Given the importance of the ethical climate in the operating room and its impact on the ethical and professional competence of employees, it is necessary to develop the educational program by effective strategy. The results of our study showed that the educational effect of the interventions was favorable and the scores of ethical climate improved significantly among the participants in interprofessional education interventions.
Due to the effect of an ethical climate on the quality of services teaching ethical principles in this area can be effective(17, 33). Teaching moral principles through interprofessional strategy are recommended as a way to improve ethical behaviors and consequently the moral climat(22, 29). Teaching methods including small group discussion, case-based learning method, scenario, problem-solving methods for teaching ethical values, and professionalism in the interprofessional approach were recommended(33–37) .As well, the small group discussion using the interprofessional strategy was introduced as a valid teaching method(33). In our study, we benefited from the interprofessional approach in teaching values and interprofessional professionalism. In the present study, interprofessional sessions provided a situation for learners to be familiar with different perspectives of professions, face ethical conflicts, and experience conflict resolution ways in simulation settings. In Hwang's study, he suggested conducting ethical rounds in multidisciplinary teams to create a positive ethical climate (21). In line with the present study, Nadioo et al., in the qualitative study showed the positive impact of ethics education with an interprofessional approach and group discussions (38). Similar to the present study, Manspeaker used a case-based method and an interprofessional approach in the ethics workshop (36).
Interprofessional education provides the situations for interaction in a non-hierarchical environment for ethical accountability and the promotion of ethical performance(25). Through growing ethical competencies, interprofessional education empowers students to perform ethically and safely in clinical settings (25). The results of Silen's qualitative study interprofessional collaboration effectively improve the ethical climate (7). Effective cooperation, sharing of responsibility, and interaction with others are some components of interprofessional professionalism (24). In Silen's study, paying attention to the needs of patients and other colleagues, dividing responsibilities and interacting with other members to solve problems, and attending interprofessional sessions improves moral climate and is a prerequisite for providing safe care (8). The results of the present study showed that training interventions improve people's perception of the ethical climate, which is in line with the results of Silen's study. The findings of Collin's study showed that increased collaboration, shared responsibility, recognition of the roles and responsibilities of other team members in the operating room, and the creation of a safe team environment might be the best way for strengthening interprofessional performance and developing an ethical climate (39). The results showed that teaching ethics could improve the perception of the ethical climate in the operating room by discussing ethical issues with other team members to resolve difficult situations and make ethical decisions about interprofessional care creates a positive ethical climate (40). In line with the results of the present study that showed that educational interventions improve the ethical climate in the operating room.
In the present study, we examined individuals' perceptions of the moral climate in five domains. The results of our study showed that the score of the domain of physicians after the intervention in the intervention group was higher than the control group. In this domain, participation and consultation in treatment decisions, respect for each other's opinions, and trust between operating room staff and physicians are important (3). Participants' self-report scores in the "physicians" domain before the intervention were lower in both groups than in the other domain. Similar to the results mentioned in the study of Hong et al. and in the study of Abdullah Zadeh et al., the "domain of physicians" was reported as unfavorable compared to other domains, while in Jahromi's study, the domain of physicians was reported as desirable from the students' point of view (15, 16, 32). Learners' self-report scores in the "physicians domain" improved significantly after the intervention. The present results can be due to interprofessional education, which improved the learners' view of the ethical climate in this domain. Interprofessional education leads to respectful communication between them in the operating room, increases work efficiency, and thus leads to the proper advancement of surgery (14). Learners' scores in the”physicians” domain improved less than in other domains. The results may be due to the fact that doctors do not trust the ability of operating room technicians. They do not use participatory decision-making skills. The hierarchical view that the physician is the only person who can save the patient can influence the results obtained.
Team leaders play an important role in creating a positive ethical climate (19). In the present study, the scores of the participants in the domain of "managers" before the intervention in the two groups were acceptable compared to other domains. In several studies similar to the present one, the domain of "managers" has a high score (16, 31, 41). Therefore, we can say that the managers and leaders of this section had a better understanding of their role as an effective factor in creating and developing a positive ethical environment and have been able to provide sufficient support to operating room staff and fulfill their responsibilities well. This indicates the importance of the role of leadership in creating a positive moral climate (10, 40). The results of the (19, 29)"managers" improved significantly after the intervention and were higher in the intervention group than the control group. In addition, the scores of the participants in system managers and education officials from the inter-professional approach and their continuous presence in sessions and educational processes, sincere communication, attention, and empathy of managers with learners of different professions, made this area improve more than other areas. The results of Rathert's study showed that the behaviors displayed by team leaders are effective in creating a positive climate (18). It is consistent with the results of the present study.
Among the domains of ethical climate, the domain of "colleagues" had the highest score after the domain of "managers" and improved significantly. Paying attention to each other's opinions about patient care and helping each other solve problems and issues of patient care in this area is important. In a study conducted by Pauly et al., they reported the domain of colleagues to be positive (42). The present results showed that improving the understanding of team members about colleagues’ domain leads to improved group cooperation. This is the first condition for success in any surgery; it leads also the surgeons to establish more effective interactions and communication with operating room staff and other colleagues (15). Overall, the results of the present study showed that holding training sessions with an interprofessional approach causes the operating room team members to react better to tensions in the workplace. Holding these sessions resolves ethical conflicts in the stressful conditions of the operating room and improves the moral virtues and ethical climate and, consequently, provides quality services.
Non-equivalent group control and the limited sample size are some of the limitations of this study.