An-Najah National University Faculty of Graduate Studies THE IMPACT OF ETHICAL LEADERSHIP ON NURSES’ MOTIVATION AND PATIENT’S CARE OUTCOME FROM THE PERSPECTIVE OF INTENSIVE CARE NURSES IN NABLUS HOSPITALS: A CROSS-SECTIONAL STUDY By Kamel Ahmad Dababsah Supervisor Dr. Maryam Al Tall This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Health Management, Faculty of Graduate Studies, An-Najah National University, Nablus - Palestine. 2024 II THE IMPACT OF ETHICAL LEADERSHIP ON NURSES’ MOTIVATION AND PATIENT’S CARE OUTCOME FROM THE PERSPECTIVE OF INTENSIVE CARE NURSES IN NABLUS HOSPITALS: A CROSS-SECTIONAL STUDY By Kamel Ahmad Dababsah This Thesis was Defended Successfully on 22/2/2024 and approved by Dr. Mariam Al Tall Supervisor Signature Dr. Rebhi Bsharat External Examiner Signature Dr. Ahmed Hanani Internal Examiner Signature III Dedication First, I thank God Almighty for everything. Then, to my beloved mother and father, whose love, sacrifice, and unwavering support are my pillars of strength: You have made me the person I am today and I will be forever grateful. To my beloved wife, whose love, patience, and unwavering faith in me have been my inspiration. Your presence in my life is a constant source of joy and comfort. To my beloved children, who bring light and laughter every day. Your innocence and curiosity remind me of the beauty of the world. To my extended family, thank you for your constant encouragement, understanding, and shared moments of joy and laughter. Your presence in my life is a precious blessing. This journey would not be possible without each of you. Thank you for being my rock, my inspiration, and my biggest supporter. IV Acknowledgment I begin by expressing our gratitude to the Almighty for his steadfast grace and blessings that have guided us through the trials and tribulations encountered during this study. I am extremely grateful for the strength that has been given to us throughout our journey. Our deepest gratitude goes to our esteemed supervisor, Dr Maryam Al Tel, whose guidance; expertise and support were instrumental in the success of the research project. Dr. Al Tel's unwavering commitment to excellence has been an inspiration to us. I would also like to extend our sincere thanks to Dr. Hamzeh Alzabadi, Master of Public Health Program Coordinator, for his invaluable contributions and constant encouragement throughout the research process. Furthermore, I would like to express our sincere gratitude to all the dedicated nurses in Palestine, whose invaluable ideas and cooperation were indispensable to my research progress. Their commitment to patient care and willingness to share their experiences has enriched our research. Special recognition goes to the Intensive Care Unit (ICU) nurses whose willingness to participate and share their perspectives with me essential to the depth and breadth of the findings. Their expertise and dedication in the demanding field of critical care nursing is commendable. Once again, I extend our sincere thanks to everyone who played a role, big or small, in making this research possible. Your contributions are highly appreciated. V Declaration I, the undersigned, declare that I submitted the thesis entitled: THE IMPACT OF ETHICAL LEADERSHIP ON NURSES’ MOTIVATION AND PATIENT’S CARE OUTCOME FROM THE PERSPECTIVE OF INTENSIVE CARE NURSES IN NABLUS HOSPITALS: A CROSS-SECTIONAL STUDY I declare that the work provided in this thesis, unless otherwise referenced, is the researcher‟s own work, and has not been submitted elsewhere for any other degree or qualification. _____________________________________ Student's Name: _____________________________________ Signature: _____________________________________ Date: VI List of Contents Dedication ....................................................................................................................... III Acknowledgment ............................................................................................................ IV Declaration ....................................................................................................................... V List of Contents ............................................................................................................... VI List of Tables ............................................................................................................... VIII List of Figures ................................................................................................................. IX List of Appendices ........................................................................................................... X Abstract ........................................................................................................................... XI Chapter One: Introduction and Theoretical Background .................................................. 1 1.1 Background ................................................................................................................. 1 1.2 Theoretical Framework ............................................................................................... 3 1.2.1 Ethical Leadership in Healthcare ............................................................................. 3 1.2.2 Motivation in Nursing .............................................................................................. 5 1.2.3 Patient Care Outcomes ............................................................................................. 7 1.3 Concepts and Operational Definitions ........................................................................ 9 1.4 Problem Statement .................................................................................................... 10 1.5 Significant of Study .................................................................................................. 11 1.6 Aims of Study ........................................................................................................... 11 1.6.1 Specific Objectives ................................................................................................ 11 1.7 Hypothesis ................................................................................................................ 12 1.8 variables .................................................................................................................... 12 1.8.1 Independent variable .............................................................................................. 12 1.8.2 Dependent variables ............................................................................................... 12 Chapter Two: Methodology ............................................................................................ 13 2.1 Study Design ............................................................................................................. 13 2.2 Site and Setting ......................................................................................................... 13 2.3 Study population and sample size ............................................................................. 13 2.4 Inclusion criteria and Exclusion criteria ................................................................... 14 2.4.1 Inclusion criteria .................................................................................................... 14 2.4.2 Exclusion criteria ................................................................................................... 14 2.5 Data Collection Tool ................................................................................................. 14 2.6 Validity and Reliability ............................................................................................. 15 2.6.1 Validity .................................................................................................................. 15 2.6.2 Reliability ............................................................................................................... 15 2.7 Data Collection Procedures /Field Work .................................................................. 16 VII 2.8 Data Analysis ............................................................................................................ 16 2.9 Ethical Consideration ................................................................................................ 17 Chapter Three: Results .................................................................................................... 18 3.1 Demographic of the Nurses ...................................................................................... 18 3.2 Nurses‟ Work Motivation ......................................................................................... 24 3.3 Ethical Leadership .................................................................................................... 28 3.4 Patients‟ Care Outcome ............................................................................................ 32 3.5 Description of scales‟ overall scores and classification ............................................ 34 3.6 Analytical Results ..................................................................................................... 35 Chapter Four: Discussion and Conclusions .................................................................... 39 4.1 Introduction ............................................................................................................... 39 4.2 Hypotheses Discussion ............................................................................................. 39 4.3 Conclusion ................................................................................................................ 45 4.4 Limitations ................................................................................................................ 45 4.5 Recommendation ...................................................................................................... 46 List of Abbreviations ...................................................................................................... 49 References ....................................................................................................................... 50 Appendices ...................................................................................................................... 60 ب ............................................................................................................................... الملخص VIII List of Tables Table 2.1: Distribution the Number of Nurses and ICU Beds in Nablus Hospitals ....... 13 Table 3.1: Normality Tests of the Data Based on the Age and Monthly Income ........... 18 Table 3.2: Distribution Percentage of Participants According to their Demographic Data .............................................................................................................. 20 Table 3.3: Distribution Percentage of Participants According to their „Work Motivation Scale Items‟ .................................................................................................. 26 Table 4.3: Distribution Number and Percentage of Participants According to their Responses to Ethical Leadership Scale Items .............................................. 30 Table 3.5: Distribution of Number and Percentage of Participants According to their Responses to Patient Care Outcome ............................................................ 33 Table 3.6: Distribution of nurses‟ work motivation, ethical leadership and patient‟s care outcome scoring classifications ................................................................... 35 Table 3.7: Relationship between Nurses‟ Demographic data and Work Motivation ..... 36 Table 3.8: Relationship between Nurses‟ Demographic data and Patient Care Outcome ....................................................................................................... 