Original Article
Nurses’ adherence to ethical codes: The viewpoints of patients, nurses, and managers
Nursing Ethics 1–10 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015583927 nej.sagepub.com
Marzieh Momennasab, Afifeh Rahmanin Koshkaki, Camellia Torabizadeh and Seyed Ziaeddin Tabei Shiraz University of Medical Sciences, Shiraz, Iran
Abstract Background: Ethical codes are guidelines that orient nurses and ensure that their decisions are in accordance with the values of the professional system. These codes show that there is a connection among values, patients’ rights, and nurses’ duties. Objectives: This study aimed to compare the viewpoints of patients, nurses, and nurse managers regarding the extent to which clinical ethical codes are observed. Research design: In this descriptive–comparative study, data were collected using three questionnaires based on Iranian nurses’ ethical codes with a focus on clinical care. The reliability of the questionnaire was verified by test–retest method (r ¼ 0.9). The patients were interviewed by the researcher, but nurses and managers completed the questionnaires themselves. After all, the data were analyzed using the SPSS statistical software (v 15). Participants and research context: In all, 100 patients, 100 nurses, and 30 managers from internal and surgical wards of two major hospitals in Shiraz, Iran, participated in 2014. Ethical considerations: This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants signed written informed consents. Findings: According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses’ adherence to ethical codes as satisfactory. The mean scores (standard deviation) of the level of adherence to ethical codes were 38.44 (6.91) in the patients, 41.08 (4.82) in the nurses, and 37.83 (6.98) in the nurse managers. The results of analysis of variance revealed a significant difference between the attitudes of the nurses and the other two groups (p ¼ 0.001). Discussion: Nurses’ adherence to ethical codes was satisfactory in all three groups. Accordingly, our findings agree with the results of some national and international studies, although there are still controversies in this regard. Conclusion: Although the nurses rated their performance in certain fields more satisfactory compared to the patients and managers, all the three groups agreed that clinical ethical codes were properly observed in the internal and surgical wards. Nurses can improve the quality of care by considering the viewpoints of patients and managers about their ethical performance.
Corresponding author: Marzieh Momennasab, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Zand St., Namazee Sq., 7193613119 Shiraz, Iran. Email: [email protected]
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Keywords Adherence, ethical codes, nurse managers, nurses, patients, viewpoints
Introduction Since nurses are in direct contact with patients, it is necessary that they observe the ethical principles during professional practice.1 Professional ethics demand nurses to obey the principles which will not only earn nurses the trust of their patients2 but also create positive psychological changes in nurses, including satisfaction, higher motivation, and feeling of competence.3 Nursing ethical codes have been designed to meet the need for ethical principles and standards and proper guidelines. Ethical codes provide nurses with guidelines that will help them when they need to make decisions and when they are faced with moral challenges. These codes are meant to act as standards in the nursing profession, and the society needs to be made aware of them.4 Since nurses have the highest contact with patients and are faced with more moral challenges compared to the other members of the health team,4 ethical codes that fit the society’s culture and religion will prove an effective way to improve the quality of the care provided by nurses.5 Ethical codes should be studied in their cultural, social, and historical contexts. Accordingly, many countries have reviewed and revised their ethical codes and guidelines so that they would match their cultures.6 Ethical codes for nurses in Iran include 12 values and 71 provisions in five parts and were approved by the High Committee of Medical Ethics of Ministry of Health and Medical Education in 2011. The values are related to concepts such as patients’ dignity, professional commitments, responsibility, patients’ privacy, higher academic and practical competence, and personal independence. The parts that deal with ‘‘Nurses and People’’ with 9 provisions, ‘‘Nurses and the Profession’’ with 14 provisions, and ‘‘Nurses and Practice’’ with 23 provisions provide nurses with guidelines on how to work and make decisions in the clinical environment. In addition, the parts ‘‘Nurses and Coworkers’’ with 15 provisions and ‘‘Nursing, Education, and Research’’ with 10 provisions provide ethical instructions in the field of communication, research, and education.7 