Ethical leadership of head nurses perceived by nurses and its relationship with nurses’ organizational justice

doi:10.21203/rs.3.rs-3912680/v1

Background: Ethical leadership is an altruistic-centered, ethical norm-driven leadership style that can help foster positive work attitudes among nurses. However, the relationship between ethical leadership by nurse leaders and nurses' sense of organizational justice has not been adequately studied.

Objective: To investigate the level of ethical leadership among head nurses and its relationship with organizational justice among nurses.

Method：This cross-sectional study was conducted with a convenience sample of 501 clinical nurses from four tertiary-level hospitals in Zhengzhou, Henan Province of China in May 2023. The Ethical Leadership at Work Questionnaire and the Organizational Justice Scale were used as data collection instruments. Multiple stratified linear regression was used to analyze the relationships.

Results：The mean score of ethical leadership of head nurses was 4.13±0.46, which is at a high level. Marital status, department, and monthly income were the influencing factors of nurses’ perceived ethical leadership. Head nurses’ ethical leadership was positively correlated with nurses’ organizational justice (r = 0.513, P < 0.01). Stratified linear regression analysis showed that the people orientation, power sharing and sustainability dimensions explained 23.0% of the variance in nurses’ organizational justice (P< 0.05).

Conclusions: The subscales of people orientation, power sharing and sustainability significantly influence nurses’ organizational justice. Therefore, nurse managers need to pay more attention to nurses’ personal development and needs, give them more opportunities to participate in decision-making, and strengthen their organizational justice.

Nurses

Head nurses

Ethical leadership

Organizational justice

Nursing management

As the grassroots leaders of frontline nursing staff, head nurses play a crucial role in influencing the development of nursing organizations. Their leadership is essential in ensuring patient safety and promoting the professional growth of nurses, with ethics and morality being considered the core elements of leadership^{[1, 2]}. Ethical leadership, which is centered around altruism and driven by ethical standards, was first established by Brown and others in the early 21st century^{[3, 4]}^, garnering widespread attention and research from scholars in the field of management. In recent years, ethical leadership has developed into an independent theoretical system and has been introduced into the field of nursing management, yielding positive results^[5]. As moral role models and moral managers, head nurses’ ethical leadership plays a regulatory role in nurses’ ethical behavior, helping to cultivate their moral sensitivity and positive work attitudes^{[5, 6]}. Previous research has confirmed that head nurses’ ethical leadership has a significant positive impact on nurses’ patient-oriented organizational citizenship behavior^[7], work engagement^[8], well-being^[9], and job satisfaction^[10].

Organizational justice is defined as employees’ perception of the fairness of decision-making and treatment in the organization^[11]^. Nurses expect to be treated fairly in the allocation of organizational resources, decision-making, and interpersonal relationships. A respectful and fair work environment is crucial for the physical and mental well-being of nurses, and research has found that ethical leadership is key in promoting such a work environment^[12]. However, there is currently a relatively limited amount of research on the correlation between the ethical leadership of head nurses and nurses’ organizational justice. Therefore, it is necessary to further explore the relationship and implications between these two factors.

Ethical leadership is defined as a leader who demonstrates relatively normative and appropriate behavior to subordinates through personal behavior and interpersonal relationships and promotes employees’ performance of this behavior through two-way communication, reinforcement, and decision-making^[3]. This definition implies the two main roles undertaken by ethical leaders: being a moral person and being a moral manager. Being a moral person emphasizes the leader’s own values and ethical traits, such as honesty, fairness, and trustworthiness. As moral managers, leaders prioritize the long-term interests of employees and the organization in organizational decision-making, care about and respect employees, solicit and consider employee opinions, and promote ethical decision-making and behavior among subordinates^{[4, 9]}. Compared to other types of leadership styles, ethical leadership places more emphasis on the ethical qualities of leaders and the impact of their leadership behaviors on the sustainable development of organizations^[13]. Additionally, Kalshoven et al.^[14] have examined the characteristics of ethical leadership from various perspectives including moral virtues, ethical content, and processes of influence, and established seven criteria for measuring ethical leadership: integrity, fairness, people orientation, power sharing, concern for sustainability, role clarification, and ethical guidance, which have been widely adopted in academic research.