37 Table 3.9: Correlation between Work Motivation, Ethical Leadership and Patient Care Outcome ....................................................................................................... 38 IX List of Figures Figure 3.1: Distribution of nurses' age categories........................................................... 21 Figure 3.2: Distribution of nurses' genders ..................................................................... 21 Figure 3.3: Distribution of nurses' qualification ............................................................. 22 Figure 3.4: Distribution of nurses' workplace ................................................................. 22 Figure 3.5: Distribution of nurses' experience ................................................................ 23 Figure 3.6: Distribution of nurses' employment status ................................................... 23 Figure 3.7: Distribution of nurses' monthly income ....................................................... 24 Figure 3.8: Distribution of nurses' responses to nurses' work motivation scale ............. 27 Figure 3.9: Distribution of nurses' responses to nurses' to ethical leadership scale ....... 31 Figure 3.10: Distribution of nurses' responses to patient outcome scale (modified SAQ) ......................................................................................... 34 X List of Appendices Appendix A: Structured questionnaire for data collection ............................................. 60 Appendix B: IRB Approval ............................................................................................ 64 Appendix C: Nablus Specialized Hospital approval ....................................................... 65 Appendix D: Specialized Arab Hospital approval .......................................................... 66 Appendix E: An-Najah National University hospital approval ...................................... 67 Appendix F: St. Luke's Hospital approval ...................................................................... 68 Appendix G: Women's Union Hospital approval ........................................................... 69 Appendix H: MOH hospital (Alwatany Medical Hospital and Rafidia Surgical Hospital) approval ........................................................................................................ 70 Appendix I: Specialists to determine questionnaire validity .......................................... 71 XI THE IMPACT OF ETHICAL LEADERSHIP ON NURSES’ MOTIVATION AND PATIENT’S CARE OUTCOME FROM THE PERSPECTIVE OF INTENSIVE CARE NURSES IN NABLUS HOSPITALS: A CROSS-SECTIONAL STUDY By Kamel Ahmad Dababsah Supervisor Dr. Maryam Al Tel Abstract Background: Ethical leadership is an essential element of a safe and effective healthcare environment. It is characterized by leaders who demonstrate honesty, integrity, fairness, and respect for others. Ethical leadership has been shown to have a positive impact on nurse motivation and patient care outcomes. Aim: This study aims to investigate the impact of ethical leadership on nurse motivation and patient care outcomes from the perspective of ICU nurses at Nablus Hospitals. Method : A cross-sectional study was conducted on 150 intensive care nurses at Nablus hospitals. Data were collected using a self-administered questionnaire covering ethical leadership measures, nurse motivation, and patient care outcomes, in addition to demographic data about each participant; the period of the study is between March and December of 2023, a period of seven months. Result: The results show that higher work motivation among ICU nurses is significantly correlated with ethical leadership, while there is a significant correlation between ethical leadership and patient care outcomes. The result of this study shows a significant relationship between demographic data related to the work motivation scale (gender, monthly income, and employee status) among participants, while no significant difference in motivation is noticed between the nurses‟ experience, income, age, or qualification in the ICU. Additionally, ICU nurses with higher qualifications are significantly related to patients' outcomes, while other demographic data are not statistically significant. XII Conclusion: The results of this study suggest that ethical leadership plays an important role in promoting nurse motivation and improving patient care outcomes. Keywords: Ethical Leadership, Nurses' Motivation, Patient‟s Care Outcome, nursing, ICU. 1 Chapter One Introduction and Theoretical Background 1.1 Background The intensive care unit (ICU) is an important section of each hospital, providing specialized and life-saving care to patients experiencing severe and complicated medical illnesses. The intensive care unit (ICU) placement is defined by high acuity, frequent monitoring, and demanding patient care, making it one of the most challenging and stressful environments for healthcare staff (Behzadi et al., 2021). Nurses constitute key members of the ICU team since they are responsible for the well- being and recovery of critically ill patients. Their commitment, knowledge, and motivation are critical characteristics that have a direct influence on the quality of patient care and clinical results in the ICU (Vranas et al., 2018). The concept of ethical leadership behavior has attracted a lot of focus in the fields of healthcare management and organizational psychology in recent years. Ethical leaders not only adhere to ethical ideals but also show integrity, fairness, and responsibility in their actions and judgments. Ethical leaders serve as good role models for their teams, encouraging and motivating them to exhibit ethical behavior and an intense commitment to patient well-being (Sharma et al., 2021). Ethical leadership conduct has been recognized as a significant driver of nurses' motivation and overall job satisfaction in the seeking and emotionally charged setting of the ICU (El-Gazar & Zoromba, 2021a). Ethical leadership plays an essential role in creating a positive work atmosphere for ICU nurses. Leaders can help ICU nurses reduce stress, enhance communication, and improve their level of satisfaction by showing openness, truthfulness, and an allegiance to ethical standards. This can result in improved care for patients and results (Uzelli Yılmaz et al., 2020). Honesty, openness, and charge in nursing are exhibited by an emphasis on patient-centered care and nursing staff well-being. These leaders promote ethical decision-making, follow professional rules of conduct, and protect patient confidentiality. They stimulate nurses' desire and dedication by guaranteeing equitable resource allocation and providing possibilities for advancement. Ethical leaders assist 2 ICU nurses in dealing with problems such as high patient acuity and ethical quandaries by giving emotional support and encouraging open communication (Flaubert et al., 2021). The positive influence of ethical leadership on patient care outcomes may be shown in increased satisfaction, fewer mistakes, and increased safety (Franczukowska et al., 2021b). Motivation for work is an essential measurement of healthcare professionals' responses to rising difficulties and demands in healthcare organizations (Aydoğdu, 2023). Motivation is defined as a process that begins with an inspiration to perform and continues to the end it begins behaviors in order to get the outcomes you want (Uzelli Yılmaz et al., 2020). Because motivation is a complex, multifaceted event, it is described as the force within an individual that affects or drives behavior (Baljoon et al., 2018). Nurse Motivation and Influencing Factors The performance and pleasure of nurses in their job responsibilities are greatly influenced by motivation. Nurse motivation is influenced by a variety of external and internal variables ( Gunawan et al., 2019). Numerous important motivating variables that are significant for nurses have been emphasized in studies. A competitive salary, a feeling of job security, clear career advancement pathways, decision-making autonomy, opportunities for ongoing skill development, fostering positive relationships with coworkers and managers, creating intellectually stimulating work, and recognition for significant contributions are a few of these (Alotaibi et al., 2016; Baljoon et al., 2018; Brown and Lam, 2008). It has been demonstrated that a supportive corporate culture and the compatibility of individual values with the goals and values of the organization have a substantial impact on nursing motivation (Smama‟h et al., 2023). Ethical Leadership's Influence on Nurse Motivation In various ways, ethical leadership may affect nursing motivation (Breed et al., 2020). Ethical leaders build a pleasant work atmosphere that encourages open communication, cooperation, and the well-being and professional growth of their nursing staff. Ethical leaders offer emotional support to nurses and foster an open communication culture, allowing nurses to express their problems and seek help (El-Gazar & Zoromba, 2021a). They actively listen to their workers, giving compassion and empathy, which may help ease the emotional toll of working in the ICU. ethical leaders provide nurses the courage to make tough decisions 3 because they know they have the backing of their colleagues (Barkhordari-Sharifabad et al., 2017). Patient care outcomes are critical markers of medical care effectiveness, encompassing health status, quality of life, Ethical leadership behavior in the ICU has a positive impact on patient safety(Aiken et al., 2002; Zaheer et al., 2021). Nurse motivation has a positive impact on the quality of care provided to patients (Ozden et al., 2019). Ethical leadership behavior and staff motivation contribute to shorter lengths of stay in the ICU (Prasad and Jubi, 2023; Batool et al., 2023). Previous studies have shown that ethical leadership behavior can have a positive impact on nurses' motivation. However, the specific factors of ethical leadership behavior that contribute to nurses' motivation in the ICU context are not well understood. The present study aimed to fill this gap in the literature through inquiries into the characteristics of ethical management, such as honesty, equity, responsibility, openness, and empathy." emphasizing the Nablus hospitals. We aim to gain a better understanding of how ethical leadership practices can improve patient care outcomes in the critical care setting by investigating the impact of ethical leadership on nurses' motivation. 1.2 Theoretical Framework The theoretical dimensions for examining how ethical leadership affects ICU nurses' motivation and patient care outcomes in Nablus hospitals is provided by these interrelated characteristics of ethical leadership, motivation, and patient care outcomes. 