Awareness on Ethical and Legal Aspects of Nursing Practices among nurses at Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
Author(s) : Gaga Dukpa 1 and Gyan Prasad Bajgai 2
1 Deputy Registrar , Bhutan Medical and Health Council (BMHC) , Bhutan
2 Oral Medicine Specialist and Infection Control Focal, Dental Department, , Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) , Bhutan
J Clin Adv Nur
Article Type : Research Article
Background: Nurses have to deal with human complexities and are highly vulnerable to face legal and ethical issues. With the advent and easy access to social media, there are increasing numbers of public grievances being filed against health professionals either in real life or in social media. Therefore, this study is being done to assess and to create awareness on ethical and legal aspects related to nursing practices at Jigme Dorji Wangchuck National Referral Hospital (JDWNRH).
Methods: It is a cross-sectional descriptive survey with nurse representatives from both Inpatient and outpatient departments of the National Referral hospital. A simple random sampling technique was used for selecting respondents from each ward. 250 nurses were interviewed on various aspects of nursing knowledge, perception of law and ethics and its application in nursing practices using standard and validated questionnaires.
Results: Over 74% of the nurses responded that they had attended law and ethics classes during their nursing training. More than 50% of the nursing staff had less than 5 years of job experience. Most of the nurses were females (> 65%) and were less than 30 years of age. All the nurses interviewed agreed that knowledge regarding ethics was important in their workplace.
Conclusion: Majority of the nurses had adequate knowledge and perception regarding Law and Ethics. They agreed that knowledge and perception regarding ethics was important to their workplace. However, there were some lacking among nurses pertaining to knowledge on medico-legal Law and Ethics and clinical experience. Therefore, we from BHMC and Infection Control recommend a proper prospective study with a larger sample size on sensitization and continuing medical education for nurses on relevant topics to improve the work ethics and clinical knowledge.
Keywords: Ethical; Health profession; Knowledge; Legal issues; Nurses: Practice
Nurses form the largest group of health professionals, who are directly involved in patient care. They function within the narrow limit of ethical complexity respecting the law and provide care during the most fundamental human events like birth, illness, suffering, and death. The working environment consists of ethical and legal constraints and they are at risk of getting victimized and face legal consequences while performing normal duty [1]. Therefore, for nurses, technicians, hygienists or any other medical/dental practitioner, it has become a necessity to be armed with ethical and legal knowledge and awareness for timely and proper management of patients [2]. In addition, nurses are at risk of falling into a legal disaster while working with patient. As a nurse it has become an absolute necessity to be aware of ethical and legal aspects associated with the management of patients [3]. Ethics refers to the consideration of standards of conduct or the study of philosophical ideas of right and wrong behavior while dealing with human life[4]. The public concern regarding the moral behaviors of health workers has been growing over the years in Bhutan and in the outside world [5]. The trend of medico-legal issues is not a current problem in Bhutan. In 2016, a father of a three-year-old boy registered a case with the Bhutan Medical and Health Council (BMHC) alleging that his son died due medical negligence [6]. In 2019 BMHC reprimanded 6 health professionals including three nurses for the breach of duty of care [7]. Nurses have to function competently within the limited available resources in a confined boundary defined by law and ethics for the protection and safety of the patients and themselves. Amidst the rising medico-legal allegations of the health professionals, it is unclear whether the cases are due to lack of awareness of medico-legal and ethical aspects or negligence. It apparently seemed that a gap in knowledge about ethical and legal issues were prominent because of which the legal cases were on rise every year. To the knowledge of the authors, there are no studies conducted on this topic in Bhutan till now. The ethical approval to conduct the study was obtained from the Research Ethics Board of Health, Ministry of Health (MOH), Bhutan and the administrative approval from the Medical Muperintendent (MS) JDWNRH. The objective of the study was to assess the level of knowledge of nurses at JDWNRH regarding ethical and legal aspects in nursing practice and to assess their clinical proficiency in their relevant fields.
It is a cross-sectional descriptive survey with nurse representatives from both Inpatient and outpatient departments of the National Referral hospital. A simple random sampling technique was used for selecting respondents from each ward. 250 nurses were interviewed on various aspects of nursing knowledge, perception of law and ethics and its application in nursing practices using standard and validated questionnaires. Data was collected with utmost care keeping in mind the legal and ethical issues. The data for the study was collected using a semi structured self-administered questionnaire adapted from Dangyangs et al. [8] and contextualized to the Bhutanese situation. Data collected were double entered and validated using Epi-Data version 3.1 for entry and version 2.2.2.183 and analyzed using Microsoft Excel. The findings are presented as frequencies and percentages.
