head nurses, to guide their employees' actions and facilitate a balance between administrative duties and the principles of nursing practice.24 Ethical leaders can lead by example to develop a workplace environment where people expect and value doing the proper things. In fact, Shin25 found that ethical leadership is a critical precursor to a positive ethical climate. Hence, ethical climate is considered to be an adaptable factor at the organizational level that can improve the health care environment11,26 and offer the framework for implementing ethical choices.11 As a result, ethical leadership and the ethical climate are hypothesized to have the following influences in a professional setting:

  • H1: Ethical leadership positively relates to the ethical climate in the workplace.
  • H2: Ethical leadership in the workplace positively relates to nurses' moral sensitivity.
  • H3: The ethical climate in the workplace positively correlates to nurses' moral sensitivity.
  • H4: Ethical leadership will have an indirect effect on nurses' moral sensitivity through the ethical climate in the workplace.

At present, the scarcity of nursing staff is becoming a worldwide challenge for health institutions, clinicians, and nursing researchers.27 This trend cannot improve until corrective measures are put in place.28 To address the serious problem of talent shortage, most Chinese public hospitals have implemented the “dual-track system” employment, which provides 2 main types of employment for nurses: contract-based work and state-based work. Nurses employed by the state are regular employees who are paid by the state, while a contract-based nurse signs work contracts with each hospital that pays salaries. Furthermore, state-based nurses are permanent employees of the hospital, which was the dominant mode of employment prior to the health care reforms since the 1980s in China. However, since the mid-1990s, contract-based work has become an increasingly popular form of employment adopted by hospitals.29 As each public hospital is given a quota of the number of nurses it can employ, the extensive use of contract nurses is a mechanism to overcome the constraint of quotas of permanent nurses set by the health authority.29

In general, contract-based nurses are usually new graduates with nursing certificate or diploma qualifications, who are less well qualified, young, and inexperienced.29 Nursing graduates with master's degrees could become state-based nurses directly. However, for the vast majority nurses of undergraduate and junior college, only when they make important contributions to the country and society, they may have the opportunity to become state-based nurses. To gain their first job and get on the career ladder, most nurses accept this type of employment contract and are willing to withstand the demanding working conditions. However, if contract-based nurses are deemed unproductive or unsuitable, hospitals are rather ruthless in dismissing them.

All qualified nurses, whether state-based or contract-based, share the same type of work and responsibility disregarding their seniority, grades, and educational qualifications, and can get promotion in their clinical grade by passing the national examinations. Besides, all the nurses can get promotion in positions based on their experience, knowledge, and performance. Head nurses can be either state-employed or contract-employed, who retain certain responsibilities and power in the employment, performance evaluation, and retention of general contract nurses. However, there is still a growing gap between these 2 groups of nurses in terms of economic security, political rights, and social recognition even in the same organization.30,31

The Nurses Regulation effected by the Central Government of China in 2008 states that contract-based and state-based nurses should have identical salaries and benefits; however, this is not actually the case. An independent study found that the pay and benefits of contract-employed nurses are much lower than those of state-employed nurses working in the same department of the same hospital.32 A second study confirmed that state-employed nurses enjoy much higher pay, a better benefits package, and lifetime job security.33 What is more, in some hospitals, a contract-based nurse earns about only half of the bonuses of a state-based nurse.2 Therefore, the double-track employment system led to nurses being treated differently in the workplace and lowered contract-employed nurses' perception of workplace justice. As Wang et al34 pointed out: “... employees' perceptions of organizational justice can influence their emotions, attitudes, and behaviors in the workplace.” This means that the contract-based nurses and the state-based nurses may show different moral sensitivities even if they work in the same unit. Based on this, the following conclusion is entirely reasonable that the category of employment held by a nurse within the dual-track system could affect the relationship between their workplace environment and the nurse's moral sensitivity. Accordingly, we predict that:

  • H5: The effect of the ethical climate in the workplace on nurses' moral sensitivity is moderated by their employment type.

In sum, Our H4 is a hypothesis that proposes that ethical climate can facilitate the relationship between ethical leadership and the moral sensitivity of nurses. H5 suggests that nurses' employment type affects the relationship between the ethical climate and the nurse's moral sensitivity. Thus, we hypothesize that:

  • H6: Nurses' employment type moderates the mediating effect of ethical leadership on moral sensitivity.