1.2.1 Ethical Leadership in Healthcare It has been recognized that the Authentic Leadership Theory is a powerful framework associated with several advantageous results. The Authentic Leadership Theory holds great potential for clarifying the critical relationship between ethical behavior, nurse motivation, and patient care outcomes in the environment of intensive care unit nursing (Avolio and Walumbwa , 2014; Wong et al., 2020). In healthcare management, the theory of ethical leadership has drawn more attention, especially when it comes to nursing and patient care. Integrity, openness, and ethical standards are given top priority by leaders who practice ethical leadership in their interactions and decision-making. It has a significant impact on nurses' attitudes and 4 behaviors in besides motivating them. A culture of trust, accountability, and respect is created by ethical leaders, strengthening the organizational culture generally and encouraging ethical behavior (Brown et al., 2005; Mayer et al., 2012). In a variety of settings and sectors, it has been established that ethical leadership behavior positively correlates with worker motivation and job satisfaction. It has been demonstrated that ethical leadership in the medical field improves quality of care for patients and improves workforce involvement and retention (Kalaitzidis et al., 2020). According to research, ethical supervisory conduct can create a productive workplace and increase staff members' feelings of trust and respect (Malik & Khan, 2018). Specifically, by providing employees with an impression of direction and significance in their position, encouraging justice and equity in the workplace, and creating a sense of belonging and partnership, ethical leadership conduct can increase employee motivation (Eisenbeiss et al., 2008). Several behaviors and actions that promote or hinder ethical leadership conduct in healthcare settings have been discovered by previous studies. To encourage ethical leadership conduct, for instance, organizations should establish explicit ethical standards and rules, educate and train people on ethical concepts and values, and set an example of ethical behavior for others to follow. (Kalaitzidis et al., 2020; Hoang et al., 2023; Boatright, 2018; Franczukowska et al., 2021a) On the other hand, dishonesty, favoritism, and a lack of transparency on the part of executives can cause employee satisfaction and confidence in an organization to decrease (Mansour et al., 2020) . According to an Iranian study (2017), ethical sensitivity is an important trait for ethical nursing leaders. Twenty Iranian nurses participated in the study and data were gathered through semi-structured and in-depth interviews. Following traditional content analysis of the data, five major categories sensitivity to care, errors, communication, decision- making, and ethical practice were identified. According to the study, ethical awareness can significantly influence several professional practice domains and improve the ethics of nursing (Esmaelzadeh et al., 2017). 5 The study was conducted in Iran to examine the relationship between ethical leadership, conscientiousness, and moral courage among nurses. The study involved 180 nurses in central Iran and used three questionnaires: Ethical Leadership, Conscientiousness, and Moral Courage. The results showed that nurses who believed their managers were ethical were more attentive and fearless. Regression research also indicated that moral courage and conscientiousness could be predicted by ethical leadership. This suggests that ethical leadership is crucial for creating a work environment where nurses feel supported and encouraged to act ethically. When leaders are ethical, nurses are more committed to their work and uphold high standards of care. They are also more likely to speak up when they see something wrong, even if it means going against their superiors' wishes. The study provides valuable insights into the meaning of ethical leadership in nursing, suggesting that ethical leadership can positively impact nurses' conscientiousness and moral courage, leading to improved patient care and a more positive work environment (Pakizekho & Barkhordari-Sharifabad, 2022). 1.2.2 Motivation in Nursing Self-Determination Theory (SDT) is a measure of work motivation for nurses. A commonly used guideline for understanding human motivation and behavior is named self-determination theory (SDT). According to Deci and Ryan (1985), people are motivated by both internal and external factors. Internal elements including a sense of autonomy, competence, and interpersonal connectedness give birth to intrinsic drive (Sansone & Tang, 2021; Deci & Ryan, 1985). On the other hand, extrinsic motivation is fueled by external demands or incentives. SDT provides significant insight into the elements that affect nurses' motivation within the framework of the Nurses' Work Motivation Scale. For nurses, intrinsic motivation can come from having autonomy in decision-making, being competent in-patient care, and having meaningful interactions with fellow nurses and patients (Deci and Ryan, 2013; Flannery, 2017). Motivation is a complex psychological construct that is essential for nurses' job satisfaction, performance, and commitment. Ethical leadership acts as a catalyst for enhancing nurses' intrinsic motivation. By emphasizing moral values and purpose- driven actions, ethical leaders inspire nurses to find meaning and fulfillment in their roles. Nurses who perceive their leaders as advocates of patient well-being and ethical 6 standards are more likely to be engaged and dedicated to their work (Huang et al., 2021b). Intensive care nurses face unique challenges in their work environment, including high levels of stress, long working hours, and exposure to traumatic events. These factors can contribute to burnout, low job satisfaction, and reduced motivation among intensive care nurses (Mansour et al., 2020). A study in Saudi Arabia aims to investigate the relationship between authentic leadership, trust in managers, and job performance among nurses in Saudi Arabia. The study utilizes a non-experimental, cross-sectional design, and three different scales to test the study variables. A total of 116 nurses who meet the inclusion criteria completed the results of the study indicated that there are significant and positive effects of authentic leadership and its four components on trust in managers. However, no relationships are found between authentic leadership and its four elements, and job performance. The study concludes that authentic leaders have the ability to improve work environments by building trustful relationships with nurses, and future researchers in Saudi Arabia should focus on conducting studies of authentic leadership in nursing and examining its effects on outcomes related to nurses (Alilyyani, 2002). According to the study by Alhaddad and Hamdan-Mansour (2020), there is a significant positive correlation between ethical leadership behavior and work motivation among ICU nurses. The study uses the Ethical Leadership Scale and Nurses' Work Motivation Scale to measure the variables. The results show that intensive care nurses who perceived their leaders as more ethical reported higher levels of work motivation. In addition, the study find that the sub-dimensions of ethical leadership, including being a role model, communicating ethical values, and showing concern for employees, are positively associated with work motivation. Overall, the study suggests that ethical leadership behavior is an important factor in promoting work motivation amongintensive care nurses. The findings highlight the need for healthcare organizations to prioritize ethical leadership development as a means of promoting a positive work environment and enhancing the motivation and well-being of nurses (Alhaddad et al., 2020). 7 1.2.3 Patient Care Outcomes Expectancy Theory, developed by Vroom (1964), suggests that individuals are motivated to act in ways that they consider will lead to desired outcomes(Vroom 1964).Patient care outcomes encompass the tangible and intangible results of healthcare interventions. Ethical leadership has a significant impact on patient care outcomes by creating an empowering environment. Ethical leaders encourage nurses to provide patient-centered care, characterized by open communication, shared decision-making, and a commitment to patient safety. Guided by ethical leaders, nurses demonstrate heightened clinical judgment, empathy, and a dedication to delivering high-quality care. As a result, patient outcomes such as satisfaction, recovery rates, and overall well-being improve due to the ethical behavior fostered by leadership (Storaker et al., 2022; El- Gazar and Zoromba, 2021b). A study conducted by Zhang (2019) indicates a substantial positive relationship between organizational ethical leadership and nurse service behavior. Specifically, the study finds that ethical leadership have a direct positive effect on nurses' service behavior, as well as an indirect effect mediated by moral climate and moral sensitivity. The study also finds that moral climate and moral sensitivity mediated the relationship between ethical leadership and service behavior. In other words, nurses who perceived a positive moral climate and who are more morally sensitive are more likely to engage in positive service behaviors, which are in turn positively influenced by ethical leadership., the findings suggest that ethical leadership shows an vital role in shaping the moral climate and moral sensitivity of nurses, which can ultimately lead to improved service behavior and better patient outcomes (Zhang et al., 2019). Purposive sampling is used to select 14 nursing supervisors and faculty members at various levels, and a qualitative technique utilizing traditional content analysis is used. Latent analysis of content and constant comparison analysis is used to conduct and analyze semi-structured interviews. The study finds that the moral conduct of nursing leaders resulted in improvements in productivity through better service delivery and the inspiration of moral behavior in staff members. Additionally, the leaders' satisfaction is found to be positively correlated with ethical behavior. The study highlights how crucial moral leadership is to the development and growth in the nursing field. There is concern for ethical issues (Barkhordari-Sharifabad et al., 2018). 8 The aim of the study that is conducted in 2021 is the use of a cross-sectional study to investigate the relationship between ethical leadership, trust in management, psychological well-being, and organizational citizenship behaviors (OCB) among 495 nurses from six hospitals in China. Results indicate that ethical leadership is totally associated with trust in management and psychological well-being, and trust in management is positively associated with OCB. The study also finds that the indirect effects of perceived ethical leadership on OCB through belief in management and psychological well-being are significant. The findings suggest that creating a fair work environment can enhance nurses' psychological health, trust in leadership, and OCB towards improving patients' satisfaction (Huang et al., 2021b). Researcher's opinion The relationship between leadership ethics, motivation, and various aspects related to institutional work is indeed a topic of significant interest and importance in organizational research. Leadership ethics refers to the ethical principles and values upheld by leaders in their decision-making and actions within an organization. Ethical leadership is often associated with positive outcomes such as employee trust, commitment, and organizational performance. Motivation, on the other hand, plays a crucial role in driving individual and collective behavior within an organization. Motivated employees are more likely to be engaged, productive, and committed to achieving organizational goals. Previous studies have consistently shown that there is a strong connection between leadership ethics and employee motivation. Leaders who demonstrate ethical behavior and integrity tend to inspire trust and confidence among their employees, which in turn fosters a positive work environment and enhances motivation. Furthermore, ethical leadership has been found to have a significant impact on various other aspects of organizational functioning, including employee satisfaction, job performance, organizational culture, and overall effectiveness. 9 By cultivating a culture of ethical leadership and promoting motivation among employees, organizations can create a supportive and conducive work environment that not only enhances individual well-being but also contributes to the long-term success and sustainability of the institution. In summary, the relationship between leadership ethics, motivation, and other matters related to institutional work is complex and multifaceted. However, existing research suggests that ethical leadership and motivation are crucial drivers of organizational performance and employee well-being. Further research in this area can provide valuable insights for organizations seeking to foster a positive and ethical workplace culture. 