بررسی میزان رعایت آیین اخلاق حرفه ای در عملکرد پرستاری از دیدگاه پرستاران، دانشجویان و بیماران

Examining the level of compliance with professional ethics in nursing practice from the point of view of nurses, students and patients

Rostami F.,[1] Akbarnataj Bisheh K.,*[2] Ramezani Toyeh A.,[3] Akbarzadeh H.,[4] Talebishelimak S.,[5] Abdi H.[6]

Abstract

Introduction: Observance of ethical standards in nursing work leads to the improvement of nursing services. The aim of this study was to determine the level of professional ethics in nursing practice from the perspective of nurses, students and patients of medical centers of Mazandaran University of Medical Sciences and Social Security in 2019.

Research Methods: This descriptive-analytical cross-sectional study was performed with the participation of 299 nurses, 287 nursing students by census method and 384 hospitalized patients using cluster sampling in internal medicine and surgery wards of Mazandaran University of Medical Sciences and Social Security. The research instrument was a questionnaire consisting of 31 questions specific to the nursing community, 22 questions for the student community and 22 specific questions for the patient community. Data were analyzed using descriptive statistics and Chi-square, correlation and Kruskal-Wallis and Mann-Whitney tests.                 

Results: Observance of professional ethics from the perspective of nurses, students and patients in terms of responsibility were 51.5%, 44.6% and 61.7%, respectively, improving the quality of patient care, respectively, 39.1%, 78.7% and 56.2%, respectively. Patient respect was 59.5%, 36.2% and 63.2%, respectively. Also, there was a significant difference between the perspective of nurses, students and patients in all three dimensions (P <0.05) and the highest average of professional ethics was observed in nurses.                                         

Conclusion: According to the research results, training and holding effective retraining courses for nursing staff and also teaching professional ethics codes in the course and related workshops to nursing students with the aim of raising their awareness and performance and quality of optimal health care.                   

Keywords: Inpatients, Nursing staff, Nursing student, Professional ethics

Received: 4/ January/ 2023            Accepted: 26/February/ 2023 

Introduction:

Ethics is a fundamental and integral part of health care education and practice (1). Equally important, nurses are a major group of health care professionals and are at the forefront of providing services to patients in health care settings (2). They should improve their skills to make correct decisions and actions in dealing with conflicts when caring for different patients (3). Therefore, one of the main goals of the nursing university is to educate nursing students while observing ethical principles in their practice (4). Advances in technology and expansion of nursing roles have led to complex ethical challenges in nursing (5). Nurses must work in a complex and ever-changing system (6, 7). In this situation, hospitals should provide suitable conditions for effective patient care along with respecting patients' rights. The correct observance of the bill of rights of patients leads to patient satisfaction, better communication between staff and patients, and faster recovery (8). In addition, by following professional ethical codes, nurses demonstrate their commitment to their professional duties: protecting the patient and providing care that leads to recovery (9). Patients' satisfaction with nursing care is an indicator of the quality and effectiveness of a health care system. Patient satisfaction is a subjective and unique perception that is influenced by various factors, including the way nurses provide care (10) and respect for patients' rights (11, 12). Since respect for patients' rights is critical to providing compassionate and ethical care, nurses who are unfamiliar with ethical concepts cannot cope with professional challenges (8). Adherence to ethical values, including respect for patients' rights and moral virtues, along with clinical competence, reflects ethical nursing care (7). Since nurses face ethical challenges in their daily activities, acquiring ethical knowledge and observing the principles of professional ethics is an integral part of the nursing profession. Knowledge of ethical principles makes nurses competent and ethical who are able to provide effective and satisfactory care (7, 13). Ethical education serves as a strong antidote to issues of moral distress and thus strengthens nursing (14). However, the results of several studies in Iran show that nurses are not sufficiently familiar with ethical laws and do not follow them in medical centers (7, 15-17). In Osingada et al.'s study, nurses' knowledge of ethical principles was not satisfactory and 93% of interviewed nurses stated that continuing nursing workshops is necessary (11). In another study, only 25% of nurses are familiar with ethical codes (18). Several studies also report that current programs for ethics education are not satisfactory (19, 20).There are many ways to deliver ethics education, including lectures, workshops, seminars, distance learning, and group discussions (21). Traditional teaching methods, for example, lectures, can be useful for conveying large amounts of information in short periods. However, in such approaches, learners play a passive role in their education and do not develop the skills needed for problem solving, decision making, and critical thinking (22). Therefore, there is a need for active learning strategies to improve the outcome of education in ethics (23). In their study, Chao et al. Use a combination of interactive approaches—lecture, video, and group discussion—to teach nurses about professional ethics. The results show that an integrated approach can be effective in increasing the moral awareness, decision-making and analytical skills of nurses (24). Considering the novelty and limited studies in the field of ethics in Iran, and also considering that nurses and nursing students are more in contact with patients and their care than other health care professions, and since there are limited studies, more in It is related to the awareness of nurses regarding professional ethics and less has been addressed to the level of compliance with ethics in nursing practice from the perspective of nurses, nursing students and patients. Therefore, this study aims to determine the level of compliance with professional ethics in nursing practice from the perspective of nurses and students. and patients of Mazandaran University of Medical Sciences educational centers.