Demographic Characteristics 250 nurses were recruited in this study. From that, our study showed that the highest number of participants belonged to the age group of less than 30 years [Table 1]. Female participants constituted the highest percentage with 67.6%. Among the respondents, 60.4% of them were married followed by 37.6% with the marital status as single. Regarding the place of study, 51.2% of the participants have completed nursing education from Bhutan, 42.4% from India and 5.6% from Thailand. The highest percentage obtained for the level of qualification among the respondents was diploma (57.2%) followed by 33.6% with bachelor’s degrees and 4% with master degree. The distribution of participants according to the institutional responsibility were nurse in-charge (10.8%), staff nurse (57.2%), clinical nurse (26%) and assistant nurse (6%). Half the nurses had less than 5 years (50%) of work experience, followed by 6 to 10 years and the least was 3.2% who had more than 20 years of work experience. Characteristics f % M (SD) Age <30 years 132 52.8 31.37 (6.5) 31 – 40 years 86 34.4 41 – 50 years 32 12.8 Gender Female 169 67.6 Male 81 32.4 Marital Status Married 151 60.4 Divorced 5 2 Single 94 37.6 Place of Study Bhutan 128 51.2 India 106 42.4 Thailand 14 5.6 Others 2 0.8 Qualification Master 10 4 Bachelor 84 33.6 Graduate Diploma and below 156 62.4 Institutional Responsibility Nurse In-charge 27 10.8 Clinical Nurse 65 26 Staff Nurse 143 57.2 Assistant Nurse 15 6 Years in Practice <5 125 50 6.66 (5.3) 6 to 10 83 33.2 11 to 15 19 7.6 16 to 20 15 6 ≥ 21 8 3.2 Table 1: Demographic characteristics (n=250). Attended class on law and ethics f % Yes 186 74.4 No 64 25.6 Knowledge about ethical and legal issues f (yes) % (yes) Knowledge of ethics is important to my work everyday 250 100 Ethical issues require skill in decision making 245 98 When ethical principle are violated, a civil lawsuit often follows 236 94 Ethical relates to morality and moral principles, involving human character and conduct, decision between right and wrong 245 98 Health workers are to be held responsible when they delegate responsibility to junior staff 232 93 An illegal act is that which is against the law and is most unethical 240 96 Do you know that the practical application of moral philosophy of good or bad, right or wrong is called ethics 216 86 Ethics means moral principles or moral roles to be followed 247 99 Knowledge level f % Inadequate knowledge (<50%) 1 0.4 Moderate knowledge (51 to 75%) 15 6 Adequate knowledge (> 75%) 234 93.6 Table 2: Knowledge about ethical and legal issue in nursing practice (n=250).
Knowledge about Ethical and Legal Issues in Nursing Practice
Among the representation of 250 samples, 74.4% (n=186) of them responded that they had attended classes on law and ethics [Table 2]. All (100%) the respondents agreed that knowledge of ethics was important for their daily work.
From this study, the majority of nurses had adequate knowledge regarding Law and Ethics. Most of them had a good level of knowledge regarding Law and Ethics at their workplace and attended Law and Ethics classes during their formal nursing training. It also showed that 250 nurses who responded to the study revealed that the majority of them (93.6%) had adequate knowledge on law and ethics and 100% of the respondents agreed that knowledge regarding ethics was important for their daily job. This finding was similar to that of the study done in Ghana [2-6-7-1] that revealed high awareness and knowledge among participants about ethical and legal issues in medical practice. Similarly, the finding of another study conducted among nurses in Nepal, show a majority 50% of nurses had adequate knowledge regarding nursing ethics and law [9,10]. In contrast, another study [11] by Thirunayukarasu et al. among nurses at a tertiary hospital in rural India showed that the majority of the participants had inadequate knowledge regarding law and ethics in Nursing. Similarly, the study by Verghese D et.al in 2016 [12], Sharmil SH in 2011[13] and Devi WA, 2019 [14] has similar findings. One of the main reasons behind this may be the few hours given to this topic in nursing schools [15]. The maximum number of participants in this study belonged to the age group of less than 30 years. Female participants constituted the highest percentage with 67.6%. This is similar to the study conducted at Sree Gokulam Nursing College Venjaramoodu, Trivandrum, Kerala, India by Ponnayyan et al. [16] where majority of staff nurses where 48.9% (n=90) belonged to 20-25 years of age, 87.8% were females. The study by Subhashini N et.al [17], Nellore and Pradhan N et.al [18] had similar findings where most participants were of 21-23 years and 80% of the participants were females. The study by Verghese D et.al in 2016 [12] has similar findings like our study. Another study by Kaur H et.al [19] also had similar findings where 96.67% of the participants were females.
The major strength of the study is that, nurses from all levels of qualifications were included in the study such that nurses with various academic qualifications were well represented. The participants were randomly assigned to groups providing equal opportunity for every nurse to participate in the study. In addition, our study is the first of its kind to provide baseline information on Nurses’ awareness regarding Ethical and Legal aspects in nursing practice. Some limitations were all groups of medical and health professionals were not included in the study.
A majority of the nurses had adequate knowledge regarding Law and Ethics and all agreed that knowledge regarding ethics was important to their workplace. However, some nurses had inadequate knowledge regarding Law and Ethics. The study concluded that there was a need for periodic continuing medical education on ethical and legal aspects on a regular basis. As such, BMHC being a regulatory and monitoring body would recommend regular CME and timely updation in law and ethics pertaining to daily work practices.
The researchers would like to extend gratitude and are thankful to the Medical Superintendent and all the staff who were actively involved in the study and furnished details as required for the study from JDWNRH.
There is no conflict of interest among authors.