1.3 Concepts and Operational Definitions Concept: Ethical Leadership Definition: Ethical leadership refers to leaders consistently demonstrating ethical values, making transparent decisions, and fostering an environment that upholds moral principles in the healthcare setting (Van Diggele et al., 2020; Northouse, 2021). Operational Definition: Ethical leadership was assessed using the Ethical Leadership Scale (ELS) questionnaire. This questionnaire measures nurses' perceptions of their leaders' ethical behaviors, including fairness, integrity, role modeling, and the establishment of an ethical work culture (Brown et al., 2005, Khan and Javed, 2018). This is based on a Likert scale of 5, where: strongly disagree=0, disagree=1, no opinion=2, agree=3, strongly agree=4, that consist from 20 questions that response from strongly disagree to strongly agree. Concept: Nurses' Motivation Definition: Nurses' motivation represents their internal drive and dedication to their roles, patient care responsibilities, and professional growth in the intensive care unit (Bahlman‐van Ooijen et al., 2023; Hesselink et al., 2023). Operational Definition: Nurses' motivation was measured using the Nurses' Work Motivation Scale (NWMS). The NWMS evaluates both intrinsic and extrinsic motivational factors, such as job satisfaction, recognition, autonomy, career advancement, and alignment with ethical values (Dor and Halperin, 2022). That scored 10 according to Likert scale 5 where: None =0, Little =1, enough =2, Much =3, Very much =4, that consist from 17 question that response from none to very much Concept: Patient Care Outcomes Definition: Patient care outcomes encompass measurable and qualitative results of healthcare interventions, including patient satisfaction, recovery rates, safety, and overall well-being (Sonğur et al., 2018). Operational Definition: Patient care outcomes were evaluated using a modified version of the System Assessment Questionnaire (SAQ) adapted for nursing perspectives. The SAQ examines how patients perceive the effect of ethical behavior and nurses' motivation on patient safety, quality of care, and the length of stay in the intensive care unit (Malinowska-Lipień et al., 2021). That was assessed using the Likert scale 5, which has three questions ranging from strongly disagree to strongly agree. Strongly disagree = 0, disagree = 1, neutral = 2, agree = 3, and strongly agree = 4. 1.4 Problem Statement This study addresses the problem of judgments made by leaders in intensive care departments. Through my work in hospitals and my experience in intensive care for 3 years, there were problems in nurses‟ dealings with leaders, and leaders used to deal with nurses by making ethical problem judgments. Palestinian hospitals need to examine the relationship between ethical leadership, nurses' motivation, and patient care outcomes, particularly in intensive care units (ICUs). Despite the recognized importance of ethical leadership in healthcare settings, there is a gap in understanding how it specifically impacts the motivation levels of intensive care nurses and, subsequently, the quality of patient care provided in these settings. This study aims to address this gap by investigating the influence of ethical leadership on nurses' motivation and its subsequent impact on patient care outcomes, as perceived by intensive care nurses in Nablus hospitals, as many studies have indicated the presence of ethical problems between leaders and nurses in intensive care departments, and failure to implement ethical leadership behavior has had negative effects on the relationship between nurses‟ motivations and patients care outcomes (Lotfi et al., 2018; Uzelli Yılmaz et al., 2020). 11 1.5 Significant of Study It is essential to research the relationship between ICU nurses' motivation and ethical leadership in Nablus hospitals for several reasons. It adds something new to the body of knowledge regarding the significance of ethical leadership in healthcare settings. The study has practical implications for healthcare leadership. By demonstrating the importance of ethical leadership behavior in motivating ICU nurses, the study highlights the need for healthcare organizations to prioritize ethical leadership development programs and ensure that their leaders demonstrate ethical behavior in their daily practices (Malik & Khan, 2018). The importance of this study lies in its ability to inform the development of effective leadership strategies that promote ethical behavior and promote motivation in critical care nurses. These findings could have broad implications for healthcare organizations across a variety of settings, including Nablus. By improving leadership methods to align with ethical principles, organizations can aspire to achieve better outcomes for patients and create a more positive and productive work environment for their patients, and their healthcare professionals. 1.6 Aims of Study The study aims to investigate the impact of ethical leadership behavior on the motivation of working and patient care outcomes among intensive care nurses in Nablus hospitals. 1.6.1 Specific Objectives  To assess the ICU nurses' motivation score.  To find out the patients care outcome score.  To investigate the leadership behaviors from the point view of ICU nurses. 12 1.7 Hypothesis  There is a relationship between ethical leadership behavior demonstrated by nurse managers and work motivation among intensive care nurses in Nablus hospitals."  There is a relationship between ethical leadership behavior demonstrated by nurse managers and patient care outcomes among intensive care nurses in Nablus hospitals.  There is a relationship between Patient's care outcome and demographic data (age, qualification, experience, monthly income, gender, work place and Employment status).  There is a relationship between Nurses' motivation in relation to demographic data (age, qualification, experience, monthly income, gender, work place and Employment status). 1.8 variables 1.8.1 Independent variable  Ethical leadership.  Demographic data (age, qualification, experience, monthly income, gender, work place and Employment status). 1.8.2 Dependent variables  Nurses' motivation  Patient's care outcome 13 Chapter Two Methodology 2.1 Study Design A cross-sectional design was used in this study to investigate the relationships between ethical leadership behavior, work motivation, and patient care outcomes among ICU nurses in Nablus hospitals, Palestine. A cross-sectional design refers to a research design that involves collecting data from a population or sample at a single point in time. Cross-sectional studies can provide a snapshot of the prevalence or relationship of variables, but cannot establish cause-and- effect relationships (Rubin & Babie, 2016). 2.2 Site and Setting The study was conducted with intensive care nurses at seven hospitals. The seven hospitals consist of private and government hospitals (An-Najah National University Hospital, Nablus Specialized Hospital, Specialized Arab Hospital, Women's Union Hospital, St. Luke's Hospital and two governmental hospitals Rafidia Surgical Hospital and Alwatany Medical Hospital). 2.3 Study population and sample size The population for this research was all intensive care nurses working in the selected hospitals during the indicated study period, which represented the sample size. A non- probability convenience sampling method was used to enroll participants in the study, and the return-on-investment rate was 100% as per Table2.1. Table 2.1 Distribution the Number of Nurses and ICU Beds in Nablus Hospitals Name of hospital ICU beds N. of Nurses Sample size An-Najah National University Hospital 11 40 40 Nablus Specialized Hospital 14 18 18 Specialized Arab Hospital 8 24 24 Women's Union Hospital 4 12 12 St. Luke's Hospital 4 12 12 Alwatany Medical Hospital (governmental) 8 20 20 Rafidia Surgical Hospital (governmental) 10 24 24 Total 150 150 (100%) 14 2.4 Inclusion criteria and Exclusion criteria 2.4.1 Inclusion criteria  All nurses who work in the ICU department of the hospital that were mentioned in the previous schedule  All head nurses in the ICU were considered highly experienced people in the department. 2.4.2 Exclusion criteria  Any nurse who does not work in the ICU department. 2.5 Data Collection Tool It is a self-administrative questionnaire, composed of four parts (appendixes A). Part one: Consisted of Socio-Demographic Data of the Participants. Part two: Ethical Leadership Scale. This part was adopted from a study by Brown (2005). It consisted of 20 statements with five Likert scale choices ranging from strongly agree to strongly disagree. It involved three categories: ethical behavior, employee engagement, and ethical decision-making. Used to assess how the ICU nurses see a leader's ethical behavior (Brown et al., 2005). This is based on a Likert scale of 5, where: strongly disagree = 0, disagree = 1, no opinion = 2, agree = 3, and strongly agree = 4. It consists of 20 questions that range from strongly disagree to strongly agree. Part three: Motivation Nurse Scale The Motivation Nurse Scale was developed by Deressa and Zeru. It is composed of 17 closed-ended questions with five Likert scale choices that range from none to very much. The scale is used to assess salary, job security, ability development, autonomy, skill enhancement, relationships, recognition, organizational culture, and leadership support (Deressa & Zeru, 2019). That was scored according to the Likert scale 5, where None =0, Little =1, Enough =2, Much = 3, and Very Much =4, which consists of 17 questions that range from none to very much. 15 Part Four: Patients Care Outcome This part consists of three closed-ended questions with five Likert scale choices that range from strongly agree to strongly disagree. It was used to assess the patient's care outcome from the nurses‟ point of view on patient safety, the standard of care (quality), and hospital stay times adopted by Bondevik, G. T., D. Hofoss, B. S. Huseb, and E. C. T. Deilkås (Bondevik et al., 2019). That was assessed using the Likert scale 5, which has three questions ranging from strongly disagree to strongly agree. Strongly disagree = 0, disagree = 1, neutral = 2, agree = 3, and strongly agree = 4. 2.6 Validity and Reliability 2.6.1 Validity A panel of specialists is consulted to determine its validity. As arbitrators, the questionnaire was presented to a panel of specialists (Appendix I) with competence and expertise in management to provide their judgments and recommendations on the questionnaire's suitability and adequacy, identify and assess whether the items of the questionnaire are in line with the aims of the study and the extent to which these items represent the research topic, and estimate whether the questionnaire used is valid statistically and well-designed enough to examine variables and provide relationships. The specialists provided their comments on the clarity, straightforwardness, simplicity, and sufficiency of the parts. As a result, the researchers made some adjustments to the questionnaire, such as using gender rather than sex. After some changes, the questionnaire is considered valid. 2.6.2 Reliability Reliability was conducted to evaluate the internal consistency of a measurement instrument comprising three scales: leadership, motivation, and patient care outcome, with a total of 40 items. A pilot study was conducted on a sample of 30 participants who were selected and included in the study. The time required to fill out the questionnaire is about 15 minutes. A reliability analysis was conducted to assess the internal consistency of the measurement instrument used in the pilot study; the Cronbach's alpha coefficient is 0.78, which indicates the questionnaire is reliable. 