Effectiveness of Educational Program on Nurses Knowledge toward Ethical Rule in Kirkuk Pediatric Hospital

Aram Omar Mohammed^* and Khatam Mutashir Hatab AL-Mosawi

^*Correspondence: Aram Omar Mohammed, Department of Pediatric Nursing, College of Nursing, University of Baghdad, Iraq, Email:

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Introduction

Ethics is concerned with ‘right and wrong’, although agreeing what is ‘right’ can be challenging. An understanding of ethics is essential to the delivery of skilled professional care. It is vital that nurses appreciate the value of ethics in their work. Ethics is relevant to clinical, practice-based issues and affects all areas of the professional nursing role. to apply ethics effectively, nurse’s must develop reasoning skills and understand the concepts and principles that assist ethical analysis, Consideration of ethical issues is an essential component of providing care within the therapeutic nurse-client relationship. Nurses encounter ethical conflict, uncertainty and distress in their everyday practice. Continuous changes in the health care system, in areas such as technology and in values, contribute to these ethical dilemmas. Understanding and communicating beliefs and values helps nurses to prevent ethical conflicts and to work through them when they do occur. There are many ways to understand and work through ethical situations [1].

The nursing code of ethics is part of the guidelines for nurses, to prevent the misconceptions that occur, between the health workers and patients. This followed the results of a research that observed, a significant relationship between nurses’ knowledge of ethic codes, job satisfaction, and complaint of ethical performance, he application of nursing ethics depends on the personal nurses, and other influential factors, which includes their caring behaviors. Furthermore, caring behaviors are for patients that, needs to be watched over by nurses. Nurse ethics, caring behaviors, and influential factors have not been studied yet, making it necessary to conduct factor analysis research related to the application of nurses’ ethical behavior, in implementing nursing care to patients [2].

The ethical aspect of nursing is very important for nurses in health services. Most of the issue of medical ethics occurs in the implementation of nursing care, whether accidental or not. The complaints from patients are about the indifference of nurses, to them, and their families. The number of ethical case violations that occurred in Indonesia, such as, the blistered baby abandoned by the nurse, the wrong injection, mishandling of patients, and the neglect in getting early treatment, proves that the services provided, does not meet the ethical principles [3].

Background

Ethics are the science of what is good, what is worse and of their rights and moral obligation. This sense appears remember ethics derived from the ancient Greek ethos, which means that custom, thinking way, behavior, attitude, a cheerful, manner of acting. Subsequently derived ethics said. Ethics comprise three the meaning, and this is science of what is good and bad, a collection of value, and in it values about right and wrong. By fine distinctions three define that ethic but then we get more complete understanding of ethics which about what it ethics, at the same time we are more capable of being comprehended understanding of ethics which appear in daily talks a lot, either verbally and written. Object ethics were nature changed, especially a natural drainage human. A part of the ethics of the people connected with, in respect of a whether true or false and does occur right or wrong. The connotations have a negative aspect of the law [4].

Nurses at present are facing various personal, interpersonal, professional, and institutional and socio cultural challenges in their professional performance. Dealing with these issues may not be always clear. The lack of one correct approach in addressing different contextual issues may lead to ethical dilemmas. Responding to this complex issues demand nurses to acquire comprehensive ethical knowledge and skills in various decision making process. Although teaching materials have a pivotal role to play in helping nurses in this endeavor [5].

Early work to define ethics in nursing focused more on the virtues that would make a good nurse, which focuses on the nurse's conduct in relation to the person in the nurse's care. In recent times, the ethics of nursing has also shifted more towards the nurse's obligation to respect the human rights and dignity of the patient and this is reflected in a number of professional codes for nurses, (McHale ,2003) such as in the latest code from the International Council of Nurses (ICN, 2012).

Pediatric nurse ethics is vital for providing high-quality, compassionate care to pediatric patients and their families. It ensures that ethical principles are upheld throughout the care process, focusing on the well-being, rights, and dignity of the child, Ethical considerations continue to evolve as healthcare advances, and nurses must stay informed and committed to ethical standards.

Materials and Methods

Study Design, Sample and Setting

A quasi experimental design that implemented at Pediatric hospitals in Kirkuk city to ascertain the evaluation of the instructional program on nurse's Knowledge regarding Ethical consideration.

Data Collection and Tool

The tools were employed in this study are questionnaire that compose of two parts.

Part 1

Demographic information of pediatric nurses, Include demographic variables characteristics of the staff nurses as: age, department, educational qualification, experience.