Research Method:

This study was cross-sectional descriptive-analytical research. The research community consists of all nurses and patients admitted to internal surgical and women's departments of educational hospitals affiliated to Mazandaran University of Medical Sciences and Social Security and nursing students engaged in internships (seventh and eighth semesters) from Islamic Azad University of Mazandaran province. They gave. 299 nurses and 287 nursing students participated in the study by census.

The sampling method of patients was a multi-stage cluster. In this way, all educational hospitals affiliated to Mazandaran University of Medical Sciences and Social Security, where nursing students (seventh and eighth semesters) from the Islamic Azad University of Mazandaran province were engaged in internships in the desired areas of the research, as a cluster in It was considered and listed and numbered, and a number of them were selected by a simple random method (Razi and Ayatollah Taleghani Chalous hospitals, Wali Asr (A.S.) and Razi Qaimshahr hospitals and Imam Khomeini (RA) and Buali Sari hospitals. ) and then the sample size in the desired departments was selected according to the number of patients who met the research criteria in a quota manner (64 patients from each hospital) and in an accessible manner. Data collection tool:

It includes three questionnaires, each of which is arranged in two sections. The first part includes demographic information and the second part is related to measuring compliance with the standards of professional ethics specific to the perspective of the subjects of each group.

Questionnaire to assess compliance with professional ethics criteria from the nurses' point of view

It was designed by Dehghani et al. (25) and includes 31 questions on a five-point Likert scale (always, often, sometimes, rarely, never) that assess nurses' views on compliance with professional ethics in three dimensions of responsibility. (11 questions), improving the quality of patient care (8 questions) and respect for the patient (12 questions). In the analysis of the research findings, the answers of never, rarely and sometimes as unfavorable performance, the answer often as relatively favorable performance and the answer always as favorable performance were classified and calculated. Thus, a score less than or equal to 62 was classified as unfavorable performance, a score of 63-93 as relatively favorable performance and a score of 94-124 as favorable performance. The validity of the questionnaire in the research of Dehghani et al. (25) was confirmed based on the validity of the content and its reliability with an alpha coefficient of 94. It is calculated.

Questionnaire for assessing compliance with professional ethics criteria from the patients' point of view

It was designed by Dehghani et al. (25) and it includes 22 questions (with the answer scale of yes, meaning that the item in question is observed and no, meaning that the item in question is not observed) that shows the patients' point of view towards compliance It examines the criteria of professional ethics in three dimensions: responsibility (6 questions), improving the quality of patient care (6 questions) and respect for the patient (10 questions). In this way, a score less than or equal to 12 was classified and calculated as unfavorable performance, a score of 13-17 as relatively favorable performance and a score of 18-22 as favorable performance. The validity of the questionnaire in Dehghani et al.'s research (25) based on the confirmed content validity; its alpha coefficient is 89/. Was calculated.

Questionnaire for assessing compliance with professional ethics standards from the point of view of nursing students by the researcher which was adjusted and designed based on the questionnaire for assessing compliance with professional ethics standards from the perspective of nurses, Dehghani et al. (25) and includes 22 questions on a five-point Likert scale (always, often, sometimes, rarely, never) that It examines nursing students regarding the observance of professional ethics in three dimensions of responsibility (7 questions), improving the quality of patient care (6 questions) and respect for the patient (9 questions). In the analysis of the research findings, the answers of never, rarely and sometimes as unfavorable performance, the answer often as relatively favorable performance and the answer always as favorable performance were classified and calculated. Thus, a score less than or equal to 44 was considered as unfavorable performance, a score of 45-66 as relatively favorable performance and a score of 67-88 as favorable performance. To determine the validity of the questionnaire from the validity of the content, PThe guidelines were given to ten faculty members and three nursing doctoral students, and their opinions were applied to the questionnaire items. Cronbach's alpha internal correlation test was used to determine reliability, and its reliability was 91/ alpha coefficient. It was approved. The collected data was analyzed using spss version 20 software in two sections of descriptive and inferential statistics.

Results:

The demographic characteristics of patients, nurses and nursing students are shown in tables number one, two and three.