According to the literature reviewed above, there is an apparent complexity of the relationships between organizational ethical leadership, organizational ethical climate, nurses' moral sensitivity, and their employment type. This study aims to address these issues. Taking the organizational ethical climate as the mediating variable and the nurse's employment type as the moderating variable, this study constructs a multilevel moderated mediation model to study the relationship between organizational ethical leadership and nurses' moral sensitivity. A brief overview of the proposed model is in Figure 1.

Figure 1.
Figure 1.:
Proposed model.

Statement of Significance

What is known or assumed to be true about this topic?

Moral sensitivity is the core of nursing ethics and a prerequisite for nurses' ethical decision-making. Although nurses' individual perception of their work environment can influence the identification of ethical issues and their subsequent actions to resolve them, the empirical knowledge of ethical work environment in enhancing nurses' moral sensitivity in China is limited. A more thorough understanding of factors, both in organizational and individual levels, that influence nurses' moral sensitivity is needed. Additionally, in public hospitals in China, there are 2 employment types of nurses: contract-employed and state-employed. Because of the discriminative practices in recruitment and dismissal/retirement, nurses' employment type may moderate the effect of the work environment on their moral sensitivity.

What this article adds:

This study explores the relationship between ethical leadership (a contextual factor at higher organizational level) and nurses' moral sensitivity (the individual outcome at a lower level), and furthermore examines the mediating effect of organizational ethical climate and the moderating effect of nurses' employment type. The results indicate that the link between ethical climate and moral sensitivity of contract nurses was stronger than that of nurses employed by the state. This study provides useful information about the effects of ethical work environment on nurses' moral sensitivity. Health care institutions should select and educate ethical leaders to foster an ethical climate and increase moral sensitivity of nurses, especially to implement new workforce management strategies to reduce the contract-employed nurses' perceptions of job insecurity.



Based on quantitative design and investigation, this study adopts a random and convenience sampling design. A comprehensive and advanced hospital, which provides high-quality services and crosses regional high-level education and research, can be qualified as a tertiary hospital in China.35 The researchers selected the top 3 largest cities in Hebei Province, and from each city, one tertiary hospital was randomly selected, where all participants were clinical nurses who were randomly selected in 3 shifts: morning, evening, and night shifts.

Ethical considerations

The research design was approved by the biomedical research ethics committee of the Medical College of Hebei Engineering University. Prior to data collection, subjects signed informed consent to participate in this study. Only the results of the study were reported in aggregate rather than reporting the identity of the subjects. Moreover, the raw data were destroyed after the data analysis process was completed, which ensured the privacy and confidentiality of the data. Participants were advised that participation in this study (including completing the questionnaire) was not mandatory and that they could stop participating at any time and for any reason. Not only would their employment be adversely affected, but the data would be kept strictly confidential.

Data collection

The third author distributed questionnaires in person to these nurses in the duration of June and July in 2017. After the researcher introduced the purpose, risks, and benefits of the study, the participants read and signed a consent form indicating that their participation was voluntary and guaranteeing the anonymity of their responses. With the permission of the head nurse, all nurses in the sample completed the questionnaire during their working hours. Respondents were acquainted with the fact that the purpose of the survey was to have a better understanding of the nurses and providing the name of their department was voluntary, and that the results had nothing to do with their career development. After signing and returning the consent form, each nurse was presented with the survey instrument, which contained information about demographics, ethical leadership of their immediate supervisor, the ethical climate of their hospital departments, and their own ethical sensitivities. Dedicated letterboxes were set up in each hospital to collect completed questionnaires. At last, the completed questionnaires were collected by the third author. A total of 600 questionnaires were distributed, 572 nurses consented to participate, 548 nurses turned in the questionnaires, and 525 valid questionnaires were returned finally, with a response rate of 87.5 %.


