Awareness of Nurses on Legal and Ethical Aspects of Nursing in Selected Hospitals of Lalitpur

Introduction

Nurses are at risk of falling into a legal disaster while working with a patient. As a nurse it has become absolute necessity to be aware of ethical and legal aspects associated with the management of patients [2].

Nurses are the largest group of health professionals directly involved in patient care. They deal with human life events as birth, death, illness, and well-being thus their working environment consists of ethical and legal constraints [3].

Ethics refers to the consideration of standards of conduct or the study of philosophical ideas of right and wrong behavior [4]. A standard code of ethics developed for nurses have been adopted by International Council of Nurses (ICN) in 1953. The ICN code of ethics guides nurses to make decisions at work and it supports the patient’s right to refuse care and treatment [5]. Law can be defined as “the sum total of rules and regulation by which the society is governed”.

A research study of Manipal University among nurses working in critical care units showed that only 10% had good knowledge and 77% had average knowledge regarding the legal and ethical aspects of nursing [6]. A study of Manipal teaching hospital, Nepal showed that a maximum of nurses (58.4%) had inadequate knowledge regarding laws and ethics [7]. One of the main reasons behind this may be few hours given to this topic in nursing schools [8].

In the present context, the value of knowledge of ethics and law and its appliances in behavior in the health care sector has increased for reducing such conflicts. It will help to provide a clear scenario regarding the present status of awareness of nurses in ethical and legal aspects and thus imply the need to focus on providing training courses, refresher training.

Methodology

It is a quantitative study using a cross-sectional descriptive design. This study was conducted in private hospitals which include Sumeru hospital, Sumeru city hospital and Ganeshman Singh Memorial hospital of Lalitpur district from 25^th March to 23^rd April 2018. The sample size was calculated by using Cochrane formula n₀= [Z²* P (1 − P)/d²] with known prevalence value. The required sample size was 150 at 95% confidence level and 0.05% allowable error. The purposive sampling technique was used and a self-constructed questionnaire was disseminated to 104 nurses from Sumeru hospital, 22 nurses from Sumeru city hospital and 42 nurses from Ganeshman Singh hospital who wished to take part in the study.

A semi-structured questionnaire was distributed to the study participant to self-administer the questionnaire. The questionnaire consists of three sections; socio-demographic data, knowledge related to ethical aspects and knowledge related to legal aspects. There were 14 questions to assess the knowledge on the ethical aspects and 9 questions to assess the knowledge on the legal aspects. The level of knowledge on ethical aspects was shown in two levels; an inadequate and adequate level which was based on mean. The mean value less than 6.83 is categorized as inadequate and above/equal to 6.83 is categorized as adequate. The knowledge level on legal aspects was divided into two levels: inadequate and adequate level which was based on mean. The mean value less than 13.66 is categorized as inadequate and above/equal to 13.66 is categorized as adequate. This was based on study conducted by Sahid Gangalal hospital [9].

The researcher collected data on her own. Sufficient time was provided to administer the questionnaire. After the data collection, variables were coded and entered into SPSS version 16. Descriptive analysis: frequency, percentage, the mean, median, and standard deviation was used to reveal the demographic information and knowledge level of ethical and legal aspects. Chi-square tests were used to find out the association between the selected demographic variables and knowledge level of nurses. Similarly the findings of the study were compared with related types of study nationally as well as globally.

Findings

The mean age of the respondents was 23.96. The majority of respondents (58.3%) had a PCL degree while 41.7% of them had bachelor degree in nursing. The working areas of nurses were 26.2% in ICU, 23.2% in general ward, 19% in emergency, 10.1% in Nephrology ward, 9.5% in OT and Private ward and least (2.4%) were working in ANC/PNC ward. The mean working years of experience were 3.69 years.

Maximum (93.5%) of respondents said they hadn’t faced any ethical dilemmas till now while least (1.8%) of the respondents said they had faced ethical dilemmas out of which 45.45% of respondents didn’t respond to the related area where they faced ethical dilemmas. Among the respondents who faced ethical dilemmas were related to extubation and care of dying patients.

The majority of respondents chose the correct definition of responsibility (80.4%). More than half of the respondents chose the correct definition of accountability (60.1%) and confidentiality (65.5%). Most of the respondents (82.9%) had lack of knowledge of justice.

The highest portion of respondents (55.4%) gave correct responses for informed consent whereas the least of them (5.9%) chose correct responses for False imprisonment and Good Samaritan law.

The majority (83.9%) of the respondents said refusing patients to give information about ongoing treatment about the patient will violate patient right. About half (47%) of the total respondents said that it is violation of patient right if we provide information to support staff about HIV positive patients. Almost all (95.8%) said that patient should be informed and taken consent before involving them in research.

The mean score of knowledge on ethical aspects obtained was 6.83, the minimum score obtained by respondents was 0, and maximum score obtained was 12 and standard deviation was± 2.315.

