Knowledge regarding law and ethics among nurses at a tertiary care hospital in rural India

INTRODUCTION

There is a growing public concern over the ethical misconduct among healthcare professionals.¹ This mistrust is equally contributed by the increasing public awareness, technological advances enabling the general public to access information, which was previously difficult to access, as well as awareness regarding unethical practices by some healthcare professionals. Ethical misconduct among the healthcare professionals may also be possible indicators for increasing litigation against healthcare practitioners and violence against doctors. Teaching medical ethics is essential to create a health care professional capable of analyzing and resolving various ethical dilemmas encountered in clinical and research activities.^2,3

Excellence in clinical skills along with a sound knowledge of standard practices related to bioethics and its application in the clinical settings is essential for healthcare providers. There are various guidelines for the teaching and application of ethical principles in various fields of medicine including clinical practice and research. Globally, various professional bodies have stressed the need for incorporating ethical and legal issues into medical education curriculum. In India, the ethical practices focus on mainly four principles of autonomy, beneficence, non-maleficence and justice.^4-8

Nurses play a pivotal role in the healthcare team, being involved in various aspects like clinical care, research and medical education. It is essential for nurses to be aware of the ethical practices for effective patient care. The present study was carried out, to assess the level of knowledge regarding law and ethics among the nursing staff and use the obtained data to prepare an information booklet for the study population. The study aims to serve as a platform for creating awareness regarding ethics and law among the study participants.

METHODS

Study design

The study was a hospital-based descriptive study.

Study setting

The study was conducted at St. Johns Hospital, run by Brothers of St. John of God. The hospital is a 450 bedded multi-specialty tertiary care hospital.

Study population

Nurses from both genders, with more than one year experience were included in the study.

Sample size and sampling

The study was conducted among 50 staff nurses; all the staff nurses who satisfied the inclusion criteria and offered voluntary informed consent were included in the study.

Data collection tool

A pre-tested questionnaire covering socio-demographic information and questions regarding law and ethics was used to collect the data.

Study duration

The study was carried out between March 2016 - June 2017.

Data collection procedure

The study was conducted at St. John’s hospital, Kattappana, at a time feasible to the participants A written permission was obtained from the Director of St. Johns hospital. Ethical clearance was obtained from the Ethics Committee of St.John’s Hospital, Kattappana. The purpose and nature of the study was explained to the participants and they were asked to fill in their responses. Their responses were then graded to obtain scores. The scores were grouped into three categories namely inadequate knowledge (<50%), moderate knowledge (<51-75%) and adequate knowledge (>76%).

Analysis

The data was entered and analysed by using Statistical Package for the Social Sciences (SPSS) Version 18.0. software package. The frequencies and percentages were prepared for all the independent variables. The responses were grouped into three categories based on the scores obtained as inadequate knowledge, moderate knowledge and adequate knowledge. Chi square test was used to compare categorical and continuous variables, p value of less than 0.05 was considered to be statistically significant

RESULTS

Socio-demographic characteristics

Our study shows that 33 (66%) participants were in the age group of 20–30, 15 (30%) in the age group of 31- 40 years. Among the participants, 7 (14%) were male and 43 (86%) were female. Nurses with designation as junior staff nurses were 11 (22%), ward in charge were 7(14%), and 32 (64%) staff nurses. Regarding education qualification of the respondents, 6 (12%) had diploma, 41(82%) had undergraduate degree and 3 (6%) had post graduate degree. Of all the participants, 21 (42%) had 1-3 years of experience, 20 (40%) had 4-6 years of experience. Among the participants, 9 (18%) had attended classes regarding law and ethics previously and 41(82%) had not attended any class regarding law and ethics previously (Table 1).

Knowledge regarding law and ethics

Our results showed that among the study participants, 4 (8%) were found to have adequate knowledge, while 7 (14%) had moderate knowledge and 39(78%) participants had inadequate knowledge regarding law and ethics in nursing (Table 2).

Association of knowledge regarding law and ethics with selected demographic variables

Participants belonging to the younger age group (21-30), had a significantly higher level of knowledge regarding law and ethics. Educational qualification, designation of the respondents was also found to be statistically significant regarding the knowledge of law and ethics among the participants. Knowledge regarding ethics was not statistically significant irrespective of the gender and previous exposure to classes on law and ethics (Table 3).

*P value less than0.05 was considered to be statistically significant.