Ethical codes for nurses have only recently been set down in Iran; therefore, few comprehensive and organized studies have been conducted on nurses’ level of adherence to the ethical codes and the consequences of such adherence. Moreover, contradictory results have been obtained in the available studies.8–10 For instance, according to one study, 77% of the patients rated the nurses’ observance of ethical codes as satisfactory,8 while another study demonstrated average observance of ethical codes.10 Most studies in this area have focused on nurses’ attitudes toward ethical codes,10 while the real beneficiaries of the codes are patients,11 and their opinions have to be taken into account in order to improve the quality of care. Moreover, evidence has shown that nurses and patients hold significantly different views about nurses’ adherence to ethical codes. According to one study, while 91.9% of the nurses believed that their performance was satisfactory regarding the ethical codes, only 41.8% of the patients rated their performance as acceptable.9 In addition, although nurse managers are responsible for monitoring nurses’ observance of the ethical codes, their attitudes have been the subjects of few studies. For instance, Aitamaa et al.12 indicated that nurse managers’ main concern about ethical codes was regarding nurses’ provision of high-quality care. Thus, it is important to study managers’ views on observance of ethical codes on the part of their nurses. Furthermore, different perceptions and viewpoints of patients, nurses, and managers may lead to dissatisfaction with nursing care. Therefore, comparison of these three groups can help achieve a common viewpoint. This study aims to compare the patients’, nurses’, and nurse managers’ points of view regarding the extent to which ethical codes are observed in clinical environments.
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Methods Setting This descriptive–comparative study was conducted in the internal and surgical wards of two major educational hospitals in Shiraz, south of Iran in 2014. These hospitals are the largest educational centers in the capital of Fars province and cover other areas in southern part of the country, as well. These two hospitals include a total of 28 internal and surgical wards. This study population included all the patients, nurses, head nurses, and supervisors in these wards.
Data collection Based on the pilot study and probability of loss, the sample size was set at 100 patients, 100 nurses, and 30 managers. It should be noted that the head nurses and supervisors of the internal and surgical wards as well as the matrons at the two hospitals participated in the study as the nurse managers. At first, the researcher visited the 28 wards in the two hospitals and chose four patients from each ward who were qualified for the study via simple random sampling. Besides, the nurses were selected using convenience sampling. In doing so, the researcher visited the wards at different work shifts and the present nurses were given the questionnaires. In case there were more than four nurses present on the shift, they would be randomly sampled. Likewise, the managers were selected by convenience sampling. Since most nurses in Iran work in clinical environments, that is, hospitals and clinics, among the five main parts of ethical codes, the researcher addressed the ‘‘Nurses and Practice’’ which focuses on clinical care. Accordingly, three questionnaires were designed for the three groups under study. Each questionnaire consisted of two sections, the first of which involved the participants’ demographic characteristics. The second section of the questionnaire, on the other hand, included items on the ethical codes. Initially, the items following each code were rephrased so as to fit each target group, that is, patients, nurses, and managers. This section included 16 items scored through a Likert scale including the following options: never (0), occasionally (1), often (2), and always (3). Thus, the minimum and maximum scores of the questionnaires were 0 and 48, respectively. However, 10 code items in the area of clinical care which were related to research and education were omitted from the questionnaire due to the patients’ unfamiliarity with the concepts. The participants’ responses to the items were scaled in the following order: less than satisfactory (0–24), average (24–36), and satisfactory (36–48). To verify the content validity of the questionnaires, five nursing faculty members were consulted. Additionally, test–retest method was employed to verify the reliability of the questionnaires. In doing so, 20 nurses and 20 nurse managers were asked to complete the questionnaires in two stages with an interval of 2 weeks, and the reliability was confirmed with a correlation coefficient of 0.9. The nurses and nurse managers completed the questionnaires themselves, while the researcher interviewed the patients to complete the questionnaires.