Head nurses’ ethical leadership has a significant impact on nursing practice. From an organizational view, head nurses’ ethical leadership serves as a role model exemplar for nurses, encouraging nurses to follow ethical norms by promoting ethical practices in the organization^[15], which is beneficial for the organization to establish a good ethical climate and create a healthy professional environment^{[6, 16]}. From the nurses’ perspective, head nurses’ ethical leadership may help nurses find meaning in their work and increase their level of work engagement^[8], while significantly reducing their emotional exhaustion and tendency to leave^[17], which is an important protective factor in maintaining the stability of nurses’ human resources. In addition, it was found that head nurses’ ethical leadership is negatively related to missed nursing^[18], may directly or indirectly influence nurses’ occupational safety behaviors and organizational silence ^{[19, 20]}, and facilitate the improvement of patient safety culture^[21].

Organizational justice encompasses three dimensions: distributive, procedural, and interactional justice^[22]. Distributive justice is based on Adams' equity theory, which suggests that individuals perceive fairness based on the distribution of rewards^[23]. Thibaut et al.^[24] introduced the concept of procedural justice, which focuses on whether the decision-making process, including motives, methods, and mechanisms, adheres to fair procedures. Interactional justice refers to the appropriateness of leadership when explaining the process and methods of result distribution, with a key element being the provision of genuine information from leaders^[25]. Greenberg^[26] further defined interactional justice as interpersonal justice and informational justice, where interpersonal justice relates to the degree of respect and care employees receive during procedural execution or result in decision-making, and informational justice refers to the extent to which organizations communicate and provide explanations for decision outcomes.

As an important organizational resource, organizational justice influences the quality of nursing work, the physical and mental well-being of nurses, and the stability of nursing teams^[27]. Prolonged exposure to unfair work environments may potentially lead nurses into moral dilemmas^[28], result in workplace deviant behaviors^[29], and even foster intentions to leave their jobs^[30]. Nurse leaders have a crucial responsibility in maintaining fairness in the nursing work environment. Research showed that high-quality leader-member exchange relationships facilitate nurses’ perceptions of organizational justice^[31].

Fairness is one of the important ethical traits of ethical leaders. Ethical leaders tend to make fair and responsible ethical decisions and they are perceived to be honest, upright, and principled in their decision making^[14]. Qiu et al.^[7] found that ethical leadership is significantly and positively related to interactional justice among nurses. In addition, ethical leadership treats others fairly and establishes effective ethical standards and a just work environment in the organization, which may be predictors of organizational justice for nurses^[12]. Al Halbusi et al.^[32] also found that followers of ethical leadership were more likely to perceive more organizational justice and tended to exhibit more ethical workplace behaviors. Thus, head nurses’ ethical leadership may influence nurses’ organizational justice to some extent. However, the relationship between head nurses’ ethical leadership and nurses’ organizational justice has not been adequately studied. Therefore, the purpose of this study is to explore the current status of head nurses’ ethical leadership and its relationship with nurses’ organizational justice, to provide a reference for the nursing management to develop ethical leadership and enhance nurses’ organizational justice.

3.1 Aim

The aim of this study was to assess the ethical leadership behavior of head nurses in China and its relationship with nurses’ organizational justice.

3.2 Design and sample

This study utilized a descriptive cross-sectional study design and strictly followed the guidelines of the STROBE statement. Registered nurses were recruited to conduct an online questionnaire survey from four well-known tertiary hospitals (all public hospitals) in Zhengzhou City, Henan Province of China in May 2023. Nurses who met the following inclusion criteria were considered as study participants: i) clinical registered nurses; ii) at least 1 year of work experience; and iii) informed consent and voluntary participation in this study. Head nurses or those with serious health conditions were excluded.

The sample size was measured with the formula: \(n=\frac{{u}_{\alpha /2}\sigma }{{\delta }}\)². In our study, the significance was set at a level of α = 0.05, u_0.05/2 = 1.96, the overall standard deviation σ = 1.06 was derived from the pre-experiment, and the allowable error δ = 0.1 was set so that the theoretical sample size was calculated to be 432 cases. Taking into account a 10% loss to visit rate, the sample was expanded to 480 cases. Finally, this study collected 550 questionnaires from convenience, non-probability samples, out of which 501 questionnaires were valid with a valid response rate of 91.09%.