16 2.7 Data Collection Procedures /Field Work Data was collected between 15 August to 15 September of 2023, a period of two months. The questionnaire was sent to hospital nurse managers for completion after hospitals had approved it. Using convenient procedures, forms were handed to the nursing staff at the end of each shift. The questionnaire was collected by the researcher in nursing after three weeks. The study's goals and the confidentiality of the data were made clear by the nurse manager. Nurses completed questionnaires that were collected equally. 2.8 Data Analysis The data analysis was performed using version 20 of the Statistical Package for the Social Sciences (SPSS). Correlations and the effect of ethical leadership behavior on the motivation of ICU nurses to perform their jobs were examined through data analysis. Descriptive statistics were used to describe the main study variables and the demographic data of the participants. Included in this are percentages, frequencies, means, and standard deviations. The study hypotheses were tested, in which the relationship between nurse demographics, motivational and ethical leadership scores, and patient care outcomes, as well as the relationship between measures, was tested. The use of non-parametric tests is associated with violating the assumption of normal distribution, as the Mann-Whitney U test is used to investigate differences in mean scores according to binary factors (gender and employment status) as an alternative to independent samples. The t-test, while the Kruskal-Wallis was used to investigate differences according to non-binary factors (age as a categorical factor, qualification, experience categories, monthly advertising income), was an alternative to one-way analysis of variance (ANOVA). The Spearman correlation test was used to determine the direction and strength of the association between continuous factors (age, experience, and income) and the measures, and between the measures themselves, as an alternative to the Pearson correlation test. 17 2.9 Ethical Consideration To ensure that the study based on the research ethics (IRB) approval letter (Appendix B) was obtained. Then approval from each involved hospital was also obtained (Appendix C, D, E, F, G, H). A consent form was also collected from each participant before to the start of data collection, and they were informed of their right to decline or withdraw from the study at any time. 18 Chapter Three Results This chapter is dedicated to demonstrate the descriptive and analytical results of the current study, where descriptive results were considered with the distribution of nurses‟ demographic, as well as their responses to the provided scales, that included Nurses‟ Work Motivation, Ethical Leadership and Patients‟ outcomes, in term of frequencies and percentages, in addition to the means (± standard deviations) and medians (and interquartile ranges) of their scores, while the analytical results were considered with using the suitable inferential statistics to investigate the relationship between nurses‟ demographic and the scales‟ scores, in addition to the correlation between the scores on the scales themselves, in order to answer the study‟s objectives and test its hypotheses. First, the data was tested for its normality, in which age and monthly income of the nurses were used to explore the distribution of the data and investigate whether they followed the normal distribution or not. Using Kolmogorov-Smirnov and Shapiro-Wilk normality tests, as shown in Table 3.1, the significance level (p-value) of the tests is < 0.001, which leads to the rejection of the null hypothesis that assumes the normal distribution of the data, indicating the need to use non-parametric tests in the descriptive and analytical parts of the analysis. In addition, the distribution of nurses‟ age and monthly income are shown below. Table 3.1 Normality Tests of the Data Based on the Age and Monthly Income Independent variable Normality test Statistic p-value Interpretation Age Kolmogorov-Smirnov 0.163 < 0.001 Not normal Shapiro-Wilk 0.861 < 0.001 Not normal Monthly Income Kolmogorov-Smirnov 0.159 < 0.001 Not normal Shapiro-Wilk 0.926 < 0.001 Not normal 3.1 Demographic of the Nurses The following table (Table 3.2) distributes the demographic of the ICU nurses who participated in the current study, which shows that around half of the nurses (47.3%) are between 26 and 30 years old, with another fourth (25.3%) are between 31 and 35 years old, at a median age of 30 years old (IQR = 7 years), ranging from 23 to 56 years old 19 (figure 1.1), while there was more male (64.0%) than female (36.0%) nurses (Figure 1.2). Additionally, most of the nurses (75.3%) acquire the bachelor‟s degree in nursing, with approximate percentages of ICU nurses who acquire the diploma (12.0%) and master‟s (12.7%) degrees (Figure 1.3). Nurses were recruited from the targeted hospitals in a proportional way, where more than one fourth of them (26.7%) work at An-Najah National University Hospital, followed by equal percentages of nurses who work at Specialized Aran Hospital and Rafidia Surgical Hospital (16.0% each, Figure 1.4). There was also approximate percentages of nurses who have a total experience in nursing of between 1 and 5 years (35.3%) and 6 to 10 years (36.7%), with a median experience of 7 years (IQR = 6 years) ranging from 1 to 35 years, while in the ICU setting, the nurses who have an experience between 1 and 5 years possess more than one half of them (54.0%), with a median experience of 5 years (IQR = 6 years) ranging from 1 to 35 years (Figure 1.5). The vast majority of ICU nurses work full-time job in the targeted hospitals (91.3%, Figure 1.6), with around half of them (47.3%) having a monthly income of 3001 to 4000 NIS, with a median income of 4000 NIS (IQR = 1300 NIS), ranging from 2200 to 8000 NIS (Figure 1.7). 20 Table 3.2 Distribution Percentage of Participants According to their Demographic Data Variables Values N % Age (in complete years) 22 – 25 years old 15 10.0 26 – 30 years old 71 47.3 31 – 35 years old 38 25.3 36 – 40 years old 11 7.3 > 40 years old 15 10.0 Median (IQR, min – max) 30 (7, 23 – 56) Gender Male 96 64.0 Female 54 36.0 Qualification Diploma 18 12.0 Bachelor‟s degree 113 75.3 Master‟s degree 19 12.7 Place of Work An-Najah National University Hospital 40 26.7 Nablus Specialized Hospital 18 12.0 Specialized Arab Hospital 24 16.0 Women‟s Union Hospital 12 8.0 St. Luke‟s Hospital 12 8.0 Al-Watani Medical Hospital 20 13.3 Rafidia Surgical Hospital 24 16.0 Total Experience in Nursing 1 – 5 years 53 35.3 6 – 10 years 55 36.7 11 – 15 years 23 15.3 > 15 years 19 12.7 Median (IQR, min – max) 7 (6, 1 – 35) Experience in ICU setting 1 – 5 years 81 54.0 6 – 10 years 43 28.7 11 – 15 years 17 11.3 > 15 years 9 6.0 Median (IQR, min – max) 5 (6, 1 – 35) Employment Status Full time 137 91.3 Part time 13 8.7 Monthly income Up to 3000 NIS 16 10.7 3001 – 4000 NIS 71 47.3 4001 – 5000 NIS 35 23.3 > 5000 NIS 28 18.7 Median (IQR, min – max) 4000 (1300, 2200 – 8000) IQR = Interquartile range, min = minimum, max = maximum, ICU = Intensive care unit, NIS = New Israeli Shekel (currency). 21 Figure 3.1 Distribution of nurses' age categories Figure 3.2 Distribution of nurses' genders 10.0% 47.3% 25.3% 7.3% 10.0% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% 22 – 25 years old 26 – 30 years old 31 – 35 years old 36 – 40 years old > 40 years old P er ce n ta g e Age groups Male, 64.0% Female, 36.0% 22 Figure 3.3 Distribution of nurses' qualification Figure 3.4 Distribution of nurses' workplace 12.0% 75.3% 12.7% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Diploma Bachelor’s degree Master’s degree P er ce n ta g e Educational qualification 26.7% 12.0% 16.0% 8.0% 8.0% 13.3% 16.0% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% An-Najah National Hospital Nablus Specialized Hospital Specialized Arab Hospital Women’s Union Hospital St. Luke’s Hospital Al-Watani Medical Hospital Rafidia Surgical Hospital P er ce n ta g e Workplaces 23 Figure 3.5 Distribution of nurses' experience Figure 3.6 Distribution of nurses' employment status 35.3% 36.7% 15.3% 12.7% 54.00% 28.70% 11.30% 6.00% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 1 – 5 years 6 – 10 years 11 – 15 years > 15 years P er ce n ta g e Experience categories Nursing profession ICU setting Full time, 91.3% Part time, 8.7% 24 Figure 3.7 Distribution of nurses' monthly income 3.2 Nurses’ Work Motivation The second part of this analysis is dedicated to distributing the frequencies and percentages of the participants‟ responses to “Nurse‟s Work Motivation Scale”, which is interested in assessing the motivators of nurses in the context of work. Overall, most of the nurses are little too much motivated by the provided items, with the most motivating items are found to be good relationships with colleagues (mean = 3.15 ± 0.89), followed by good relationship with the managers (mean = 3.34 ± 0.79) and developing skill and knowledge (mean = 3.21 ± 0.88), while the least motivating items were salary (mean = 2.56 ± 0.74), followed by ability development (mean = 2.94 ± 0.88), job security feeling (mean = 2.95 ± 0.83) and autonomy (mean = 2.96 ± 0.86). In more details, more than half of the nurses are little motivated by salary (55.3%) and autonomy (36.7%), while nurses are enough motivated by job security feeling (47.3%), ability development (42.0%), developing skills and knowledge (37.3%), interested job object (41.3%), equal treatment (45.3%), good working conditions (42.0%), recognition and bid estimate (36.7%), supportive organizational culture and teamwork (39.3%), opportunities for innovation and creativity (36.7%), supportive leadership (33.3%) and 10.7% 47.3% 23.3% 18.7% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Up to 3000 NIS 3001 – 4000 NIS 4001 – 5000 NIS > 5000 NIS P er ce n ta g e Monthly income categories 25 flexibility in scheduling and work arrangements (39.3%), with much motivation by good relationships with managers (40.0%) and colleagues (45.3%) and appreciation from colleagues and superiors (42.0%). The following figure illustrates the distribution of nurses‟ responses to items of Nurse‟s Work Motivation Scale (Figure 3.8). 