Data analysis The collected data were analyzed using the SPSS statistical software (v 15). Descriptive statistics, that is, frequency, percentage, mean, and standard deviation (SD), were used to describe the participants’ demographic characteristics and viewpoints toward adherence to ethical codes. Besides, inferential statistics, namely, analysis of variance (ANOVA), t-test, and chi-square test, were used to describe the relationships between the variables and the differences among the three groups. Pearson’s correlation coefficient was also
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employed to assess the correlation between the participants’ scores and their personal and professional characteristics.
Participants Nurses. The inclusion criteria of the study for the nurses were having bachelor or above degrees and having at least 1 month experience of professional practice in an internal or surgical ward. The majority of the nurses under study were female (78%), married (55%), and had bachelor’s degrees (90%). The nurses’ ages ranged from 22 to 40 years, with a mean age of 30.05 + 4.91 years. In addition, their working experience ranged from 1 to 15 years, with a mean of 5.28 + 3.59 years. Moreover, 66% of the nurses had attended continuing education programs on nursing ethics. Patients. The inclusion criteria of the study for the patients were having experienced at least 1 day of hospitalization in an internal or surgical ward, having no cognitive disorders, and being able to talk. In this study, 52% of the patients were female, 75% were married, and 55% had below diploma degrees. Besides, the patients’ ages ranged from 18 to 72 years, with a mean age of 41.71 + 20.65 years. In addition, their length of hospitalization ranged from 2 to 65 days, with a mean of 9.14 + 9.67 days. Nurse managers. The inclusion criteria of the study for the nurse managers were having bachelor or higher degrees and having at least 3 months’ experience of professional practice as a manager. In this study, 80% of the managers were female and 73% were married. The managers’ ages ranged from 25 to 51 years, with a mean age of 36.60 + 6.11 years. Most of the nurse managers (80%) had bachelor’s degrees. Besides, their mean working experience as nurses and nurse managers was 12.30 + 5.98 (ranging from 3 to 28) and 4.56 + 3.64 years, respectively. All the participating managers had attended continuing education programs on nursing ethics.
Ethical considerations This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants received verbal explanation about the study objectives and procedures and then signed written informed consents for taking part in the study. The participants were also reassured about the anonymity and confidentiality of their information.
Results According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses’ adherence to ethical codes in the internal and surgical wards of their hospitals as satisfactory. Additionally, 43.3% of the managers rated adherence to ethical codes as average. The results of chi-square test showed a significant difference among the three groups in this regard (p ¼ 0.001; Table 1). The mean score of nurses’ adherence to ethical codes was 38.44 + 6.91 by the patients, 41.08 + 4.82 by the nurses, and 37.83 + 6.98 by the nurse managers, and the results of ANOVA showed that the differences were statistically significant (p ¼ 0.003; Table 2). In addition, the results of Tukey’s post hoc test demonstrated a significant difference between the patients’ and the nurses’ viewpoints (p ¼ 0.007) as well as between the nurses’ and the managers’ points of view (p ¼ 0.030). However, no significant difference was found between the managers’ and the patients’ viewpoints (p ¼ 0.88). The results of Pearson’s correlation coefficient indicated a weak significant correlation between the nurses’ age and their adherence to ethical codes (p ¼ 0.04, r ¼ 0.077). However, no significant relationship
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Table 1. Viewpoints of patients, nurses, and nurse managers toward nurses’ adherence to ethical codes. Group
Satisfactory, n (%)
Average, n (%)
Less than satisfactory, n (%)
p value
70 (70) 86 (86) 16 (53.3) 172 (74.8)
24 (24) 13 (13) 13 (43.3) 50 (21.7)
6 (6) 1 (1) 1 (3.3) 8 (3.5)
0.001*
Patients Nurses Nurse managers Total *Chi-square.
