# Perception of the Ethical Climate Among Hospital Employees in a Public Healthcare System: A Qualitative Study at the University Hospital of Split, Croatia

## TL;DR

This study explores how hospital employees in Croatia perceive the ethical climate at their workplace and how it affects their daily decisions and challenges.

## Contribution

The study provides new insights into how ethical climates are shaped by professional values and informal norms rather than institutional rules.

## Key findings

- The ethical climate is primarily influenced by healthcare professionals' shared values and informal norms.
- Nurses face significant ethical dilemmas due to perceived subordination and patient pressures.
- Institutional leadership is seen as underutilizing tools to support ethical behavior and address misconduct.

## Abstract

Background/Objectives: The ethical climate in a healthcare institution encompasses the shared perceptions of how ethical issues are managed in everyday practice. Our prior survey at the University Hospital of Split, Croatia, showed a simultaneous predominance of the “Rules” and “Laws and professional codes” ethical climates. Building on these findings, we explored how these climates manifest in everyday practice, how they align with staff values and guide their ethical decision-making, and how they are shaped by external factors. Methods: We conducted seven focus groups with 31 participants: nurses, residents, specialists, and members of the Hospital Ethics Committee (HEC). We identified patterns in the data using Graneheim and Lundman’s qualitative content analysis. Results: Three themes emerged from our analysis. We observed that the ethical climate was shaped predominantly by healthcare professionals themselves based on shared professional values and informal norms, rather than explicit institutional rules. Nurses, positioned as frontline workers, felt particularly exposed to ethical dilemmas, reporting perceived subordination to physicians, increased pressures from patients, and vulnerability in ethically ambiguous situations. The participants generally believed that institutional leadership insufficiently utilised existing tools, bodies, and mechanisms to support ethical behaviour and sanction misdemeanors, resulting in gaps in human resource management, a lack of practical protocols, and a weak HEC. Conclusions: To strengthen the ethical climate, institutional leadership should provide clear and practical guidelines, effectively utilise regulating bodies and support services, establish dedicated mechanisms to support nurses, and consistently enforce sanctions for unethical behaviour.