DISCUSSION

Our study shows that majority of the nurses were female (86%) aged between 20-30 years (66%). More than half (64%) of the participants were designated staff nurses. Nurses with qualified undergraduate degree in nursing constituted 82% of the respondents. More than 80% of the participants had a work experience of six years or less. Only 18% of the respondents had attended classes related to law and ethics previously. Our results showed that majority (78%) of the participants had inadequate knowledge regarding law and ethics in Nursing. In the present study the knowledge regarding law and ethics was found to be significantly associated with younger age (21-30), educational qualification, designation and work experience.

Khongshei et al reported in their study that majority (89.3%) of respondent nurses were in the age group of 21-30 years. Among the respondents, 118 (78.7%) of them were unmarried and graduates (46.7%). The highest number of subjects, that is 127 (84.7%) of them, were the staff nurses and 115 (76.7%) of them had below three years of work experience.⁹ These findings are in line with our findings. These variables indicate the demographics associated with the nursing field, where majority of the nursing staff are female. In India there is a predominantly younger workforce, which is evident from both studies.

Saini et al reported that majority (67.7%) had not attended any training program on bioethics, whereas.¹⁰ In our study only 82% of the respondents had attended classes related to law and ethics previously. These findings are almost similar indicating the need for incorporate the education of bioethics as a separate subject into the nursing curriculum.

Majority of the participants scored less than average while asked about bioethics and law, a study done among nurses in Mangaluru have also reported similar findings were 92% of the respondents, scored below average on questions regarding bioethics. nursing students had below average knowledge regarding bioethics.¹⁰ Various international studies suggest that the integrated nature of assessment in nursing curriculum leads to a compensation of deficiency in one area by another of strength, Suggestive that a student can clear the examinations with minimal understanding of bioethics.^2,5-7,11-13

Hariharan et al described learning at workplace as a valuable resource to gain knowledge regarding ethics and law, in our findings we found a strong association between younger age (21-30), educational qualification, designation and work experience and knowledge regarding ethics and law. These findings can be correlated considering the younger age groups with growing experience are more receptive to education regarding bioethics. They have also suggested that practical education in ethics tailored to mimic the local Socio-cultural background, particularly in a multidisciplinary setting, could assist in better understanding of ethics.²

CONCLUSION

Healthcare professionals, especially nurses encounter various forms of ethical dilemmas in their day to day hence it is essential they are aware of the ethical issues associated with clinical care and research. These are a dire need for periodic tailored training in bioethics to address the ethical issues associated with patient care. The study results were used to structure a handbook for use in training workshop for staff nurses.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of St. John’s Hospital, Kattappana

REFERENCES

1. 1. Subramanian T, Mathai AK, Kumar N. Knowledge and practice of clinical ethics among healthcare providers in a government hospital, Chennai Indian J Med Ethics. 2013;2:96-100.
2. 2. Hariharan S, Jonnalagadda R, Walrond E, Moseley H. Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados. BMC Medical Ethics. 2006;7:7.
3. 3. Nagpal N. Incidents of violence against doctors in India: Can these be prevented? Natl Med J India. 2017;30:97-100.
4. 4. Zahedi F, Sanjari M, Aala M, Peymani M, Aramesh K, Parsapour A, et al. The Code of Ethics for Nurses. Iran J Public Health. 2013;42:1-8.
5. 5. Mattick K, Bligh J. Teaching and assessing medical ethics: where are we now? J Med Ethics. 2006;32:181-5.
6. 6. Eckles RE, Meslin EM, Gaffney M, Helft PR. Medical ethics education: where are we? Where should we be going? A review. Acad Med 2005;80:1143-52.
7. 7. Roff S, Preece P. Helping medical students to find their moral compasses: ethics teaching for second and third year undergraduates. J Med Ethics. 2004;30:487-9.
8. 8. Ethical guidelines for biomedical research on human participants. New Delhi: Indian Council for Medical Research; 2008.
9. 9. Khongshei V, Pinto MS, Khriam S, Brigit SJ, D’Silva P. Knowledge of registered nurses regarding bioethics. Manipal J Nursing Health Sci. 2017;3:50-4.
10. 10. Saini R, Saini P, Alagh P. Assessment of knowledge of nurses regarding bioethics. Nurs J India. 2014;105:101-4.
11. 11. Mattick K, Bligh J. Teaching and assessing medical ethics: where are we now? J Med Ethics. 2006;32:181–5.
12. 12. General Medical Council. Tomorrow’s doctors: recommendations on undergraduate medical education, London. 1993: 7-10.
13. 13. Fulford KW, Yates A, Hope T. Ethics and the GMC core curriculum: a survey of resources in UK medical schools. J Med Ethics. 1997;23:82–7.