Table 2. Mean scores of adherence to ethical codes from the three groups’ viewpoints. Group Patients Nurses Nurse managers
N
Minimum
Maximum
Mean
df
p value
100 100 30
16 18 16
48 48 48
38.44 41.8 37.83
6.91 4.82 6.98
0.003*
*Analysis of variance (ANOVA).
was observed between their other demographic characteristics and the scores of adherence to ethical codes given by the three groups (p > 0.05). Considering the patients’ points of view regarding different items in the questionnaire, ‘‘The nurse provides all the nursing interventions with respect to the patient and preserving his or her dignity’’ was the most observed code, while ‘‘The nurse reports any objection or problem of the patient to the ward supervisor’’ got the lowest score. The nurses, on the other hand, gave the highest score to ‘‘The nurse avoids any action, even at the patient’s request, that requires ethical, legal, or religious violation.’’ From the managers’ viewpoint, the most observed code by the nurses was ‘‘The nurse performs the nursing care based on current knowledge and common sense.’’ Both nurses and managers gave the lowest score to observation of the code ‘‘The nurse introduces himself or herself with name, title, and his or her professional role to the patient’’ (Table 3). Based on the results of ANOVA, significant differences were found among the patients’, nurses’, and managers’ viewpoints with respect to 4 out of the 16 questionnaire items. There was a significant difference between the nurses’ and patients’ viewpoints regarding the item ‘‘The nurse, in order to empower the patient, educates him or her and his or her family based on the care plan and discharge program’’ (p ¼ 0.0001). In addition, a significant difference was found between the nurses’ and managers’ points of view concerning ‘‘The nurse respects the patient’s privacy when performing any nursing intervention’’ (p ¼ 0.004). Considering the item ‘‘The nurse reports any objection or problem of the patient to the ward supervisor,’’ the patients’ viewpoints differed significantly from those of the nurses and the managers (p ¼ 0.001). Finally, a significant difference was observed between the nurses’ and managers’ points of views regarding the item ‘‘The nurse avoids any action, even at the patient’s request, that requires ethical, legal, or religious violation’’ (p ¼ 0.04; Table 3).
Discussion Based on the results of this study, the nurses’ adherence to ethical codes in internal and surgical wards was satisfactory from the patients’, nurses’, and nurse managers’ points of view. This finding agrees with the results of another study in which 77.1% of the patients in a hospital in south of Iran rated the nurses’ performance with regard to ethical codes as satisfactory.8 However, another research revealed that 51.8% and 41.8% of the patients rated the nurses’ adherence to ethical codes as average and satisfactory, respectively.9
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Table 3. Comparison of the mean scores of adherence to each ethical code from the three groups’ viewpoints. Mean + SD Ethical codes The nurse: 1. Introduces himself or herself with name, title, and his or her professional role to the patient 2. Provides all the nursing interventions with respect to the patient and preserving his or her dignity 3. Considers the patient’s demands regardless of their age, sex, race, economic status, lifestyle, culture, religion, political beliefs, and physical abilities 4. Performs the nursing care based on the current knowledge and common sense 5. Produces a gentle behavioral and verbal communication, in a way that by attracting the patient’s trust, his or her needs and concerns could be understood 6. Before performing any nursing interventions, obtains the patient’s or his or her legal guardian’s informed consent 7. Provides sufficient information about nursing interventions to the patient 8. When presenting or applying a new product in clinical practice, has a complete knowledge of its risks 9. In order to empower the patient, educates him or her and his or her family based on the care plan and discharge program 10. Considers all the information given or obtained during the care process as the professional secrets and does not reveal them without patient’s permission except in legally permissible cases 11. Informs the patients that part of his or her medical record might be disclosed to other team members for medical consultation 12. Uses the medical information of the patients in research or education with their permission. Presentation of the results is done without mentioning the name, address, or any other information that could lead to identification of the patient 13. Respects the patient’s privacy when performing any nursing intervention 14. In case of patient dissatisfaction or other problems, respects their right to change the charged nurse or other healthcare providers and, to the extent possible, tries to satisfy the patient 15. Reports any objection or problem to the ward supervisor 16. Avoids any action, even in patient’s request, that requires ethical, legal, or religious violation