3.3 Measurements

3.3.1 Nurses’ socio-demographic information

The socio-demographic information of the nurses included gender, age, working years, marital status, education (diploma, baccalaureate, master), professional title (primary nurse, senior nurse, Nurses-in-charge, professor of nursing), personnel status (temporary nurses, employed nurses, and official nurses), department, and monthly income.

3.3.2 Ethical Leadership at Work Questionnaire (ELW)

Based on a 38-item questionnaire developed by Kalshoven et al^[14], the ELW consists of seven dimensions: people orientation (7 items), fairness (6 items), power sharing (6 items), concern for sustainability (3 items), ethical guidance (7 items), role clarification (5 items), and integrity (4 items). Ethical leadership was rated by ELW on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The ELW was translated into Chinese to accommodate Chinese culture. Our team strictly followed Brislin's translation model to translate the ELW. A Chinese version of the ELW was formed after a large-sample reliability test, containing 37 items and 6 dimensions, respectively, people orientation (7 items), fairness (7 items), power sharing and sustainability (8 items), ethical guidance (7 items), role clarification (5 items), and integrity (3 items), which has good reliability and validity among nurses, with a Cronbach's alpha of 0.96 and a retest reliability of 0.93^[33]. In our study, the overall Cronbach's alpha was 0.98, and the Cronbach's alpha for the dimensions ranged from 0.90 to 0.96. Higher scores indicate higher levels of ethical leadership.

3.3.3 Organizational Justice Scale

The scale was developed by Colquitt^[22] and consists of 20 items classified into four dimensions: distributive justice (4 items), procedural justice (7 items), interpersonal justice (4 items), and informational justice (5 items). The scale was based on a 5-point Likert scale, with 1 indicating strong disagreement and 5 indicating strong agreement. Higher scores indicate that nurses perceive more organizational justice. The Cronbach's alpha was 0.91, and the cumulative explained variance of the 4 factors was 65.554%. The Cronbach's alpha in our study was 0.95, with the Cronbach's alpha for the dimensions being 0.73 to 0.92.

3.4 Data collection

Our research utilized the online questionnaire star platform to launch an online questionnaire survey. After obtaining the consent of the hospital management, a nurse of the selected department was contacted as the person in charge, and the nurse sent the electronic questionnaire to the nurses of the corresponding department to fill in the questionnaire in a one-to-one way, avoiding as much as possible the interference of the head nurse in the questionnaire filling in, and only one questionnaire could be filled in by each IP address to ensure the quality of the questionnaire recovery.

3.5 Data analysis

IBM SPSS Statistics 25 was used to analyze the data. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize data on nurses’ sociodemographic characteristics, perceived ethical leadership behaviors, and organizational justice; Pearson correlation analyses were used to explore the correlation between ethical leadership and nurses’ organizational justice. A t-test or one-way ANOVA was used to test whether there were differences in perceived ethical leadership among nurses with different demographic characteristics. In addition, the total score of perceived organizational justice was used as the dependent variable, and general information (gender, age, working years, marital status, education, professional title, personnel status, department, and monthly income) was included in the first level (Model 1), and sub-scale scores of ELW were included in the second level for a stratified linear regression analysis (Model 2), to explore the effect of ethical leadership on nurses’ organizational justice. The test level was α = 0.05.

3.6 Ethical considerations

This study was approved by the University Ethics Committee (ZZUIRB2023-031). The subjects were fully informed of the purpose, content, methods, and precautions of the study, and were assured that they had the right to freely choose to participate or withdraw from the study and that their relevant interests would not be jeopardized. Ultimately, this study achieved informed consent from all participants.

4.1 Socio-demographic characteristics and ethical leadership

The age of the nurses was in the range of 22–55 (M:10.05; SD:5.40) and the average working experience was 10.05 ± 5.40 years. Most of the participants were female (83.2%), married (73.7%), with a baccalaureate degree (83.6%), and employed nurses (85.0%). More than half of the nurses had the professional title of nurse-in-charge (58.5%). They worked in the critical care, emergency, operation theatre, and other departments (Table 1).