Table 1: Demographic characteristics of the units under research (patients)

Table 2: Demographic characteristics of the researched units (nurses)

Table 3: Demographic characteristics of the units under research (nursing students)

According to the results of Table No. 4 entitled distribution of the frequency of compliance with professional ethics in the investigated dimensions from the point of view of nurses, nursing students and patients (separately), the highest frequency of patients, i.e. about 61.7% of them, is in the dimension of compliance with the responsibility of nurses. have shown a favorable opinion, which is higher compared to the figure of nurses and students, which are equal to 51.5 percent and 44.6 percent, respectively. Therefore, it can be said that patients had a more positive view about the responsibility of nurses than nursing students and nurses. In the dimension of improving the quality of patient care, students have a higher view of the desired quality equal to 78.7% and next, the favorable attitude of patients towards the dimension of respect for patients is equal to 63.2%, compared to the desirability of this dimension in nurses and students. The order equal to 59.5% and 36.2% had a higher degree.

Table 4: Distribution of the frequency of compliance with professional ethics in the examined aspects from the point of view of nurses, nursing students and patients (separately)

The results of Pearson, F and T tests for the desired comparative hypotheses by maintaining the presuppositions of the F test (the measurement level of the variable under study should be distance and relative, the groups under study should be independent from each other, the condition of equality of variances with the use of Lunn's test is observed, the distribution of the studied variable is normal using the Kolmogorov-Smirnov test.) The following tables show that the average rank of the variable of compliance with professional nursing ethics in the two groups of nursing students and nurses is different and this rank It is higher in nurses than in nursing students (numbers 5 and 6). Also, the average rating of the variable of professional ethics is higher in the group of nurses than in the group of patients. In other words, the level of attitude towards compliance with professional nursing ethics is different among nurses and patients (numbers 7 and 8). Also, there was a difference between the average compliance of professional ethics from the point of view of nursing students and patients, and this average is higher among nursing students than from the point of view of patients.

Table 5: Number of two groups and average rank of professional ethics

Table 6: U-Man Whitney test result

Table 7: Number of two groups and average rank of professional ethics

Table 8: The result of the U-Man Whitney test

Table 9: Number of two groups and average rank of professional ethics

Table 10: The result of the U-Man Whitney test

Considering the non-normality of the variable of professional ethics, the results of the Kruskal-Wali's test showed that three groups of nurses, nursing students and patients had different views regarding professional ethics compliance. From the point of view of three groups, it has been shown that among them, the rank of nurses is higher than the other two groups (Table 12).

Table 11: Kruskal-Wali's test result of professional ethics variable

Table 12: The average compliance with professional ethics in the view of nurses, nursing students and patients

Discussion and conclusion:

The present study was conducted in order to determine the level of compliance with professional ethics in nursing practice from the point of view of nurses, nursing students and patients of Mazandaran University of Medical Sciences. The result of the Yeoman-Whitney test at a significance level of 0.00 (sig>0.05), with 95% confidence, showed that the difference in the average compliance with nursing professional ethics in nurses and nursing students was significant and this rank was higher in nurses than in nursing students. Also, the average rank of the variable of professional ethics in the group of nurses was higher than in the group of patients. There was a difference between the average compliance of professional ethics from the point of view of nursing students and patients, and this average was higher among nursing students than from the point of view of patients. The findings of the present study were consistent with the study of Jozi et al. (26), Dehghani et al. (25), Mohjal Aghdam et al. But it was inconsistent with the findings of Kohan et al. (31), Dadkhah et al. (32), Jaremsari et al. (33). The results of the Kruskal-Walli's test in the general hypothesis test of the research indicated that the three groups of nurses, nursing students and patients had different views regarding the observance of professional ethics, and the highest average was observed in the group of nurses. In search of supporting sources for this finding In their research, the researchers compared nursing ethics two by two from the perspective of patients-nurses and patients of nursing students. Not seen.

      In explaining the findings of the research, it can be said that Iran's nursing code of ethics has been compiled in order to complete the ethical guidelines related to the health field for all nurses in the fields of educational, research, management, health and clinical services, and it directly affects the performance of nurses in care. It focuses on the patient. Although nurses and nursing students are aware of the ethical aspects of their work and its importance, the main concern about implementing ethical aspects in the bedside is that this is not only achieved through scientific care, but also by using ethical methods and Correct communication with the client is possible. Therefore, following the nursing code of ethics is an effective way to prevent nurses' moral disturbances, increase patient satisfaction and improve the quality-of-care services, Khaki et al. (34). The results obtained from the research findings can help health system policy makers in designing educational and management programs to improve the status of compliance with ethical principles and be a suitable guide for nursing managers to change or adjust nursing students' course units. At the same time, it helps to think of solutions to improve the ethical performance of nursing and to continue it, and along with the advancement of medical technologies, to train nurses who are able to provide comprehensive and holistic care in compliance with their professional ethics standards. to be