Patients
Nurses
1.54 + 1.1
1.81 + 0.85
1.7 + 0.91
0.15
2.73 + 0.5
2.67 + 0.55
2.4 + 0.56
0.13
2.72 + 0.55 2.76 + 0.49
2.58 + 0.56
0.29
2.7 + 0.52 2.68 + 0.51
2.66 + 0.47
0.91
2.67 + 0.65 2.64 + 0.52
2.5 + 0.5
0.39
2.51 + 0.74 2.56 + 0.71
2.46 + 0.68
0.76
2.45 + 0.79 2.59 + 0.6
2.34 + 0.55
0.16
2.17 + 0.98 2.54 + 0.59
2.3 + 0.59
0.08
2.32 + 0.96 2.73 + 0.46
2.44 + 0.63
0.001
2.69 + 0.61
2.51 + 0.57
0.41
2.47 + 0.89 2.61 + 0.54
2.5 + 0.62
0.76
2.57 + 0.78 2.58 + 0.55
2.55 + 0.57
0.97
2.64 + 0.67 2.78 + 0.45
2.37 + 0.62
0.004
2.56 + 0.89
2.6 + 0.6
2.48 + 0.63
0.72
2.77 + 0.44
2.33 + 0.66
0.001
2.64 + 0.73 2.79 + 0.43
2.5 + 0.62
0.04
2.6 + 0.8
0 + 0.0
SD: standard deviation.
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Nurse managers p value
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One other study also demonstrated that nurses rated the observance of ethical codes as average.10 In Iran, few studies have addressed patients’ level of satisfaction with observance of ethical codes in hospitals. However, based on the results of the studies on the patients’ level of satisfaction with nursing services, it can be estimated that patients’ satisfaction depends on the factors addressed in the ethical codes. For instance, Joolaee et al.’s13 study showed that the patients were most satisfied with factors such as nurses’ accessibility, the manner of their relationship with the patients, and the timely performance of the interventions, all of which were mentioned in the codes. In this study, the nurses rated their adherence to the ethical codes more satisfactory compared to the patients and mangers. Similarly, a previous study indicated a difference between the viewpoints of the patients and nurses concerning the nurses’ adherence to ethical codes.9 One reason for this difference can be the nurses’ imperfect awareness of the applications of the ethical codes in practice. In a study in the United States, only half of the nurses acted according to the ethical codes or other ethical frameworks. This showed a need for continuing educational programs on ethical codes so that nurses would use ethical codes as a framework for their practice.14 The results of a study in Ghana also demonstrated that the nurses’ reactions to ethical issues did not always agree with the codes set by the International Council of Nurses. The nurses in that study acted based on the local ethical codes, and both their awareness and practice of the standard codes were imperfect.15 Evidently, there is an increasing concern regarding the nurses’ ethical competence. The studies conducted on nurses’ observance of ethical codes have also disclosed that the nurses were not highly competent with respect to the knowledge and practice of ethical codes.16,17 In general, there seems to be three common reasons for nurses’ failure to observe the ethical codes: ineffectiveness of the codes in daily clinical practices, disparity between the codes and the realities in clinical environments, and nurses’ unawareness of the codes.18 Moreover, the differences between the nurses’ and patients’ viewpoints regarding nurses’ adherence to ethical codes in Iran imply that although the ethical codes for nurses have been set in accordance with the Iranian culture, it is essential to hold more educational programs for the staff as well as nursing students and monitor nurses’ ethical performance more carefully.9 In fact, more informed nurses can respect and protect their patients’ rights more effectively.19 Factors, such as disproportion between the number of nurses and patients, can affect nurses’ ethical performance, as well. Bennett et al.20 also mentioned insufficient time and staff, compared to the large number of patients, as the main barriers to nurses’ observance of professional ethics at work. The findings of this study indicated no significant difference between the managers’ and the patients’ viewpoints. However, the difference between those of the managers and the nurses was statistically significant. A possible explanation for these results can be the managers’ critical view toward nurses’ ethical performance as a part of their supervisory responsibilities. The managers monitoring of nurses’ adherence to ethical codes is important because the patients’ rights are not protected solely by ethical regulations, and some strategies must be considered for constant evaluation and monitoring of nurses’ performance in this regard.19,21 It is also possible that patients or their relatives report cases to managers that eventually affects their attitude and causes them to have different opinions from nurses. Since a limited number of studies have been carried out in this area, especially on nurse managers’ viewpoints, future researches are recommended to investigate the nurse managers’ viewpoints concerning observance of ethical codes in the units that they are responsible for. Besides, the differences between the nurses’ and managers’ points of view should be examined in larger sample sizes. In this study, the patients rated the nurses’ performance with regard to reporting their complaints and problems to supervisors as unsatisfactory. However, both the nurses and managers rated the nurses’ observance of this code as satisfactory. Consistently, the findings of a study in Greece showed that the patients believed that their right to complain was not properly respected by nurses.22 Upon entering the new environment of the hospital and experiencing unfamiliar situations, patients need more support and expect nurses to perform their advocating role more efficiently.21 According to the results of a qualitative study,