Based on the results of the t-test and one-way ANOVA, marital status, department, and monthly income were influential factors in nurses’ perceived ethical leadership behaviors (P < 0.05). Married nurses had higher perceived scores than single nurses. Compared to other departments, nurses in pediatrics reported the highest ethical leadership scores for head nurses. In addition, the higher the monthly income, the higher the nurses’ perceived ethical leadership scores (Table 1).

Table 1

Participants’ demographics and ethical leadership distribution (n = 501)
Characteristics	N (%)	ethical leadership (M ± SD)	F/t	P
Gender
Female	417 (83.2)	152.65 ± 17.14	0.758	.449
Male	84 (16.8)	154.18 ± 15.44
Age (R:22 ~ 55; M:32.53; SD:5.15)
<30	135 (26.9)	151.68 ± 15.89	0.503	.605
30–40	331 (66.1)	153.41 ± 17.20
>40	35 (7.0)	152.86 ± 17.55
Working years (R:1 ~ 32; M:10.05; SD:5.40)
<10	241 (48.1)	151.65 ± 16.78	1.592	.205
10–20	240 (47.9)	154.30 ± 16.80
>20	20 (4.0)	151.25 ± 18.16
Marriage
Single	132 (26.3)	148.80 ± 17.32	-3.295	.001^**
Married	369 (73.7)	154.38 ± 16.47
Education
Diploma	41 (8.2)	153.61 ± 17.32	1.959	.142
Baccalaureate	419 (83.6)	153.32 ± 16.90
Master	41 (8.2)	147.93 ± 15.59
Professional title
Primary nurse	41 (8.2)	150.88 ± 15.40	0.536	.657
Senior nurse	149 (29.7)	152.64 ± 15.89
Nurses-in-charge	293 (58.5)	153.09 ± 17.49
Professor of nursing	18 (3.6)	156.78 ± 18.14
Personnel status			0.837	.433
Temporary nurses	44 (8.8)	149.93 ± 16.30
Employed nurses	426 (85.0)	153.28 ± 16.92
Official nurses	31(6.2)	151.97 ± 16.90
Department
Critical care	73 (14.6)	149.33 ± 14.36	2.538	.014^*
Emergency	30 (6.0)	151.13 ± 13.43
Internal department	120 (24.0)	154.46 ± 16.88
Obstetrics and gynecology	21 (4.2)	147.86 ± 19.18
Operation theatre	31 (6.2)	148.45 ± 20.25
Pediatrics	41 (8.2)	159.68 ± 14.72
Surgery department	109 (21.8)	151.98 ± 18.32
Others	76 (15.2)	155.47 ± 15.80
Monthly income
≤ 3000	8 (1.6)	142.13 ± 16.10	3.473	.016^*
3001 ~ 6000	87 (17.4)	150.64 ± 14.87
6001 ~ 9000	174 (34.7)	151.50 ± 16.93
>9000	232 (46.3)	155.18 ± 17.27
Abbreviation: R, range; M, mean; SD, standard deviation.
P < 0.05. *P < 0 .01.

4.2 Study variable descriptive statistics and correlation analysis

The nurses’ perceived ethical leadership score was 4.13±0.46, with scores reported on the sub-scales ranging from 3.98±0.60 to 4.34±0.44. The organizational justice score reported by the nurses was 3.82±0.64. The interpersonal justice sub-scale reported the highest mean score (4.11±0.64), while the distributive justice sub-scale reported the lowest mean score (3.62±0.90)(Table 2).

Pearson’s correlation analysis found that ethical leadership was positively correlated with nurses’ organizational justice (r = 0.513, P < 0.01). There was a significant positive correlation between ethical leadership and the distributive justice, procedural justice, interpersonal justice, and informational justice sub-scales of organizational justice (r = 0.421, r = 0.450, r = 0.514, r = 0.430, P < 0.01) (Table 2).