Part 2

Ethical knowledge of pediatric nurses, ethical Issues Knowledge Questionnaire. This tool was developed by the researchers based on scientific literature, aimed to assess nurses’ knowledge related to ethical issues and questionnaire sheet: presents the ethical issues that confront nurses during their work settings related to ethical principles. It consisted of [6] Multiple-choice questions, covering ethical principles such as

This part of questionnaire involves of seven sections (30 items) in regard to nurse's knowledge: dignity and respect, trust, consent inform, heath team working together, keep privacy of sick child, efficiency and profession skills of nurses, child risk reduction.

The scoring system for the questionnaire sheet consisted of two levels dichotomous scale, [7] points for correct answer, and (0) point for the incorrect answer which assessed by cutoff point (0.33) due to scores (0, and 1) respectively. Scores of responses are categorized according to the following level of nurses knowledge (0-0.33) = poor level of knowledge, (0.34-0.66) = fair level of knowledge and (0.67-1.00) =good level of knowledge.

Ethical Consideration

In addition to the official approvals obtained from the Council of the College of Nursing at the University of Baghdad, ethical approval for the study was obtained from the Research Ethics Committee of the College of Nursing at the University of Baghdad, and permission was granted to conduct the study research. Then approval was obtained from the Ministry of Planning regarding the research questionnaire tools. And the approval of the Kirkuk Health Department, and finally the approval and facilitation of the mission of a researcher for the purpose of starting to study and collect research samples.

The researcher takes approval from nurses before data collection in need assessment, pilot study and test and retest of nurse’s knowledge. The names of the nurses were not collected. Also, the researcher explains the research and its goals for all. Therefore, fully informed about their mission was obtained. The researcher told all participants that the results of the questionnaire would be utilized specifically for research purposes. Also told those that all participants are autonomous individuals have the right to refuse involvement.

Results

The finding in this table shows that (40%) of nurses in the study group at age (20–less than 30) years and in the control group (68%) of them at age (20 –less than 30). Regarding to gender (68%) of study group were females and (80%) of control group are females. According to educational level (44%) of study group had nursing institute graduated and (56%) of control group had nursing institute graduated. (36%) on the study group and (60%) of control group had (1-less than 6) years of service. (56%) of study group and (64%) of control group working in the medical wards (Table 1).

Table 1: Distribution Of The Study Sample By Their Demographic Characteristics.

The table show main domain of nurse’s knowledge toward ethical consideration of both group study and control. Study group show improve knowledge in posttest (I). In control croup show same result of pretest without improves in knowledge level (Table 2).

Table 2: Main Ethical Rules Knowledge Domain Results (Pretest, Posttest I) For Both Groups (Study Group and Control Group)

The table shows the overall assessment of nurses’ knowledge about Ethical consideration of nurses, the finding of this table shows that (68%) of nurses in the study group show poor level of knowledge at the pretest, (68%) had good knowledge at the posttest I. that indicate the significant changes in nurses’ level of knowledge after applying the program.

The nurses in the control group are showing poor level of knowledge during the three times of test, poor level at (68%).posttest 1 (68%) of nurses that indicate no significant change in nurses’ knowledge (Table 3).

Table 3: Overall Assessment of Total Knowledge items Results for Study and Control groups.

Figure 1 clarifies the significant change in level of nurses’ knowledge over the three times of test: pre, post 1 among study while no clear change has been seen in nurses’ knowledge among control groups.

Figure 1: Level of Nurses Knowledge Ethical rules for both Study and Control Group.

Figure 2 exhibits the noticeable increasing of nurses’ knowledge over the time among the study group while among the control group there is no clear change over the three times.

Figure 2: Estimated Marginal Mean for Nurses’ Knowledge among Study and Control Groups.

The Table 4 indicates that there no significant relationship among nurses’ knowledge with sociodemographic characteristics.

Table 4: Relationships among Nurses’ Knowledge with their Sociodemographic Characteristic among the Study Group (Post-test).

The Table 5 indicates that there no significant relationship among nurses’ knowledge with sociodemographic characteristics.

Table 5: Relationships among Nurses’ Knowledge with their Sociodemographic Characteristics among the Control Group (Post-test).