26 Table 3.3 Distribution Percentage of Participants According to their ‘Work Motivation Scale Items’ F = Frequency, SD = Standard deviation, IQR = Interquartile range Statement None Little Enough Much Very much Mean SD N % N % N % N % N % Salary 1 0.7 83 55.3 49 32.7 15 10.0 2 1.3 2.56 0.74 Job Security Feeling 4 2.7 39 26.0 71 47.3 32 21.3 4 2.7 2.95 0.83 Ability Development (Promotion) 7 4.7 39 26.0 63 42.0 38 25.3 3 2.0 2.94 0.88 Autonomy/Feature Initiative 0 0.0 55 36.7 49 32.7 43 28.7 3 2.0 2.96 0.86 Developing Skills and knowledge 1 0.7 34 22.7 56 37.3 51 34.0 8 5.3 3.21 0.88 Good Relationships with Colleagues 0 0.0 19 12.7 49 32.7 68 45.3 14 9.3 3.51 0.83 Good Relationships with the Manager 0 0.0 23 15.3 60 40.0 60 40.0 7 4.7 3.34 0.79 Interested Job Object 3 2.0 32 21.3 62 41.3 45 30.0 8 5.3 3.15 0.89 Equal Treatment 0 0.0 30 20.0 68 45.3 51 34.0 1 0.7 3.15 0.74 Good Working Conditions 2 1.3 30 20.0 63 42.0 51 34.0 4 2.7 3.17 0.82 Recognition and Bid Estimate 3 2.0 39 26.0 55 36.7 51 34.0 2 1.3 3.07 0.86 Supportive Organizational Culture and Teamwork 3 2.0 39 26.0 59 39.3 44 29.3 5 3.3 3.06 0.88 Appreciation and Feedback from Colleagues and Superiors 1 0.7 36 24.0 58 38.7 48 32.0 7 4.7 3.16 0.87 Alignment of Personal Values with the Organization's Mission and Values 1 0.7 39 26.0 53 35.3 50 33.3 7 4.7 3.15 0.89 Opportunities for Innovation and Creativity in the Job 2 1.3 45 30.0 55 36.7 44 29.3 4 2.7 3.02 0.87 Supportive leadership that Encourages and Empowers Employees 0 0.0 44 29.3 50 33.3 49 32.7 7 4.7 3.13 0.89 Flexibility in Scheduling and Work Arrangements 0 0.0 34 22.7 59 39.3 52 34.7 5 3.3 3.19 0.82 Overall (mean ± SD) Out of 5 3.101 ± 0.6017 Out of 100 62.024 ± 12.0349 Median (IQR, min – max) 3.058 (1, 1.82 – 4.65) 61.177 (20, 36.47 – 92.94) 27 Figure 3.8 Distribution of nurses' responses to nurses' work motivation scale 0.7% 2.7% 4.7% 0.0% 0.7% 0.0% 0.0% 2.0% 0.0% 1.3% 2.0% 2.0% 0.7% 0.7% 1.3% 0.0% 0.0% 55.3% 26.0% 26.0% 36.7% 22.7% 12.7% 15.3% 21.3% 20.0% 20.0% 26.0% 26.0% 24.0% 26.0% 30.0% 29.3% 22.7% 32.7% 47.3% 42.0% 32.7% 37.3% 32.7% 40.0% 41.3% 45.3% 42.0% 36.7% 39.3% 38.7% 35.3% 36.7% 33.3% 39.3% 10.0% 21.3% 25.3% 28.7% 34.0% 45.3% 40.0% 30.0% 34.0% 34.0% 34.0% 29.3% 32.0% 33.3% 29.3% 32.7% 34.7% 1.3% 2.7% 2.0% 2.0% 5.3% 9.3% 4.7% 5.3% 0.7% 2.7% 1.3% 3.3% 4.7% 4.7% 2.7% 4.7% 3.3% Salary Job security Ability development Autonomy Developing skills Relationships w/ colleagues Relationships w/ manager Interested job object Equal Treatment Good working conditions Recognition and bid estimate Supportive culture/teamwork Appreciation and feedback Alignment of values Opportunities for innovation Supportive leadership Flexibility in scheduling None Little Enough Much Very much 28 3.3 Ethical Leadership The following table (Table 3.4) distributes the responses of ICU nurses on the statements of Ethical Leadership Scale, which contains 20 items that are rated on a 5- point Likert scale of agreement. Overall, most of the nurses were in the agreement part towards the application of ethical leadership principles that were provided, with an overall score of 3.597 ± 0.5434 out of 5, with higher scores indicating more agreement towards the application of ethical leadership principles by the leaders. The most ethical leadership principles that were applied by the nurses‟ leaders were related to taking responsibility for ethical lapses or mistakes (mean = 3.71 ± 0.73) and listening to what employees have to say (mean = 3.67 ± 0.73), while the least applied ethical responsibilities were related to creating the trust of subordinates (mean = 3.49 ± 0.84) and defining success by how the result was obtained in addition to the result itself (mean = 3.50 ± 0.83), taking in consideration that all statements have high means indicating high levels of ethical leadership. All of the statements in the Ethical Leadership Scale showed that nurses agree to the provided principles, like listening to what employees say (66.7%), disciplining employees with ethical considerations violation (62.0%), as well as conducting personal life in an ethical way (54.0%) and having the best interests of employees in mind (57.3%). Also, nurses agreed that leaders make fair decisions (60.0%), create subordinates‟ trust (54.7%), discuss values business (57.3%), in addition to giving examples of the right way to apply ethical considerations (55.3%) and define success by how results are obtained in addition to results themselves (52.0%). Moreover, nurses showed agreement that leaders ask about the right thing to do (56.0%), as well as that they act as role models in providing ethical considerations (51.3%), while encouraging ethical behaviors among the employees (58.0%). Also, nurses agreed that leaders create transparent and open culture (59.3%), with taking responsibility for mistakes and lapses (60.7%), as well as prioritizing ethical considerations over personal goals (54.7%), and encouraging the employees to freely speak about ethical concerns (58.0%). 29 Lastly, most of the nurses agreed that the leaders provide ethical training to the employees (58.7%), with holding accountability for ethical behaviors (62.0%), as well as having ethical decision-making consistency (62.7%) and upholding ethical standards even in difficult and challenging situations (60.7%). The following figure illustrates the distribution of nurses‟ responses to items of Ethical Leadership Scale (Figure 3.9). 30 Table 4.3 Distribution Number and Percentage of Participants According to their Responses to Ethical Leadership Scale Items F = Frequency, SD = Standard deviation, SD = Strongly disagree, D = Disagree, N= Neutral, A = Agree, SA = Strongly agree Statement SD D N A SA Mean SD N % N % N % N % N % Listen to what employees have to say 0 0.0 15 10.0 27 18.0 100 66.7 8 5.3 3.67 0.73 Discipline employees who violate ethical standards 0 0.0 15 10.0 35 23.3 93 62.0 7 4.7 3.61 0.73 Conduct his/her personal life in an ethical manner 3 2.0 16 10.7 39 26.0 81 54.0 11 7.3 3.54 0.86 Have the best interests of employees in mind 0 0.0 20 13.3 33 22.0 86 57.3 11 7.3 3.59 0.81 Make fair and balanced decisions 1 0.7 19 12.7 32 21.3 90 60.0 8 5.3 3.57 0.81 Engender the trust of subordinates 1 0.7 23 15.3 36 24.0 82 54.7 8 5.3 3.49 0.84 Discuss business ethics or values with employees 0 0.0 23 15.3 30 20.0 86 57.3 11 7.3 3.57 0.84 Set an example of how to do things the right way in terms of ethics 1 0.7 22 14.7 30 20.0 83 55.3 14 9.3 3.58 0.88 Define success not just by results but also the way they are obtained 2 1.3 17 11.3 44 29.3 78 52.0 9 6.0 3.50 0.83 When making decisions, ask “What is the right thing to do”? 1 0.7 16 10.7 37 24.7 84 56.0 12 8.0 3.60 0.81 Act as a role model for ethical behavior 1 0.7 22 14.7 35 23.3 77 51.3 15 10.0 3.55 0.89 Encourage ethical behavior in others 1 0.7 19 12.7 29 19.3 87 58.0 14 9.3 3.63 0.85 Create a culture of transparency and openness 1 0.7 22 14.7 26 17.3 89 59.3 12 8.0 3.59 0.86 Take responsibility for ethical lapses or mistakes 0 0.0 11 7.3 35 23.3 91 60.7 13 8.7 3.71 0.73 Prioritize ethical considerations over personal gain 1 0.7 12 8.0 42 28.0 82 54.7 13 8.7 3.63 0.78 Encourage employees to speak up about ethical concerns 1 0.7 14 9.3 35 23.3 87 58.0 13 8.7 3.65 0.80 Provide ethical training and education for employees 1 0.7 24 16.0 29 19.3 88 58.7 8 5.3 3.52 0.85 Hold oneself and others accountable for ethical behavior 2 1.3 9 6.0 37 24.7 93 62.0 9 6.0 3.65 0.74 Show consistency in ethical decision-making 1 0.7 10 6.7 37 24.7 94 62.7 8 5.3 3.65 0.71 Uphold ethical standards even in difficult or challenging situations. 1 0.7 13 8.7 34 22.7 91 60.7 11 7.3 3.65 0.77 Overall score (mean ± SD) Out of 5 3.597 ± 0.5434 Out of 100 71.947 ± 10.8682 Median (IQR, min – max) 3.700 (0.75, 1.95 – 5) 74.000 (15, 39.00 – 100.00) 31 Figure 3.9 Distribution of nurses' responses to nurses' to ethical leadership scale 0.0% 0.0% 2.0% 0.0% 0.7% 0.7% 0.0% 0.7% 1.3% 0.7% 0.7% 0.7% 0.7% 0.0% 0.7% 0.7% 0.7% 1.3% 0.7% 0.7% 10.0% 10.0% 10.7% 13.3% 12.7% 15.3% 15.3% 14.7% 11.3% 10.7% 14.7% 12.7% 14.7% 7.3% 8.0% 9.3% 16.0% 6.0% 6.7% 8.7% 18.0% 23.3% 26.0% 22.0% 21.3% 24.0% 20.0% 20.0% 29.3% 24.7% 23.3% 19.3% 17.3% 23.3% 28.0% 23.3% 19.3% 24.7% 24.7% 22.7% 66.7% 62.0% 54.0% 57.3% 60.0% 54.7% 57.3% 55.3% 52.0% 56.0% 51.3% 58.0% 59.3% 60.7% 54.7% 58.0% 58.7% 62.0% 62.7% 60.7% 5.3% 4.7% 7.3% 7.3% 5.3% 5.3% 7.3% 9.3% 6.0% 8.0% 10.0% 9.3% 8.0% 8.7% 8.7% 8.7% 5.3% 6.0% 5.3% 7.3% Listen to employees Discipline employees Conduct personal life ethically Best interests in mind Make fair and balanced decisions Engender the trust of subordinates Discuss business ethics Set an example of the right way Define success by result obtaining Asking about the right thing to do Act as a role model for ethical behavior Encourage ethical behavior in others Create a culture of transparency Take responsibility for ethical lapses Prioritize ethical considerations Encourage employees to speak up Provide ethical training and education Accountability for ethical behavior Ethical decision-making consistency Ethical standards in difficult situations Strongly disagree Disagree Neutral Agree Strongly agree 32 3.4 Patients’ Care Outcome The following table (Table 3.5) distributes the responses of ICU nurses towards specific statements related to patients' care, related to ethical leadership behavior and ICU nurse motivation. The table shows that the highest agreement is on that motivation which has a positive impact on the provided healthcare services (mean = 4.13 ± 0.75), followed by the statement that ethical leadership is connected to shorter patient‟s length of stay (mean = 4.10 ± 0.080), and that it has a positive impact on the safety of the patient (mean = 4.05 ± 0.72). The following figure illustrates the distribution of nurses‟ responses to items of modified SAQ Scale (Figure 3.10). 33 Table 3.5 Distribution of Number and Percentage of Participants According to their Responses to Patient Care Outcome Statement SD D N A SA Mean SD N % N % N % N % N % 1. Ethical leadership behavior in the ICU has a positive impact on patient safety 0 0.0 3 2.0 26 17.3 82 54.7 39 26.0 4.05 0.72 2. ICU nurse motivation has a positive impact on the quality of care provided to patients 0 0.0 3 2.0 25 16.7 72 48.0 50 33.3 4.13 0.75 3. Ethical leadership behavior and staff motivation contribute to shorter lengths of stay in the ICU 0 0.0 5 3.3 26 17.3 68 45.3 51 34.0 4.10 0.80 Overall score (mean ± SD) Out of 5 4.091 ± 0.667 Out of 100 81.822 ± 13.353 Median (IQR, min – max) 4.00 (1, 2.0 – 5.0) 80.0 (20, 40.0 – 100.0) 34 Figure 3.10 Distribution of nurses' responses to patient outcome scale (modified SAQ) 3.5 Description of scales’ overall scores and classification The scores of Work Motivation, Ethical Leadership and Patient‟s care outcome scales for each participant were calculated by summing up the scores of each item and then transforming the score to a total out of 100%. As shown in Table 3.6, the mean overall score of work motivation was 62.024% ± 12.0349, with a median of 61.177% (IQR = 20), ranging from 36.47% to 92.94%. Moreover, in Table 5 the mean score of ethical leadership scale was 71.947% ± 10.8682, with a median of 74.0% (IQR = 15), ranging from 39% to 100%. Lastly, in Table 6 the mean score of patient‟s care scale was 81.822% ± 13.353, with a median score of 80.0% (IQR = 20) ranged from40.0% to 100%. The scores for each scale were categorized to three classifications, based on the three- level cut points that are shown in the table 7, which shows that around half of the nurses (49.3%) have shown a moderate level of work motivation level, while less percentage of 44.7% showed a poor level of work motivation, compared to only 6.0% showing high level of work motivation. On the other hand, nearly two thirds of the nurses (62.7%) showed a moderate level of ethical leadership, with more than one fourth of them (26.7%) showing a high level of ethical leadership, and only 10.7% showed poor levels of ethical leadership. In addition, two thirds of the nurses (66.7%) showed a high level 2.0% 2.0% 3.3% 17.3% 16.7% 17.3% 54.7% 48.0% 45.3% 26.0% 33.3% 34.0% Ethical leadership enhances safety Motivation enhances quality of care Ethical leadership shortens lecgth of stay Strongly disagree Disagree Neutral Agree Strongly agree 35 of patient‟s care, compared to another 30.7% who showed a moderate level of patient‟s care, while only 2.7% of the nurses showed a poor level of patient‟s care. Table 3.6 Distribution of nurses’ work motivation, ethical leadership and patient’s care outcome scoring classifications Scales classification N % N % N % Poor (score < 60%) 67 44.7 16 10.7 4 2.7 Moderate (score = 60% - < 80%) 74 49.3 94 62.7 46 30.7 High (score ≥ 80%) 9 6.0 40 26.7 100 66.7 3.6 Analytical Results This part is dedicated to investigating the test of study‟s hypotheses, in which the relationship between nurses‟ demographics and the scores of motivation, ethical leadership and patient outcomes, as well as the correlation between the scales, were tested. The use of non-parametric tests was related to the violation of normal distribution assumption, where Mann-Whitney U test was used to investigate the differences of scales mean scores according to the dichotomous factors (gender and employment status) as an alternative to Independent samples t-test, while Kruskal- Wallis was used to investigate the differences according to the