Table 2

Correlation and descriptive statistics between study variables (n = 501)
	M(SD)	1	2	3	4	5	6	7	8	9	10	11	12
1.ELW	4.13(.46)	α:0.98
2.People orientation	4.13(.66)	.883^**	α:0.96
3.Fairness	3.98(.60)	.822^**	.636^**	α:0.90
4.Power sharing and sustainability	4.10(.51)	.885^**	.728^**	.658^**	α:0.92
5.Ethical guidance	4.12(.47)	.784^**	.611^**	.528^**	.643^**	α:0.95
6.Role clarification	4.34(.44)	.753^**	.614^**	.543^**	.612^**	.538^**	α:0.94
7.Integrity	4.27(.61)	.795^**	.672^**	.585^**	.677^**	.585^**	.591^**	α:0.94
8.Organizational justice	3.82(.64)	.513^**	.461^**	.409^**	.489^**	.393^**	.341^**	.409^**	α:0.95
9.Distributive justice	3.62(.90)	.421^**	.386^**	.336^**	.393^**	.321^**	.297^**	.315^**	.874^**	α:0.92
10.Procedural justice	3.70(.80)	.450^**	.399^**	.360^**	.442^**	.336^**	.293^**	.367^**	.950^**	.810^**	α:0.92
11.Interpersonal justice	4.11(.64)	.514^**	.442^**	.405^**	.487^**	.428^**	.338^**	.423^**	.809^**	.567^**	.688^**	α:0.88
12.Informational justice	3.92(.55)	.430^**	.409^**	.346^**	.396^**	.318^**	.281^**	.339^**	.801^**	.560^**	.666^**	.674^**	α:0.73
Abbreviation: M, mean; SD, standard deviation; α, Cronbach’s alpha.
ELW, Ethical Leadership at Work Questionnaire
**P < 0 .01.

4.3 Stratified linear regression analysis between ethical leadership and organizational justice

The results of stratified linear regression showed that nurses’ professional title, department, people orientation, power sharing, and sustainability dimensions were the influencing factors of nurses’ organizational justice (P < 0.01). After controlling for socio-demographic characteristics, the R² increased from 0.098 to 0.328, and people orientation, power-sharing, and sustainability explained 23.0% of the variance in nurses’ organizational justice (Table 3).

Table 3

Stratified linear regression analysis between ethical leadership and organizational justice (n = 501)
	Variable	β	t	P	95% CI
	Variable	β	t	P	LLCI	ULCI
Model 1	Constant	82.534	8.471	<.001^**	63.39	101.678
	Marriage	4.699	2.863	.004^**	1.474	7.924
	Professional title	-7.771	-2.631	.009^**	-13.575	-1.967
	Department	-4.794	-2.883	.004^**	-8.061	-1.527
Model 1 F = 2.472, P < .001, R² = .098
Model 2	Constant	29.816	2.969	.003^**	10.085	49.547
	Professional title	-6.215	-2.402	.017^*	-11.299	-1.131
	Department	-3.761	-2.598	.010^*	-6.604	-0.917
	People orientation	0.426	2.451	.015^*	0.084	0.767
	Fairness	0.254	1.52	.129	-0.074	0.583
	Power sharing and sustainability	0.821	3.908	<.001^**	0.408	1.234
	Ethical guidance	0.232	1.101	.271	-0.182	0.647
	Role clarification	-0.088	-0.291	.772	-0.687	0.51
	Integrity	0.221	0.547	.585	-0.572	1.013
Model 2 F = 27.074, P < .001, R² = .328
Abbreviation: CI, confidence interval; LLCI, lower limit confidence interval; ULCL, upper limit confidence limit interval
P < 0.05. *P < 0 .01.

5.1 Ethical leadership of head nurses scores

In this study, the ethical leadership of head nurses was evaluated from the nurses’ perspectives in six dimensions: people orientation, fairness, power sharing and sustainability, ethical guidance, role clarification, and integrity. The results of the study showed that the average score of ethical leadership of head nurses was 4.13±0.46, which is at a high level and higher than the results of El-Gazar et al. (3.24±0.739)^[34]and Alan et al. (3.78±0.86)^[35] studies. The head nurse, as the manager of an ethically sustainable culture of care, is responsible for integrating the values of the organization in practice, shaping the workplace norms, and influencing the behaviors and ethical values of the nursing staff^[36], enhancing their moral sensitivity and moral responsibility to create a culture of ethical care in the service of patients’ lives and health^{[6, 15]}.