In this survey, each of the questionnaire responses was scored on a Likert-type scale, where 1 means strongly disagree and 5 equates to strongly agree. To measure ethical leadership, our study utilized the Ethical Leadership Scale (10 items), which was developed and validated by Brown et al,22 where higher scores imply better leadership. The ethical leadership scale has been widely applied among Chinese nurses.36,37 We used the 24-question Ethical Climate Questionnaire (ECQ) from Victor and Cullen,16 where the higher the mean score, the more positive the respondent's perception of their workplace's ethical climate. The ECQ has been extensively used across occupational populations in China.38–40 The Moral Sensitivity Questionnaire (MSQ) comprised 9 questions adapted from the study of Lützén et al7 and encompassed 3 subtopics under moral sensitivity: moral burden, moral strength, and moral responsibility. Employment type was set as the moderator variable and was scored as 1 (state-employed) or 2 (contract-employed). The MSQ has been used among Chinese medical personnel.4,9,37 In addition, the demographic variables included gender, age, education, experience in nursing, professional title, position, employment type, and hospital.

Data analysis

Mplus 7.4 statistical software packages were utilized for data analysis. We initially presented the means, standard deviations (SD), and correlation values among these variables. Subsequently, we adopted the 2-step analysis strategy that is put forward by Anderson and Gerbing41 to test the moderated mediation effect. First, we conducted a confirmatory factor analysis (CFA) to test the measurement model. Then, we tested the hypothesized structural model using multilevel structural equation modeling (MSEM)41 with Mplus 7.4.

Validity and reliability

First, all survey items were translated from English to Chinese using accepted translation/back-translation techniques.42 Second, we modified the scales by referring to the Chinese version scales, which were used across occupational populations in China as described in the previous section. Finally, to ensure the accuracy and readability of all the items, we recruited a few of experts from clinical nursing in China and conducted 2 rounds of expert consultation by email. Then, we revised the items according to the experts' comments and got the final version of scales.

Each individual's ratings of ethical leadership and ethical climate in their workplace were combined for further analysis at the organizational level. To warrant this aggregation, we computed 3 statistical measures for the variables of ethical leadership and ethical climate: rwg to assess data within-group agreement, ICC(1) to determine the intraclass correlation, and ICC(2) to evaluate the reliability of the means at the organizational level.43,44 Specifically, rwg assesses the consensus among raters within a single unit for a single variable, ICC(1) estimates interrater reliability or the amount of variance in individual-level responses that can be explained by group-level properties, whereas ICC(2) evaluates the internal consistency reliability of the group means in a sample.45 Thus, although all 3 indices measure group-level properties of data, ICCs are omnibus measures that apply across all groups, whereas the rwg coefficient applies only to single groups.

In our research, the ethical leadership ratings provided by the nurses within a single department were averaged to generate an overall value for ethical leadership of that department. Averaged rwg indicated strong average within-group agreement for ethical leadership (0.978), which was higher than the generally acceptable value of 0.7046; the ICC(1) statistic was 0.199, and the ICC(2) statistic was 0.938, which were higher than the acceptable value of 0.05 and 0.70, respectively.45 These statistical measures indicated that the scores of ethical leadership in the workplace showed acceptable levels of intradepartmental consistency and interdepartmental variability. Similar to the analysis procedure for ethical leadership, the direct consensus composition approach47 was used to assess the ethical climate within each department (with aggregated scores from individual nurses). The values of the ethical climate in the workplace showed satisfactory levels of intradepartmental consistency and interdepartmental variability (rwg = 0.972, ICC(1) = 0.198, and ICC(2) = 0.942).

Additionally, reliability was determined by internal consistency using Cronbach's α coefficient, and α coefficients more than 0.70 indicate acceptable reliability.48 In this study, Cronbach's α for ethical leadership was 0.933, for the ECQ was 0.783, and for the MSQ was 0.798, which all exceeded the acceptable values.