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however, patients viewed nurses as excessively task-focused, interested in their routine duties, and indifferent to their patients’ higher needs, especially their emotional and psychological needs, which resulted in patients’ dissatisfaction.19 Traditional paternalism, another prevalent phenomenon in our clinical environments, prevents patients from being fully aware of their diseases and treatments and from participating in clinical decision-making, which can result in patients’ dissatisfaction.21 Therefore, providing patients with sufficient information about their treatment procedures and attending to their emotional–psychological needs can lead to fewer complaints on the part of the patients. In our study, none of the three groups regarded introduction of nurses to patients as satisfactory, which is in agreement with the results of the study by Maarefi et al.8 However, these results were in contrast to those obtained by Sawada et al.23 in Brazil. This contradiction can be justified by the differences between the participants’ cultural backgrounds. The present study researchers’ own clinical experiences confirm that due to cultural reasons, nurses are not willing to introduce themselves to patients and introduce themselves as ‘‘your nurse!’’ upon the first meeting with their patients. Nevertheless, a proper introduction is the first step in establishment of an effective relationship and encourages the two sides to trust each other.24 According to the results of a qualitative study, patients maintained that nurses’ introduction to patients promoted a good relationship and was a sign of respect for patients’ dignity.25 Sometimes, an effective relationship is more important than physical care to patients and can improve the quality of the care provided by the nurse as well as patient satisfaction.21 In this study, all the three groups rated nurses’ respect for patients’ privacy during nursing interventions as satisfactory. This was in contrast to the findings of the study by Ebrahimi et al.,26 where invasion of privacy formed a main theme and was frequently stated by the patients. Likewise, another study revealed a significant difference between the nurses’ and patients’ attitudes regarding respect for patients’ privacy during nursing interventions.27 Since privacy includes physical, social, and informational dimensions,8 the aforementioned contradictions can be explained by the fact that privacy was used in its general sense in this study and the participants might have had different interpretations based on their backgrounds. Therefore, their general attitude toward nurses’ observance of this code was positive. Furthermore, the managers rated nurses’ observance of this code less satisfactory compared to the nurses and patients, which stresses the need for paying more attention to patients’ privacy. Since the majority (99.4%) of Iranians are Muslim28 and respecting people’s privacy is a key tenet in Islam,29 this cultural–religious code should be taken into account more. Thus, it is essential to provide educational programs on patients’ privacy for the staff and to continually evaluate the observance of this code. The patients, nurses, and nurse managers in the two hospitals in this study reported the observance of the ethical codes for nurses as satisfactory. Yet, it is necessary to keep providing educational programs, both at the professional level and for the public, to inform patients about their rights, encourage nurses to respect patients’ rights more properly, and help managers enhance the quality of care through continual evaluation. Although this study was conducted in two of the largest hospitals in the largest city in south of Iran, the study population was rather small, making the results less generalizable. Hence, more comprehensive studies with larger sample sizes are recommended to be conducted across the country so that more accurate plans can be designed. In this study, the nurses’ adherence to ethical codes was assessed by self-report. Although selfreport might be an appropriate method for evaluation, based on the findings and the significant difference between the nurses’ and other groups’ perceptions, future studies are recommended to observe nurses’ performance for assessing this issue. Qualitative approaches might be helpful, as well.