Discussion

study show regards the age of [8] (54%) out of [9] nurses were in the age group (20 –less than 30) years. same age group was higher in the both groups study an control, as the percentage of the group the study included (40%) nurses and the control group was (68%).This finding was consistent with study found that age (20 –less than 30) years and (45%) from all nurses [10] the presence of a large proportion of nurses whose age is less than 30 years of nurses in hospital as a result show . administration’s endeavor to provide a young group capable of bearing the pressures and workloads in care units. Another reason is the large number of appointments that occurred on the staff of the Ministry of Health according to conversation that has took place between the researcher and the health care providers in the hospital.

Regarding to gender (68%) of study group were females and (80%) of control group are females in total (26%) male and (74%) female in both study and control groups' nurses, the vast majority of nurses are female [11]. Mention in their study that most of gender was female (65%), male (35%) which participants in their study.

According to the researcher's opinion, there are several factors that may contribute to the predominance of women in nursing, especially in pediatric hospitals or children's departments. Among them is the historical association between women and nursing in caregiving roles that have traditionally been reserved for women. Another factor is female and male socialization, which may encourage females to pursue caring and nurturing careers such as nursing while discouraging males from doing so.

In educational level (44%) of nurses’ study group had nursing institute and (24%) of nurses had college nursing and in control group (56%) had nursing institute graduated and in total of sample of both group (50%) graduate in nursing institute. This can be explained by the fact that the similarity in educational attainment between the two groups could be related to the same location, units and work halls in the hospital or facilities in which the nurses work. Addition that most health education institutions are health institutes at the country level, and graduates of nursing elementary schools are given academic leave for the purpose of obtaining the nursing institute certificate. In marital status result show that (68%) of the study group and (56%) of control group were married in total of both groups (62%) was married [12].

This can be explained married nurses show commitment in emotionally, continuity of care, and organization of care for sick child, especially female nurses. According to years experiences the result show (36%) on the study group and (60%) of control group had (1-5) years of service and in totals both groups of nurses show (48%) have same years’ experience mention above [13]. Mention demand for nurses may continue to grow with expanded care under the Affordable Care Act, projected physician shortages, and population growth with an aging society, As more individuals become interested in a nursing career, preparing them for the realities of clinical practice assumes increasing importance in light of the changing societal sociodemographic and everyday ethical challenges in patient care delivery. According to a study published in the Journal of Clinical Nursing, nurses with more than 10 years of experience had the highest scores in professional nursing values [14].

According to units or place working nurses result show (56%) of study group and (64%) of control group working in the medical wards (divided in two section and each section have two to three wards) in totals both groups (60%) working in wards and (18%) in (NICU). Researcher point are most of nurses are working in medical wards that contain at least three room in each wards that contain six to eight beds, most of nurses are working in this places. (60%) of nurses in the study group and (76%) of the control group working in the morning shift in totals both groups most of nurses working in morning shift.

Alireza Mohajjel mention in a descriptive study indicate, the majority of nurses were female, married, educated at BS degree, work as a nurse in medical wards and with rotating shifts. Also 79% of nurses had studied ethics in nursing school and 53.6% of them had passed continuous education during their employment [15].

Researcher point are most of nurses agree to participate are working in morning shift and most of all nurses in hospital are found in morning shift in pediatric hospital.

Table 2 show Main Ethical Consideration Knowledge Domain of both groups (Study Group and control group) Study group show improves knowledge in posttest (I). In control croup show same result of pretest without improves in knowledge level. Alireza mention in their study (53.6%) of them had passed continuous education toward ethical employment. (40.5%) stated that ethic codes are given, (91.3%) of them had no complaint about their ethical performance and (68.1%) had job satisfaction [16].

In dignity and respect domain Studies confirm that when patients were treated with respect and others, including other patients, were treated with respect, their dignity was preserved. This finding has been replicated in other studies [17]. Regarding being treated as a human being, nurses' and patients' perspectives suggested that this was an important component of human dignity. As widely reported in the literature, this aspect of dignity is closely linked to the intrinsic dignity inherent in every human being simply by belonging to the human species. Without trust, relationships languish, and clinicians cannot provide all the care that patients and families need [18].

In Trust domain is essential to the clinician-family relationship in pediatrics, and it is affected by the actions or inactions of clinicians. High levels of trust can support confidence, peace of mind, and a sense of security. Broken trust can lead to anxiety, second-guessing, and frustration. In these opening statements, parents describe lapses in clinicians’ honesty, fidelity, and caring that impaired their trust [19]. In Inform consent domain The research point process to obtain valid informed consent in healthcare reflects many aspects. Healthcare professionals that take care of the patient must provide him all the necessary information and verify his understanding, considering individual characteristics. Nurses are one of the main participants in this process.