In explaining this hypothesis, it can be said that promoting the principles of professional practice by emphasizing the teaching of ethical principles is the only way for people to trust the words of the medical group. In the field of nursing, which plays a decisive role in the treatment of patients, this issue becomes even more important. The foundation stone and the original principle in nursing care is the training of nurses who have professional ethics. Vervin (35) believes that ethics education is effective in improving students' awareness of ethics issues and their application in the workplace. Although the third finding obtained from the research has shown that nursing students observe more professional ethics than patients, but the need for nursing managers to pay more attention to student education and promotion and monitoring programs on nursing ethics is still felt. Because in our country, despite the definition of 1.5 credits for professional ethics, nursing students are still familiar with ethical concepts in a random way and do not receive adequate and appropriate training. Although it cannot be claimed that with only one course unit or in-service training, it is possible to improve the moral performance of nurses and to provide reasons for patients' satisfaction; But when nurses gain theoretical knowledge and clinical preparation from nursing ethics in our country, we can expect them to fulfill their professional duties in relation to patients, companions, and colleagues with more attention to ethical concepts and themes. According to the findings of Fourth, in the present study, although the nurses were able to fulfill their professional obligations due to moral obligations based on the existing ethical standards and showed that the limitations of facilities and shortcomings in the country's health system cannot be a justification for neglecting to provide safe and ethical services. be treated as patients. But we should not forget that the existing shortcomings more or less negatively affect the standards of professional ethics in nursing. Therefore, it seems that the nursing managers and officials involved in the work by creating a tension-free work environment in the departments, emphasizing respect for the dignity and personality of the patient and his companions, and determining the final index of the number of nurses required for each hospital bed, eliminate the deficiency. existing in some departments, the adaptation of theoretical and clinical education to improve the awareness and moral attitude of nursing students, review of the in-service education system and finally follow up on cases of unethical performance of nurses, can improve the quality of performance and nursing care, gain patient satisfaction and To promote the professional ethics of nurses in different dimensions of education and bedside planning and policy making.

Research proposals

1. A) Practical suggestions based on research findings

- It is suggested to the managers of health and treatment systems to periodically evaluate the code of professional ethics with a client-centered approach in order to remove the obstacles of holding effective retraining courses in the field of professional ethics, increasing the awareness of patients in the field of their rights and frequent reviews of their views. Patients should have less professional ethics standards.

- The officials and practitioners in the health field by setting more fixed work shifts give nurses the opportunity to adapt biologically to the work time in order to help them in complying with the standards of professional ethics in the performance of care as much as possible.

- Managers of healthcare organizations can examine the current situation and barriers to professional ethics from the point of view of nurses as well as patients with periodic reviews on professional ethics.

- By providing favorable conditions for nurses, including improving the conditions of the wards and meeting their expectations in various fields such as adequate rest, income sufficiency; Establishing appropriate shifts, providing standard equipment, and also emphasizing compliance with the principles and standards of care, by removing these obstacles, take an effective step in complying with the standards of professional ethics as much as possible.

- According to the results of the research regarding the observance of professional ethics by nursing students from the patients' point of view, it is suggested to emphasize the importance of nursing ethics courses for nursing students as much as possible while presenting and explaining the codes of ethics of the nursing profession.

1. b) Suggestions for future researchers

- In future studies, other dimensions of professional ethics criteria and also the views of nurses and patients in other hospital departments of Mazandaran province should be investigated.

- Similar studies should be conducted in other clinical departments and hospitals across the country with a higher sample size to compare the quality and quantity of the results obtained in more realistic conditions.

- Factors affecting the compliance or non-compliance with the code of professional ethics in qualitative studies should be done separately from the perspective of nurses, nursing students and patients.

- Nursing researchers should investigate the factors facilitating and hindering compliance with nursing ethics codes among nursing students by conducting studies and also try to implement nursing ethics in the clinical environment by conducting interventional studies and designing models.

Acknowledgments

The present study is the result of a research project entitled "Comparison of the level of compliance with professional ethics in nursing practice from the point of view of nurses, nursing students and patients of medical education centers of Mazandaran University of Medical Sciences" approved by Islamic Azad University, Sari branch, number 18785. In this way, the researchers are grateful to all the patients, nurses and nursing students participating in the study who have helped us in carrying out this project. Also, we express our gratitude to the research vice-chancellor of Mazandaran University of Medical Sciences and the vice-chancellor of medical sciences of Islamic Azad University, Sari branch, and finally, we appreciate the research vice-chancellor of Islamic Azad University, Sari branch, for the financial support of our project.