The dimension with the highest score was role clarification, and the reason for this analysis may be that responsibilities and duties are an important part of ethical nursing practice^[37]. The ethical leadership of head nurses is needed in nursing to guide nurses to be fully cognizant of the job content and requirements to ensure that nurses fulfill their responsibilities accordingly to the patients under their care and provide high-quality care^[15]. The dimension with the lowest score was fairness, which may be related to the fact that some nursing managers have not yet standardized the resource allocation, scheduling, and leave system in clinical nursing, which influences the nurses’ perception of organizational justice^[38]. Therefore, it is suggested that nursing managers should not only clarify their subordinates’ job responsibilities and improve their sense of professional responsibility, but also pay attention to their moral character building, continuously improve their moral management level, pay attention to their subordinates’ efforts and contributions and give encouragement and support, and establish an exchange relationship of trust and respect with them to improve their motivation to work and to ensure the relative justice of nursing management.

5.2 Factors influencing nurses’ perceived ethical leadership behavior

First, the results of this study showed that marital status influenced nurses’ perceptions of nurse leaders' ethical leadership behaviors, with married nurses scoring higher than single nurses. This may be because the relatively stable family structure of married nurses provides them with access to more positive emotional support^[39]; whereas single nurses mostly live alone, have a single source of social support, are prone to negative emotions such as loneliness and helplessness, and have a relatively short length of employment, and lack belongingness and responsibility to the hospital^[40]. As a result, a certain degree of differences exists between married and single nurses’ perceptions and evaluations of head nurses’ ethical leadership behaviors.

Secondly, the nurses’ department is one of the influencing factors. Compared to other departments, the pediatric head nurses had the highest scores for ethical leadership behaviors. It may be related to the complexity of ethical issues in the pediatric setting, where pediatric nurses need to make more nursing decisions in caring for children^[41]. Head nurses are more focused on building a culture of organizational ethics^[42]. The specificity of the pediatric nursing ethical environment may influence nurses’ perceptions of ethical leadership behaviors.

Third, monthly income level was also a factor that influenced nurses’ perceptions of ethical leadership behaviors. Nurses with high monthly incomes had higher perceived ethical leadership scores than nurses with low monthly incomes. Nurses with lower monthly incomes are more likely to have a sense of effort-reward imbalance due to income levels that do not meet expectations, resulting in negative emotions such as emotional exhaustion^[43], anxiety and depression^[44], and turnover intention^[45], which may influence the nurses’ perceptions of the ethical leadership behaviors of the head nurses. Therefore, the head nurses are supposed to give more attention and support to the nurses who are single and have a low income level, and at the same time to strengthen the construction of the ethical culture of the department and their moral cultivation, to set up a good sense of responsibility, and to set a good example for the nurses.

5.3 The influence of head nurses’ ethical leadership behavior on nurses’ organizational justice

The results of this study showed a positive correlation between head nurses’ ethical leadership and nurses’ organizational justice (r = 0.513, P < 0.01), in which the dimensions of people orientation, power sharing, and sustainability explained 23.0% of the variance in nurses’ organizational justice, suggesting that the head nurses’ ethical leadership had a significant positive predictive effect on nurses’ organizational justice and that the stronger the head nurses’ ethical leadership was, the more the nurses’ perceived organizational justice was stronger (p < 0.01). The reasons for this may be that the ethical leadership of head nurses supports concern and respect for the nurses, which would give them great psychological satisfaction^[46], and the nurses’ sense of organizational justice would increase accordingly with the understanding and support of the head nurses^[12]. On the one hand, the ethical leadership of head nurses cares for and respect nurses as ethical individuals based on the principle of people orientation, consider the growth and development needs of each nurse^[16], and are conscientious in their work and focus on fairness and equity in decision-making^[47], which positively influences the nurses’ organizational justice. As an ethical manager, the ethical leadership of head nurses focuses on providing nurses with the opportunity to participate in decision making^[48], being open and transparent in the development of rules and regulations and rewards and punishments^[3], as well as focusing on the sustainability of the organization and creating a just and supportive work environment^[7].