More than half of the respondents (61.3%) have adequate knowledge score on ethical aspects of nursing. The total knowledge score of the knowledge questionnaire on ethics was 26. The mean score obtained was 13.66, range of the knowledge was 22, the minimum score obtained by respondents was 4, and maximum score obtained was 22 and standard deviation was± 3.085.

More than half of the respondents (57.1%) have adequate knowledge levels on legal aspects of nursing.

Discussion

A descriptive, cross-sectional study using a non-probability purposive sampling technique was conducted to find the knowledge level of nurses on the legal and ethical aspects of nursing.

The mean age of respondents was 23.96 years. Similarly, more than half (61.3%) of the respondents had 2-5 years of experience. The mean years of experience were found to be 3.695 years. The study conducted in Shahid Gangalal hospital had similar results where 62% of the respondents had less than 5 years of experience [9]. The lower mean years of experience indicate that fresh nurses get enrolled in the private sector, as well as high turnover of nurses in private hospitals. The present study found that majority (79.2%) of respondents hadn’t attended in-service education on legal and ethical aspects of nursing which is similar with the study conducted in Manipal Hospital, Pokhara, 69.32% of the respondents didn’t attend in-service education on legal and ethical aspects of nursing [7]. These reveal the Nepal nursing council needs to analyze the barriers, and take prompt action to ensure in-service education legal and ethical aspects to all nurses in the country.

Only a few (6.5%) of the respondents admitted facing ethical dilemmas in the present study which is in contrast to the study conducted in Malaysia where 95.2% of the respondents reported that they faced ethical issues at some time of their clinical experience [10]. It may be because healthcare ethics are often neglected in underdeveloped countries like Nepal. Ethical issues reported were related to extubation of the patient and care of dying patients. Regarding legal issues, almost all (98.2%) of the respondents reported that they had never faced legal issues in their professional life which is similar to the study where the majority (97.5%) of nurses did not face legal problems [11]. The legal problems reported by the respondents in present study were related to pediatric issues and confidentiality. For majority (87.5%) of respondents, first choice of approaching help in case of legal and ethical issues was in-charge/supervisor and least of them (0.6%) said lawyer would be their first choice for approaching help.

More than one-third of the respondents had inadequate knowledge of the ethical aspects of nursing. Among ethical principles, the majority of respondents had knowledge on responsibility and least of them had knowledge on justice. However, the findings in the similar research conducted in Western regional hospitals found that most of respondents had knowledge of Non- maleficence (76.8%) and least (51.8%) on Justice [12]. The reason could be different study settings of the research study which refers to Government and private hospitals.

In legal aspects, most of the respondents have adequate knowledge but still, a significant proportion of the sample had inadequate knowledge. This finding is similar to the study conducted in UCMS, Bhairahawa, where majority of the respondents had adequate knowledge of nursing law and about half, had inadequate knowledge [13]. One interesting statistic of this study is that 40.47% of the total respondents said that if a nurse notifies the doctor in situation like medication overdose, they wouldn’t be liable for malpractice suits. This finding can be related to the result of a study conducted in Pune, India which found that nurses were under the impression that they do not hold any accountability towards legal issues that arise during patient care. They think that the legal issues arising during patient care rest under the responsibility of hospitals and doctors [3]. Most of the respondents were not aware of legal liabilities like assault, false imprisonment, battery, etc. The majority hadn’t heard about Good Samaritan law and also among those who had heard, most of them had wrong concept on it.

Regarding the overall knowledge of respondents on ethical and legal aspects, a significant proportion of the respondents had inadequate knowledge. This result is supported by the study conducted in Manipal Hospital where the maximum of the nurses had inadequate knowledge regarding legal and ethical responsibility in nursing [14].

No significant association was found between knowledge and selected variables (age, years of experience, educational level, exposure to in-service education and area of specialty). However, in contrast to our study, a study conducted among community nurses in India says that age, years of experience and professional education affects the knowledge level of respondents on legal aspects of nursing [14]. This might be because of difference in area of scope of clinical and community nurses.

Conclusion and Recommendation

Around 40% of the nurses had inadequate knowledge of nurses on ethical and legal aspect. The knowledge can be improved through in service education and large scale research should be conducted to assess the knowledge and factors affecting the knowledge.

Ethical Approvals

• Permission was taken from the Nepal Health Research Council to conduct the study.
• For ethical consideration, verbal and written consent was taken from respective hospitals.
• Verbal and written consideration was taken from each respondent.

Conflict of Interest

There is no any conflict of interest.

Acknowledgments

Researchers’ are thankful to the research committee of Asian Collge for Advance Studies for providing opportunity to conduct research. We pay our sincere gratitude to all nurse participants of Sumeru hospitals, Sumeru city hospitals and Ganeshman Singh memorial hospitals for contributing their valuable time and co-operation for the study. We are extremely grateful to Mr. Krishna GC who played pivotal role in helping with expert opinion for statistical analysis.

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