non-dichotomous factors (age as a categorical factor, qualification, experience categories, ad monthly income) as an alternative to one-way analysis of variance (ANOVA), and Spearman Correlation test was used to investigate the direction and power of correlation between the continuous factors (age, experience and income) and the scales, and between the scales themselves, as an alternative to Pearson Correlation test. The first table(table 3.7) investigated the relationship between demographic and the scores of work motivation scale, which showed that male nurses showed higher mean ranks (81.90) than female nurses (64.13), which indicates that male nurses showed significantly higher motivation in work by the provided items than female nurses (p- value = 0.016). While there was no significant difference in motivation was noticed between the categories of nurses‟ experience in ICU (p-value = 0.284), there was a significant correlation between the experience and the motivation score (r = - 0.199, p- value = 0.015), which indicates a significant decrease in motivation with advanced experience in ICU. Also, part-time ICU nurses significantly showed higher motivation 36 mean ranks (112.69) than full-time ICU nurses (71.97), indicating more motivation among part-time ICU nurses (p-value = 0.001). Lastly, the monthly income was significantly correlated with higher motivation (r = 0.364, p-value < 0.001), indicating higher motivation among ICU nurses who have higher monthly income. On the other hand, age, qualification and experience in nursing profession were not significantly related to motivation scores (p-value > 0.05). Table 3.7 Relationship between Nurses’ Demographic data and Work Motivation Factors Values Mean SD Test value p-value Age 22 – 25 years old 3.13 0.61 6.222 0.183 26 – 30 years old 3.19 0.60 31 – 35 years old 3.07 0.60 36 – 40 years old 3.12 0.60 > 40 years old 2.73 0.49 Spearman Correlation - 0.137 0.094 Gender Male 3.19 0.61 1978 0.016 Female 2.94 0.56 Qualification Diploma 2.85 0.56 3.582 0.167 Bachelor‟s degree 3.13 0.60 Master‟s degree 3.17 0.64 Total experience in nursing 1 – 5 years 3.25 0.62 7.412 0.060 6 – 10 years 3.01 0.55 11 – 15 years 3.18 0.68 > 15 years 2.86 0.54 Spearman Correlation - 0.143 0.080 Experience in ICU setting 1 – 5 years 3.19 0.61 3.801 0.284 6 – 10 years 3.02 0.57 11 – 15 years 2.99 0.68 > 15 years 2.87 0.41 Spearman Correlation - 0.199 0.015 Employment status Full time 3.05 0.58 407 0.001 Part time 3.66 0.56 Monthly income Up to 3000 NIS 2.64 0.35 16.042 0.001 3001 – 4000 NIS 3.05 0.64 4001 – 5000 NIS 3.29 0.58 > 5000 NIS 3.26 0.49 Spearman Correlation 0.364 < 0.001 The second table(table 3.8) investigated the relationship between demographic and professional factors and the scores of ethical leadership scale, which shows that ICU nurses with higher educational qualification had higher ethical leadership opinions (p-value = 0.019), as the mean rank was higher among master‟s nurses (100.26) compared to bachelor‟s nurses (73.31) and diploma (63.14). Also, nurses with an experience of 6 – 10 years significantly had the lowest ethical leadership opinions (mean rank = 60.44) compared to others (p-value = 0.013), while there was no 37 significant correlation between the experience as a whole and the ethical leadership scores (p-value = 0.0827). Again, part-time ICU nurses showed more positive ethical leadership opinions (mean rank = 99.42) than full-time nurses (mean rank = 73.23, p- value = 0.037). Lastly, higher monthly income was significantly correlated with more positive opinion towards the ethical leadership (r = 0.303, p-value < 0.001), while age, gender and experience in ICU setting were not related to significant differences in opinion towards ethical leadership (p-value > 0.05). Table 3.8 Relationship between Nurses’ Demographic data and Patient Care Outcome Factors Values Mean SD Test value p-value Age 22 – 25 years old 4.33 0.56 7.146 0.128 26 – 30 years old 3.96 0.69 31 – 35 years old 4.17 0.68 36 – 40 years old 4.18 0.54 > 40 years old 4.20 0.64 Spearman Correlation 0.057 0.487 Gender Male 4.04 0.63 2205 0.124 Female 4.18 0.72 Qualification Diploma 3.93 0.44 9.069 0.011 Bachelor‟s degree 4.05 0.69 Master‟s degree 4.47 0.60 Total experience in nursing 1 – 5 years 4.06 0.66 0.987 0.804 6 – 10 years 4.05 0.70 11 – 15 years 4.16 0.67 > 15 years 4.21 0.61 Spearman Correlation 0.014 0.867 Experience in ICU setting 1 – 5 years 4.15 0.63 3.426 0.330 6 – 10 years 3.93 0.73 11 – 15 years 4.18 0.70 > 15 years 4.15 0.63 Spearman Correlation - 0.050 0.543 Employment status Full time 4.11 0.68 690 0.174 Part time 3.92 0.51 Monthly income Up to 3000 NIS 4.19 0.87 3.585 0.310 3001 – 4000 NIS 4.07 0.62 4001 – 5000 NIS 3.97 0.67 > 5000 NIS 4.24 0.65 Spearman Correlation - 0.032 0.693 38 Lastly, the correlations between the scales are investigated, and shown in (Table 3.9). The table shows that higher work motivation among ICU nurses is significantly correlated with more positive opinion towards the ethical leadership (p-value< 0.001) in a positive and strong way, with positive correlation between ICU nurses‟ opinion of ethical leadership and positive opinions on the impact on patient outcomes (p-value = 0.015), while there is significant correlation between the opinion of ethical leadership and the opinion on patient outcomes. Table 3.9 Correlation between Work Motivation, Ethical Leadership and Patient Care Outcome Factor Work motivation Ethical leadership Patient care outcome Correlation p-value Correlation p-value Correlation p-value Work motivation 0.560 < 0.001 0.064 0.434 Ethical leadership 0.560 < 0.001 0.197 0.015 Patient care outcome 0.064 0.434 0.197 0.015 39 Chapter Four Discussion and Conclusions 4.1 Introduction This chapter offers a clear overview of the study's findings, which explored the relationships among ethical behavior, nurse motivation, patient outcomes, and demographic information. The study's findings have significant implications for healthcare organizations and emphasize the value of ethical management in creating a culture that emphasizes patient outcomes. Because nurses frequently have to make difficult judgments including complex ethical considerations, this is essential in intensive care units. Ethics leaders can assist in establishing a setting of ethical thinking and discussion in the ICU by providing guidance and assistance to nurses. Ethical leadership can play a role in motivating nurses by creating a supportive work environment where nurses feel valued and respected. Patient outcomes are the ultimate goal of all healthcare operations, and intensive care units are no exception. By providing ethical leadership and supporting nurse motivation, healthcare organizations can create an environment in which nurses are more likely to provide quality care higher, which may result in better patient outcomes. 4.2 Hypotheses Discussion Our findings support hypothesis H1, revealing a positive and statistically significant (p 0.001) connection between nurse managers' ethical leadership practices and work motivation among ICU nurses in Nablus hospitals. This finding is agreed with study published in 2020 was conducted in a Turkish university hospital, involved 98 ICNs and utilized various data collection methods, including the Nurses' Description Form, Ethical Leadership Scale, and Nurses' Work Motivation Scale. The Ethical Leadership Scale and Nurses' Work Motivation Scale both show a significant positive correlation (p < 0.001) (Uzelli Yılmaz et al., 2020). Another study agree with my finding, published in 2019 that found a positive correlation between ethical leadership and job satisfaction (p = 0.000) among 285 nurses from two hospitals (Ozden et al., 2019). Our results were consistent with the South Korean study was conducted in 2019 from four public hospitals, and the results were high job satisfaction and motivation. (Jang & Oh, 2019). Lastly supported my finding by A systematic review of 16 Iranian studies found that ethical leadership significantly impacts nursing, leading to lower turnover, Ethical 40 leaders motivate employees, increased work motivation, reduced stress, and improved performance. This supports the idea that ethical leadership fosters a supportive work environment (Jandaghian-Bidgoli et al., 2023). Hypothesis 2 "We accept the hypothesis suggested in H2" explored the relationship between ethical leadership behaviors shown by nurse managers and their impact on patient care outcomes in Nablus hospitals. Our findings support our hypothesis that ethical leadership is essential for creating an engaging and effective ICU atmosphere, which leads to improved patient care. Notably, this study finds a statistically significant (p-value = 0.015) relationship between nurses' positive opinions of their supervisors' ethical leadership and improved patient outcomes. This agrees with previous research enhanced care for patients Lotfi et al study show similarly found an association between ethical leadership and improved patient care outcome (Lotfi et al., 2018). Another systematic review support my finding, Wong and Cummings' (2007) study found that effective nurse leadership can improve patient care outcomes, leading to higher satisfaction and fewer adverse events. The research supports the idea that strong leadership contributes to better patient care outcome, particularly in the ICU (Wong & Cumming, 2007). Update a systematic review of 20 research found that ethical leadership traits like openness, fairness, and open communication are effective techniques for improving patient outcomes. Following these principles results in increased patient satisfaction, care outcome, trust, and a more loving healthcare atmosphere. Ethical leadership also lowers prescription mistakes, infection rates, and death rates, highlighting the importance of healthcare organizations prioritizing ethical leadership among nurses (Wong et al., 2013). Our results were consistent The study finds that ethical leadership in Iranian teaching hospitals positively impacts nursing errors and error reporting behavior. Despite moderate ethical leadership levels among managers, it is found to be a critical strategy for enhancing patient outcome (Barkhordari-Sharifabad et al., 2018). Finally; our findings indicate that healthcare organizations should emphasize developing ethical leadership among nurse managers since it has a direct influence on both staff well-being and the quality of patient care provided. A qualitative study finding effectively communicates the advantages of ethical leadership for nurses and patient‟s outcome While the review does not directly answer your specific study hypothesis concerning the influence of ethical leadership on ICU nurse patient care outcomes, it does provide some context It gives context and 41 evidence to the greater relationship between nurse leadership and enhanced patient care (Barkhordari-Sharifabad et al., 2017). H3: The Current Study Confirmed the Third Hypothesis by Showing that Demographic Characteristics have Significant Effects on Motivation Among ICU Nurses. The first one Employment status the result show Employment status Compared to full- time nurses‟ motivation score (3.05); part-time nurses show considerably greater motivation levels motivation score (3.66) (p = 0.001). The study agrees with me that there is a relationship between employment and motivation. In addition, it agrees that part-time work is more motivating. Providing more opportunities for permanent positions may persuade some full-time nurses to switch to part-time schedules while still enjoying job security, which may explain the higher levels of motivation that part- time nurses exhibit (Zeytinoglu et al., 2015). A study finds that full-time nurses who have better access to resources, opportunities for professional growth, and career prospects are more satisfied with their jobs. Connect this finding and my findings by suggesting that their greater work satisfaction may also explain part-time nurses' better motivation ratings (Burke et al., 2014).On the other hand, the study conducted in 2011 disagree with my findings ,self-reported work satisfaction did not significantly differ between contract and full-time nurses, according to Chu and Hsu's study The difference suggests that several aspects of motivation may be influenced by one's workplace and that the measurements used are significant (Chu & Hsu, 2011).lastly, the study explores the benefits and drawbacks of part-time and full-time nurses in healthcare. Full-time nurses offer consistency but may face burnout or limited flexibility. Part-time nurses offer flexibility but may face skill gaps and knowledge transfer challenges. By understanding these differences, healthcare institutions can develop a diverse, well- trained staff for high-quality care (Jelodar et al., 2023). 