Conclusion The results of this study which aimed to compare the viewpoints of the patients, nurses, and nurse managers regarding the observance of ethical codes in the internal and surgical wards of two hospitals showed that the
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three groups rated the observance of the codes as satisfactory. Nurses, however, rated their performance more satisfactory compared to the other two groups. Moreover, differences were observed among the three groups’ viewpoints concerning certain codes, which can result in dissatisfaction with nursing services. Overall, by increasing the awareness of the staff and nurse managers and providing educational programs for the public, we can enhance the general knowledge of the ethical codes and patients’ rights and, consequently, increase satisfaction with clinical care. Acknowledgements This article was extracted from the thesis written by Afifeh Rahmanian Kooshkaki. The MSc thesis in nursing was approved by the Research Vice-chancellor of Shiraz University of Medical Sciences. Hereby, the authors would like to thank Ms A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript. They are also grateful for all the participants who kindly allocated their time to cooperation in this study. Conflict of interest None declared. Funding The study was financially supported by the Research Vice-chancellor of Shiraz University of Medical Sciences (grant no. 92-6921). References 1. Liaschenko J and Elizabeth P. Nursing ethics and conceptualizations of nursing: profession, practice and work. J Adv Nurs 2004; 46(5): 488–495. 2. Butts JB and Rich KL. Nursing ethics: across the curriculum and into practice. Jones & Bartlett Learning, 2013, pp. 146–149. 3. Corley M. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650. 4. Doane G. Am I still ethical? The socially-mediated process of nurses’ moral identity. Nurs Ethics 2002; 9(6): 623–635. 5. Varcoe C, Doane G, Pauly B, et al. Ethical practice in nursing: working the in-betweens. J Adv Nurs 2004; 45: 316–325. 6. Heikkinen A, Lemonidou C, Petsios K, et al. Ethical codes in nursing practice: the viewpoint of Finnish, Greek and Italian nurses. J Adv Nurs 2006; 55: 310–319. 7. Zahedi F, Sanjary M, Cheraghi M, et al. The code of ethics for nurses. Iran J Public Health 2013; 42(Suppl. 1): 1–8. 8. Maarefi F, Ashktorab T, Abbaszadah A, et al. Review of the patients in relation to respecting the codes of ethics the nurses. Bioethics Quart 2013; 3(10): 36–56 (in Farsi, English abstract). 9. Mohajjel A, Hassankhani H and Moghaddam S. Knowledge and performance about nursing ethic codes from nurses and patients perspective in Tabriz teaching hospitals Iran. J Caring Sci 2013; 2(3): 219–227 (in Farsi, English abstract). 10. Ghobadifar MA and Mosalanejad L. Evaluation of staff adherence to professionalism in Jahrom University of Medical Sciences. J Educ Ethics Nurs 2013; 2(2): 1–7 (in Farsi, English abstract). 11. Madani G. Patient satisfaction from medical and nursing care. J Nurs Midwifery Res 2004; 3(24): 15. 12. Aitamaa E, Leino-Kilpi H, Puukka P, et al. Ethical problems in nursing management: the role of codes of ethics. Nurs Ethics 2010; 17(4): 469–482. 13. Joolaee S, Givari A, Taavoni S, et al. Patients’ satisfaction with provided nursing care. Iran J Nurs Res 2008; 2(6): 37–44.