In confidentiality and privacy of sick child domain. the study on nurses' knowledge about patients’ confidentiality results total participants (59.8%) had good knowledge about confidentiality with a mean score of 3.91. from the knowledge questionnaire, most of the respondents (87.3%) said ‘access to medical records should be governed by law’ and (44.6%) argued that non-medical information is also confidential [20]

In nurse’s knowledge and professionalism domain .study conducted in a hospital in Iran aimed to assess the relationship between nurses’ knowledge and professionalism and their ethical performance. The study found that nurses’ knowledge and professionalism had a significant positive effect on their ethical performance [21].

In risk reducing of sick children domain .pediatric nurses should serve as advocates for best practices and policies to attend to risks that are unique to children, identifying and supporting a culture of safety, and leading efforts to eliminate avoidable harm in any setting in which medical care is rendered to children. Many errors were attributed to medical treatment (37%). Other errors included patient identification (22%); preventive care, including immunizations (15%); diagnostic testing (13%); patient communication (8%); and less frequent causes. Among medical treatment errors, 85% were medication errors. Of these, 55% were related to prescribing errors, 30% were related to failure to order, 11% were related to administration, 2% were related to transcribing, and 2% were dispensing errors [22].

In health team working domain Leadership in health team working plays a significant role in developing, and maintaining nursing ethics. Ethical nurse leaders create work environments that, impact employee choices, behaviors, and values. Nurse manager have to support staff, in conducting ethically sound care for ethical reflect [23]. Table 3 and Figure 1 in Overall level of Total Knowledge Items Results shows about Ethical consideration of nurses, the finding shows that (68%) of nurses in the study group show poor level of knowledge at the pretest, (68%) had good knowledge at the posttest I. that indicate the significant changes in nurses’ level of knowledge after applying the program. The nurses in the control group are showing poor level of knowledge during the three times of test, poor level at (68%), posttest 1 (68%) of nurses that indicate no significant change in nurses’ knowledge.

The study evaluated the level of knowledge among nurses regarding ethical consideration. The results indicated that the nurses exhibited a low level of knowledge during the pre-test phase but demonstrated a significant improvement in knowledge during post-test 1 , following the implementation of the program. The results of the study indicate that the nurses in the control group exhibited a suboptimal level of knowledge during the pre-test, post-test 1 and in figure 1 indicate the presence A statistically significant change in nurses’ knowledge in the study group, when there are no clear change in the control group.

According to the researcher's point of view, the results of the study indicated that the application of the ethics program had a positive impact on the cognitive level of the nurses in the study group. This improvement can be attributed to the educational components of the program, which aim to enhance nurses' understanding of ethical considerations. In addition, the results indicate that the level of knowledge among nurses in the control group remained suboptimal throughout the study period. This lack of improvement could be due to the lack of a similar educational intervention in the control group. Overall, the results underscore the importance of targeted educational and training programs in improving the knowledge of nurses, especially in child management fields.

Another study show There is no significant relationship between students'' knowledge and their demographic variables of age, parents’ education, and socio-economic status [24].

Confirms that the program is effective in teaching professional ethic [25], showed in their in instruction ethics education in nursing provides a critical foundation for addressing ethical questions that arise in the patient-provider relationship [26]. These questions are many and often include central concerns surrounding truth telling, informed consent, and protecting the rights and welfare of patients and families in decision making. Alireza mention in a descriptive study Conducted upon 345 nurses and 500 inpatients in six teaching hospitals of Tabriz, 2012. To investigate nurses' knowledge and performance results show most of nurses (97.4%) were have knowing of this ethical code like respect, privacy, autonomy and informed consent and the fewest of nurses (15.1%) knew of this ethical code [27].

The researcher considered that nurses' knowledge of the importance of ethics in enhancing the reputation of the nursing profession is very important, as well as their participation in courses and activities related to values and ethics of patient care that emphasize the importance of overcoming and resolving ethical dilemmas that a nurse faces daily [28]. The ethical problems and dilemmas faced by the nurse require the nurse to know the ethics committees and investigative committees in their places of work and how to communicate with them [29].

Conclusion

Study concluded that the nurses working in units of pediatric hospital have fair level of knowledge of ethical consideration, after applying instruction program the knowledge level will improve to good level according to the results. Current study recommends update ethical consideration of health care professionals’ team especially for nurses who daily care and management of ill children and preventing unethical issue that lead to legal litigation by applying the instruction program courses in this field.

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