Results of CFA can provide compelling evidence of the convergent and discriminant validity of theoretical constructs. It is also a popular statistical method for providing support of construct validation in the psychological assessment literature49 and social and behavioral sciences.50 Therefore, CFA was conducted to assess the model fit. To evaluate the goodness of fit of the structural equation model, we examined 5 indices: (1) χ2/df score, with a recommended threshold of less than 551; (2) goodness-of-fit index (GFI); (3) incremental fit index (IFI); (4) comparative fit index (CFI); and (5) root mean square error of approximation (RMSEA). A reasonable model fit is indicated when the GFI, IFI, and CFI are above 0.90 and the RMSEA is below 0.08.52 According to common reporting procedures,53 for testing the discrimination validity of the CFA, the study compared one 3-factor model with three 2-factor models (2-factor models 1, 2, and 3) and one 1-factor model. The results showed that the 3-factor model fit the data better than other nested models (χ2/df = 2.655, GFI = 0.938, IFI = 0.959, CFI = 0.959, RMSEA = 0.056) (see Table 1), indicating that the 3 variables (ethical leadership, ethical climate, and moral sensitivity) showed good discriminating validity. In summary, a series of CFAs results suggested that the respondents could clearly distinguish the constructs under study. The model-fitting result also suggested that the methodological bias commonly inherent to survey-response data was not present in our study.

Table 1. - Model Fit Statistics for Confirmatory Factor Analysisa
Fit Index χ2 χ2/df GFI IFI CFI RMSEA △χ2
3-factor model:EL, EC, MS 292.015 2.655 0.938 0.959 0.959 0.056
2-factor model 1:EL+ MS, EC 712.656 6.039 0.861 0.866 0.866 0.098 420.641b
2-factor model 2:EL+ EC, MS 824.396 6.986 0.841 0.841 0.840 0.107 532.381b
2-factor model 3:EL, EC + MS 695.164 5.891 0.863 0.870 0.870 0.097 403.149b
1-factor model:EL + EC + MS 869.298 7.305 0.832 0.831 0.830 0.110 577.283b
Abbreviations: CFI, comparative fit index; EC, ethical climate; EL, ethical leadership; GFI, goodness-of-fix index; IFI, incremental fit index; MS, moral sensitivity; RMSEA, root mean square error of approximation.
a+ means 2 factors combined as 1 factor; △χ2 was compared to the 3-factor model.
bP < .001.


Study participants

The study participants comprised 600 nurses from 83 different departments of 3 tertiary hospitals (>500 beds each) in Hebei Province. After excluding all of the surveys with missing values and departments with fewer than 3 participants, the operational sample size was 525 nurses from 65 departments. Specifically, there were 91 nurses from 16 departments in hospital 1, 75 nurses from 9 departments in hospital 2, and 359 nurses from 40 departments in hospital 3. The number of the sample in a department ranged from 3 to 18 in all the hospitals, and the average number of participants from each department was 8. The demographic distribution of the study cohort was heavily weighted toward young, educated, and women; 96.2% of participants were female, 94.3% were younger than 40 years, and 40.5% had a bachelor's degree or above. The nursing experience of 80% of the subjects was under 10 years. Almost all (93.9%) of the respondents were general nurses, and the remaining 6.1% were unit managers (ie, head nurses). Additionally, 82% were contract nurses.

The demographic characteristics of the sample and comparisons of moral sensitivity are displayed in Table 2. Of these subjects, gender, age, experience in nursing, educational level, professional title, position, and employment type were not significantly related to the level of moral sensitivity. In terms of hospital the subjects were from, nurses from hospital 1 (91, 17.3%) had significantly higher level of moral sensitivity (F = 3.48, P < .05) than participants from hospital 2 (75, 14.3%) and hospital 3 (359, 68.4%).