42 Monthly Income: Significant positive connection (p-value < 0.001) is found in this study between motivation and monthly income among ICU nurses, a higher monthly salary is correlated with higher levels of motivation. Consistently, previous studies that agree with my findings, the study conducted in 2019 sample's participants expressed the greatest degree of dissatisfaction with their salary, which is a result of work that is independent of the institution's administration and instead represents the nation's economic climate and the structure of its whole healthcare system (Živanović et al., 2019). Even if there is a documented link between salary and fulfillment in work, the physical aspects of work remain to be one of the biggest obstacles to professional satisfaction and motivation for nurses, not just in Serbia but also in the surrounding nations (Abduelazeez et al., 2016; Jović et al., 2015). In addition, a more thorough examination of the information gathered for our study will reveal the widespread social undervaluation of the healthcare organization, particularly the nursing profession. In addition to low pay, study participants listed the following reasons for being dissatisfied with their jobs: no one was satisfied, there were no benefits for work completed, poor working conditions and few opportunities for advancement, and there were no rewards for reaching work goals, which affected nearly three-quarters of the unsatisfied subjects overall. The degree of work motivation and, consequently, the effectiveness and quality of the professional tasks carried out are greatly influenced by each of those job satisfaction and motivation (Stepanov et al., 2016). Study conducted in Kingdom of Saudi Arabia a relevant study that examined the associations between nurses' motivation and their demographic characteristics. The findings indicated the influence of several factors, including salary, on nurses' motivation (Abu Yahya et al., 2019). The study reveals a significant correlation between motivation and gender, with male ICU nurses exhibiting higher motivation levels than their female ICU. Supported by study shows Male younger nurses and those in intensive care units scored higher on career motivation scales (Atalla et al., 2023). In general, the male nurses find that they could utilize nursing as a career to reach their desired positions (Adzei & Atinga, 2012). literature review studies have found the important role played by men in the nursing field and have noted the continued rise in the number of men in this field Since male nurses believed that they were motivated (Zhang & Liu, 2016), Furthermore, it was determined that some outside factors, such as public opinion, salary, might motivate 43 more men to become nurses These results are consistent with those of previous research (Yi & Keogh, 2016).in other hand study inconsistent our results show The study found that females were slightly more motivated than males (P = 0.034). The study aimed to assess motivation levels among 550 nurses in Saudi Arabia in a tertiary hospital setting (Abu Yahya et al., 2019). Male and female nurses are motivated by similar nursing characteristics, according (De Cooman et al., 2008). No statistically significant association was seen between motivation and several other demographic data in our study. These include age, marital status, experience, and level of education. Aligning with previous studies has not shown any connection between demographic characteristics and employee motivation (Hwara, 2009; Kontodimopoulos et al., 2009). Contradict our finding several studies show a positive and significant relationship between nurses' age and their level of motivation at work (Gaki et al., 2013; Negarandeh et al., 2015). Franco et al. noted that female health professionals in Jordan had lower ratings to motivational factors, while there were essentially no differences associated to gender or age in Georgia, even though there was no significant relationship between gender and the overall motivation score in study (Franco et al., 2004). According to Koivula et al., nurses under the age of thirty had higher levels of motivation than older nurses, and higher levels of education were associated with higher levels of motivation among nurses (Koivula et al., 1998). Marital status, same our result the study type of research was a cross sectional study. 45 nurses found No statistically significant association is seen between no relationship between nurse motivation and marital status p value (0.196) (Honesty, 2019).In the other hand study show There are significant relations between marital status (Heidarian et al., 2015). Years of experience, our findings show no statistically significant link between Years of Experience and nurse motivations. The same finding is supported by the study which showed there are no statistically significant changes in motivating level based on Years of Experience (Zinnen et al., 2012). However, a study done among Turkish nurses/midwives discovers that when the number of work years increases, job satisfaction and motivation decrease, which may be attributed to greater responsibilities in family life and an inability to get the essential satisfaction and motivation from work (Pinar et al., 2017). Further research showes that motivating variables such as rewards, 44 prestige and authority, independent study, counseling, promotion prospects, and environment are greater among nurses with less than 5 years of work (Kantek et al., 2015). Compared with previous research, the number of years worked in a current profession was linked to motivation (Sato et al., 2017). This is highlighted in research that finds significant differences in motivation based on years of experience (Negussie, 2012). Furthermore, nurses' job motivation is improved significantly whether they have a lot of experience (Koch et al., 2014). Dissimilar my results Nurses with a longer service history, more experience, and greater knowledge of their profession are more motivated at work (Mutale et al., 2013; Toode, 2015). In addition, the study in the Kingdom of Saudi Arabia 550 nurses Show a significant relationship (P = 0.021) between nurses' years of experience and their motivation levels (Abu Yahya et al., 2019). Lastly, a scoping review of nurses' work motivation and the factors influencing show a link between nurses' years of experience and their motivation levels (Baljoon et al., 2018). The level of education same our result the mean motivation score and educational level of nurses did not show a statistically significant correlation. In the study, nurse diplomas make up the majority of nursing education (61%). Following up on the investigation, the findings indicate that there is no significant link (p-value of 0.122, <0.05) between nurses' performance and their level of education. The study analyzes the impact of motivation on nurse performance in Regional General Hospitals (Gunawan et al., 2019). It also supports studies by Jeeza et al. and Mudallal and Gebregziabher that claim there is no connection between a nurse's performance and their educational background (Jeeza et al., 2015). The study Argued find that nurses with baccalaureate degrees perform better due to increased confidence, performance, and motivation (Tesfaye et al., 2015). The four hypotheses show how different demographic characteristics of ICU nurses relate to their views on the results of patient care outcome. Only qualification levels show a statistically significant correlation (p-value = 0.011) with nurses' opinions among the factors analyzed. Compared to nurses with diplomas or bachelor's degrees, those with master's degrees express more positive views about patient care outcomes. Higher qualifications in ICU nurses, particularly those with master's degrees, lead to more positive patient care outcomes, as evidence-based practice (EBP) has been proven 45 to enhance these outcomes. The result is consistent with previous review of whatever currently know regarding the positive aspects of expert certification, there is a high correlation between nurses' perceived knowledge of and value for specific evidence- based procedures and their specialty certification (Boyle et al., 2012; Kendall et al., 2011; Kitto et al., 2017). Similar to our findings, one study analyzed 15 papers in total, including two qualitative research studies and 13 cross-sectional research studies, mixed-methods methodological literature, higher education nurses often make more accurate choices about patient care because of their more advanced understanding of education. (Khan et al., 2019). Contrary to our hypothesis the study‟s found no significant correlation between the educational levels of nurses shown little association with the degree of perceived understanding and value (Aiken et al., 2002;Rose et al., 2018). Higher qualifications, especially master's degrees, among ICU nurses have been associated with more positive attitudes and improved patient care outcomes. 4.3 Conclusion This study creates a powerful harmony about the significant influence that ethical leadership and employee motivation have on the most important sounds in healthcare patient outcomes. We find that these components are in perfect harmony with one another and that they all make significant contributions to the harmony of more effective treatment. The study reveals that when ethics in leadership and staff incentives are shared, patient safety, care quality, and ICU stays decrease which reflect the patient outcome care increase among patient in ICU. Nurses who share these beliefs are empowered by leaders who maintain honesty and create an ethical atmosphere. This positive relationship extends throughout the healthcare system and impacts patient well-being. 4.4 Limitations  Data through Self-Reporting: We depend on the experiences that healthcare professionals shared with us. Sometimes people will give answers that, although not correct, they feel sound excellent. This might have an impact on the outcomes.  Since our study is conducted in a single location, we are unable to guarantee that the findings would hold true in other nations with various healthcare systems in various places of the world. 46  Few Researches: ethical leadership and employee motivation in the healthcare particularly in Palestine is limited.  Time precincts: For this study, we didn't have as much time as we would have liked. Thus, it's possible that we overlooked certain details. 4.5 Recommendation Based on the results reached by the researcher, the research recommendations can be summarized as follows: First: Recommendations directed towards those in charge of the Ministry of Health Developing a degree of sense of accountability among nurses, this reflects positively on creative performance, as follows:  Striving to enact fair laws for nurses‟ accountability that guarantee the rights of the nurse and the patient without prejudice to the rights and duties of all parties.  E