Altuntaş et al.^[49] found that nurses’ perception of values management has a significant role in their sense of organizational fairness. Based on the social learning theory perspective, head nurses’ ethical leadership, by adhering to moral values and guiding the organization’s ethical norms, set a good example for nurses to learn from, which helped to enhance their perception of values management, thus influencing nurses’ perceptions of organizational justice^[50]. Therefore, nursing managers should actively play the leadership style of ethical leadership, strengthen their awareness as moral exemplars, provide nurses with a just working environment through ethical management, and at the same time strengthen effective communication and benign guidance of ethical values with nurses, give them sufficient care and support, reinforce organizational justice, and facilitate the stable development of the nursing career.

What is advantageous about this study is that it is the first investigation in China to link head nurses’ ethical leadership and nurses’ organizational justice. Additionally, our study emphasizes a significantly positive associations between ethical leadership and organizational justice. There are some limitations to this study. First, all of the samples in this study came from the same city in China and lacked the participation of study samples from other cities in China. Second, this study had one source of data, all from nurses’ self-reports, which may be exposed to common method bias (CMB). Future studies could collect information from multiple sources such as nurses, head nurses, and their coworkers. Additionally, as a cross-sectional survey, this study was unable to determine causal relationships between variables.

In our study, the head nurses’ ethical leadership behaviors were at high levels, and head nurses’ ethical leadership behaviors were positively related to nurses’ organizational justice. People orientation, power sharing, and sustainability dimensions positively predicted nurses’ organizational justice. Nursing managers should strive to improve their ethical leadership behaviors, pay attention to nurses’ personal development and needs, increase nurses’ affirmation of their self-worth, give them more opportunities to participate in decision-making, stimulate nurses’ sense of responsibility and sense of mission, and strengthen their motivation to work, which will, in turn, raise nurses’ organizational justice. In the future, multi-geographic research can be conducted to expand the sample size and conduct an in-depth study on the influencing factors of ethical leadership of head nurses, to provide a reference for nursing managers to cultivate ethical leadership.

Acknowledgments

We would like to thank the nurses who were recruited, the hospital administrators who supported the study, and those who assisted in the research process.

Funding

No funds to declare. The authors self-funds.

Authors’ contributions

Conceptualization, J.S., R.Z and Y.M.; Methodology, J.S., Z.C and H.L.; Software, J.S.and Z.C; Validation, J.S., Y.M. and H.L.; Formal Analysis, J.S.; Investigation, Y.L. and H.L.; Resources, Y.L.; Data Curation, J.S. and Z.C; Writing-Original Draft Preparation, J.S.; Writing-Review & Editing, J.S., Z.C, R.Z and Y.M; Visualization, J.S; Supervision, J.S. and Z.C; Project Administration, J.S. and H.L. All authors have read and agreed to the published version of the manuscript.

Availability of data and materials

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate.

The Zhengzhou University Ethics Committee approved the study. Ethical approval number: ZZUIRB2023-031.The study was conducted in accordance with the ethical standards set out in the Declaration of Helsinki. All participants gave informed consent prior to data collection. The information provided by the participants will remain anonymous.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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No competing interests reported.

Ethical leadership of head nurses perceived by nurses and its relationship with nurses’ organizational justice

Status:

Version 1

Abstract

1 Introduction

2 Background

3 Methods

3.1 Aim

3.2 Design and sample

3.3 Measurements

3.3.1 Nurses’ socio-demographic information

3.3.2 Ethical Leadership at Work Questionnaire (ELW)

3.3.3 Organizational Justice Scale

3.4 Data collection

3.5 Data analysis

3.6 Ethical considerations

4 Results

4.1 Socio-demographic characteristics and ethical leadership

4.2 Study variable descriptive statistics and correlation analysis

5 Discussion

5.1 Ethical leadership of head nurses scores

5.2 Factors influencing nurses’ perceived ethical leadership behavior

5.3 The influence of head nurses’ ethical leadership behavior on nurses’ organizational justice

6 Strength and Limitations

7 Conclusion

Declarations

References

Additional Declarations

Status:

Version 1