Table 2. - Demographic Characteristics of the Sample (n = 525) and Comparisons of Moral Sensitivity
Demographics n (%) Moral Sensitivity
Mean ± SD F/t P
Gender 0.120 .730
Female 505 (96.2) 3.95 ± 0.44
Male 20 (3.8) 4.27 ± 0.42
Experience in nursing, y 1.246 .290
≤5 286 (54.5) 3.95 ± 0.46
6-10 134 (25.5) 3.94 ± 0.36
11-15 61 (11.6) 4.06 ± 0.41
16-20 17 (3.2) 4.04 ± 0.54
>20 27 (5.1) 4.04 ± 0.40
Age 1.842 .138
≤20 13 (2.5) 4.23 ± 0.43
21-30 368 (70.1) 3.95 ± 0.44
31-40 114 (21.7) 3.96 ± 0.41
>40 30 (5.7) 4.01 ± 0.38
Education level 1.706 .165
Certificate (technical school) 13 (2.5) 4.21 ± 0.36
Junior college 299 (57.0) 3.95 ± 0.45
Bachelor's degree 212 (40.4) 3.97 ± 0.40
Master's degree or above 1 (0.2) 3.67
Professional title 1.077 .366
Primary nurse 235 (44.8) 3.98 ± 0.44
Junior nurse 222 (42.3) 3.94 ± 0.45
Senior nurse 68 (13) 4.01 ± 0.37
Position 1.698 .193
General nurse 493 (93.9) 3.96 ± 0.44
Unit manager 32 (6.1) 4.06 ± 0.40
Employment type 0.211 .646
State-employed 93 (17.7) 3.99 ± 0.43
Contract-employed 432 (82.3) 3.96 ± 0.44
Hospital 3.480 .032
Hospital 1 91 (17.3) 4.07 ± 0.43
Hospital 2 75 (14.3) 3.91 ± 0.44
Hospital 3 359 (68.4) 3.97 ± 0.43

Descriptive statistics

Table 3 details the means, standard deviations, and intervariable correlations at the individual and organizational levels.

Table 3. - Means, Standard Deviations, and Correlations of Study Variables
Variables Mean SD 1 2 3 4 5 6
Individual level (n = 525)
1. Gender 0.04 0.192
2. Experience in nursing 1.79 1.101 −0.080
3. Age 2.31 0.614 −0.083 0.840a
4. Employment type 1.87 0.451 0.037 −0.652a −0.651a
5. Moral sensitivity 3.966 0.434 0.138a 0.078 −0.006 0.051
Departmental level (n = 65)
6. Ethical leadership 4.452 0.293
7. Ethical climate 3.513 0.209 0.246a
aP < .01 (2-tailed).

Hypothesis test

As data from each nurse were aggregated to assess the variables at the organizational level (individual-level data nested within groups), we ran a null-hypothesis model that did not involve any predictor variables to examine our multilevel model.54 This model determined whether a systematic between-group variance is in the nurses' moral sensitivity. The significant chi-square values were χ2(64) = 190.014, P < .001, τ00 = 0.038, σ2 = 0.153, ICC(1) = 0.199. An ICC(1) value above 0.05 suggested that the individual-level data had a systematic variance among groups, thereby justifying the multilevel analyses.55

We selected the syntax of Mplus statistical software introduced by Preacher et al56 to test our hypothesis, which uses the principle of path analysis to test the conditional indirect effect. Due to the nested nature of multilevel data, we take advantage of Mplus multilevel function “[taking] into account stratification, nonindependence of observations, and/or unequal probability of selection,”57 which allows us to control the nonindependence of nested data.

All of the path coefficients of the MSEM and the analyzed results of hypothesis testing are summarized in Table 4. As the P values between .05 and .1 are interpreted as marginally significant, which appears common in organizational psychology,58,59 we use P < .1 as the threshold of statistical significance in this research. From these paths and the results of hypothesis testing, organizational-level ethical leadership is a marginally significant affecting factor of ethical climate (β = .175, P < .1), whereas ethical climate had a significantly positive impact on nurses' moral sensitivity (β = .480, P < .05). However, the coefficient of the direct path from ethical leadership to nurses' moral sensitivity, in the absence of mediator, was found to be insignificant (β = .120, P > .1). Thus, H1 was only marginally supported and H3 was well supported, but H2 was rejected. We subsequently tested the indirect effect of ethical leadership in the workplace on nurses' moral sensitivity through organizational-level ethical climate, which was marginally significant (β = .084, P < .1).

Table 4. - Standardized Path Coefficients
Hypothesis Estimate (90% CI) P Remarks
H1 Ethical leadership → ethical climate .175 (.010, .340) <.1 Supported
H2 Ethical leadership → moral sensitivity .120 (−.060, .299) >.1 Not Supported
H3 Ethical climate → moral sensitivity .480 (.219, .740) <.05 Supported
H4 Ethical leadership → ethical climate→ moral sensitivity .084 (.004, .164) <.1 Supported
H5 Ethical climate × employment type → moral sensitivity .513 (.268, .759) <.001 Supported
H6 Ethical leadership → ethical climate × employment types→ moral sensitivity .082 (.003, .161) <.1 Supported
Abbreviation: CI, confidence interval.

Multilevel modeling software currently does not make it easy to estimate even simple indirect effects, and the Monte Carlo method is the only viable method in the multilevel context.60 According to Preacher et al60's research in the context of assessing mediation with multilevel MSEM in Mplus, we constructed the Monte Carlo confidence interval (CI) for indirect effect. We computed the 90% CI based on the distribution of 20 000 simulated indirect effects. The result did not contain zero (.031, .064), suggesting that, in the workplace, ethical leadership indirectly influences the ethical sensitivity of nurses through the ethical climate very significantly, and H4 is well supported.

Moderation was tested following completion of mediation analyses. Hypothesis 5 predicted that the nurse's employment type would moderate the relationship between ethical climate and moral sensitivity. As shown in Table 4, the ethical climate × employment-type interaction to nurses' moral sensitivity was significant (β = .513, P < .001), supporting H5. Figure 2 and a simple slope test show that the relationship between moral climate and moral sensitivity positively correlated and that this relationship is stronger for contract-based nurses than for state-employed ones. The path coefficient of ethical leadership → ethical climate × employment type → nurse's moral sensitivity was marginally significant (β = .082, P < .1). Thus, the data were marginally supportive of H6.

Figure 2.
Figure 2.:
Ethical climate × employment-type interaction for moral sensitivity.


Major research findings

Our evaluation significantly added to the field of nurse management by investigating the impact of organizational ethical leadership and ethical climate on nurses' moral sensitivity. Our multilevel model incorporated the mediating mechanism of ethical climate and the moderating effect of employment type in a single harmonious framework.

Consistent with our hypothesis (hypothesis 1), our results demonstrated that ethical leadership in a workplace positively affected its ethical climate. Therefore, we indicated that those in positions of authority in the workplace have substantial power to establish and enforce ethical standards that engender a superior ethical climate.61 This finding is in agreement with previous reports that suggested that management-level staff should lead by example to establish an ethically sustainable and caring culture in nursing practice.62 These results reinforce that ethical leaders help create an organizational climate in which doing the right thing is expected and valued through role-modeling appropriate behavior. Therefore, such ethical leaders are crucial to shaping the ethical climate of the departments that they supervise.43,61,63

Moral sensitivity involves the nurses' recognition of ethical problems and their desire to resolve those problems with a high moral standard.64 Our results indicated that ethical climate in the workplace resulted in greater moral sensitivity among nurses. In other words, when surrounded by an ethical work environment, nurses tend to have a higher degree to be sensitive to the ethical elements of a given situation. This finding corroborates similar reports from prior studies.21,61,65 It is also in line with Abdou and colleagues13 and Bégat and colleagues,66 who asserted a positive relationship among moral sensitivity and work environment in general clinical settings and in nursing academic institutions.

What is important about our study is that we revealed environmental elements within the workplace that affect the behavior of the individual (higher-level factors that impact lower-level outcomes) and clarified a crucial mediator of ethical leadership's impact on nurses' moral sensitivity. Our data revealed that ethical leadership in the workplace has a significant indirect effect on nurses' moral sensitivity, via ethical climate. In concrete terms, we found that the presence of ethical leaders in the workplace contributed only indirectly, by developing an ethical climate, to increasing nurses' moral sensitivity.67 Zhang and Zhang6 similarly found that a workplace that emphasized the importance of ethical actions could nurture employees that were more sensitive to the ethical aspects of diverse situations.

Although social learning theory suggests that ethical leaders set clear ethical standards through communication and discipline, and thus encourage followers to have ethical attitudes and psychological states and to further engage in ethical decision-making, our cross-level results showed ethical leadership in the workplace did not affect the nurse's moral sensitivity directly. A plausible reason is that, when compared with the moral person's aspect of ethical leadership, the moral manager's aspect has more instrumental influence in followers' ethical behavior by which leaders convey the importance of moral values to the staff, and establish expectations regarding ethical behavior that becomes entrenched in the organization's climate. Thus, organizational ethical climate has more immediate effects on nurses' moral sensitivity than organizational ethical leadership.

Additionally, our MSEM path analysis supported the idea that the nurse's employment type was a moderator between the ethical climate and his/her moral sensitivity, with the ethical climate in the workplace influencing contract-employed nurses more strongly than state-employed nurses. Moreover, the employment type of nurses moderated the mediating effect of the ethical leadership on their moral sensitivity. Based on the job insecurity theory,68 contract-employed nurses who perceived themselves as feeling more insecure in their job will be more morally sensitive in the work context because it is a way of achieving valued goals relating to security, and a way of presenting a self-image that would increase their likelihood of achieving a permanent job. The result was consistent with Feather and Rauter69's study on contract teachers. Conversely, nurses employed by the state have “iron rice bowls” and enjoy the treatment of lifelong employment, which means that as long as they do their job well, they can retain the entitlements and benefits of lifetime employment.70 In this sense, the job insecurity experienced by contract-employed nurses may bring about higher levels of moral sensitivity than in their state-employed colleagues, even if in the same department (same ethical climate).


We acknowledge there are limitations in this study. First, due to the limited sample size of this study, there was a large difference in size between the 2 groups of employment types. Because all Chinese public hospitals have strict national restrictions on the number of employed nurses, more nurses are being hired on a contractual basis to compensate for the acute shortage of medical staff. In some public hospitals, over 50% of the nurses have contract-based employment.29,32 However, according to consultation with hospital and nursing managers, our research cohort was reasonably representative of the nursing team. Second, all the subjects were from tertiary hospitals in the same province, while nurses from secondary, community and rural hospitals, and institutions in other provinces were not included in the study. This limits the generalizability and external applicability of the outcomes, and future studies should confirm the validity of the data in other settings. Third, according to Huang et al,71 hospital ownership could predict hospital employees' perceptions of workplace justice and work attitudes. Therefore, nurses employed by private hospitals should also be included in future studies to compare the influence of hospital ownership on the ethical work environment and nurses' moral sensitivity.

Implications for nursing management

The results of our study would be helpful to hospital administrators to improve moral sensitivity and thereby increase nursing quality in their departments and institutions. Specifically, we highlighted the importance of an ethical climate in the workplace due to its effect of facilitating nurses' moral sensitivity. Therefore, health care institutions should implement programs that cultivate an ethical climate and support their nurses to be more sensitive to the ethical components of clinical issues. Our study also indicated that it is the responsibility of leaders at all levels within an organization to foster an ethical climate and increase the moral sensitivity of nurses; accordingly, hospital departments should specifically select and educate ethical leaders in their institutions. In addition, health care institutions should commit more resources to developing ethical leadership, clearly define and communicate institutional policies regarding ethical expectations and practices, institute a reward system for exceptional ethical practice, and provide safety for reporting unethical practices. Furthermore, we found that nurses employed under contract were affected more than nurses employed by the state in terms of the impact of the ethical climate on the moral sensitivity of nurses. Because the contract-employed nurses' job duration is uncertain and they experience job insecurity, the ethical climate has a stronger effect on the moral sensitivity of contract-employed nurses. However, because of the perceptions of permanent employment and job security, the state-employed nurses often lack the motivation to obey the organizational ethical rules beyond their professional duties. Therefore, the effect of ethical climate on moral sensitivity scores was lower for state-employed nurses than for contract-employed nurses. Therefore, hospital administrators should be fair in terms of distributions, procedures, and interactions to support the well-being of all of their nurses. New workforce management strategies should be developed, which would allow for real wage increases and equal career development opportunities for contract-based nurses.


Our study demonstrated that an ethical climate in the workplace mediated the correlation among ethical leadership and moral sensitivity in nurses. Moreover, the relationship between the ethical climate and the nurse's moral sensitivity was moderated by their employment type. Finally, the association between ethical climate and moral sensitivity is stronger for contract-based nurses than for state-employed nurses. These discoveries significantly contribute to the expanding field of ethics in nursing practice and demonstrated the importance of an ethical work environment for better moral sensitivity in nurses.


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dual-track system; employment type; ethical climate; ethical leadership; moral sensitivity

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