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Nurses’ adherence to ethical codes: The viewpoints of patients, nurses, and managers
Nursing Ethics 1–10 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015583927 nej.sagepub.com
Marzieh Momennasab, Afifeh Rahmanin Koshkaki, Camellia Torabizadeh and Seyed Ziaeddin Tabei Shiraz University of Medical Sciences, Shiraz, Iran
Abstract Background: Ethical codes are guidelines that orient nurses and ensure that their decisions are in accordance with the values of the professional system. These codes show that there is a connection among values, patients’ rights, and nurses’ duties. Objectives: This study aimed to compare the viewpoints of patients, nurses, and nurse managers regarding the extent to which clinical ethical codes are observed. Research design: In this descriptive–comparative study, data were collected using three questionnaires based on Iranian nurses’ ethical codes with a focus on clinical care. The reliability of the questionnaire was verified by test–retest method (r ¼ 0.9). The patients were interviewed by the researcher, but nurses and managers completed the questionnaires themselves. After all, the data were analyzed using the SPSS statistical software (v 15). Participants and research context: In all, 100 patients, 100 nurses, and 30 managers from internal and surgical wards of two major hospitals in Shiraz, Iran, participated in 2014. Ethical considerations: This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants signed written informed consents. Findings: According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses’ adherence to ethical codes as satisfactory. The mean scores (standard deviation) of the level of adherence to ethical codes were 38.44 (6.91) in the patients, 41.08 (4.82) in the nurses, and 37.83 (6.98) in the nurse managers. The results of analysis of variance revealed a significant difference between the attitudes of the nurses and the other two groups (p ¼ 0.001). Discussion: Nurses’ adherence to ethical codes was satisfactory in all three groups. Accordingly, our findings agree with the results of some national and international studies, although there are still controversies in this regard. Conclusion: Although the nurses rated their performance in certain fields more satisfactory compared to the patients and managers, all the three groups agreed that clinical ethical codes were properly observed in the internal and surgical wards. Nurses can improve the quality of care by considering the viewpoints of patients and managers about their ethical performance.
Corresponding author: Marzieh Momennasab, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Zand St., Namazee Sq., 7193613119 Shiraz, Iran. Email: [email protected]
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Keywords Adherence, ethical codes, nurse managers, nurses, patients, viewpoints
Introduction Since nurses are in direct contact with patients, it is necessary that they observe the ethical principles during professional practice.1 Professional ethics demand nurses to obey the principles which will not only earn nurses the trust of their patients2 but also create positive psychological changes in nurses, including satisfaction, higher motivation, and feeling of competence.3 Nursing ethical codes have been designed to meet the need for ethical principles and standards and proper guidelines. Ethical codes provide nurses with guidelines that will help them when they need to make decisions and when they are faced with moral challenges. These codes are meant to act as standards in the nursing profession, and the society needs to be made aware of them.4 Since nurses have the highest contact with patients and are faced with more moral challenges compared to the other members of the health team,4 ethical codes that fit the society’s culture and religion will prove an effective way to improve the quality of the care provided by nurses.5 Ethical codes should be studied in their cultural, social, and historical contexts. Accordingly, many countries have reviewed and revised their ethical codes and guidelines so that they would match their cultures.6 Ethical codes for nurses in Iran include 12 values and 71 provisions in five parts and were approved by the High Committee of Medical Ethics of Ministry of Health and Medical Education in 2011. The values are related to concepts such as patients’ dignity, professional commitments, responsibility, patients’ privacy, higher academic and practical competence, and personal independence. The parts that deal with ‘‘Nurses and People’’ with 9 provisions, ‘‘Nurses and the Profession’’ with 14 provisions, and ‘‘Nurses and Practice’’ with 23 provisions provide nurses with guidelines on how to work and make decisions in the clinical environment. In addition, the parts ‘‘Nurses and Coworkers’’ with 15 provisions and ‘‘Nursing, Education, and Research’’ with 10 provisions provide ethical instructions in the field of communication, research, and education.7 Ethical codes for nurses have only recently been set down in Iran; therefore, few comprehensive and organized studies have been conducted on nurses’ level of adherence to the ethical codes and the consequences of such adherence. Moreover, contradictory results have been obtained in the available studies.8–10 For instance, according to one study, 77% of the patients rated the nurses’ observance of ethical codes as satisfactory,8 while another study demonstrated average observance of ethical codes.10 Most studies in this area have focused on nurses’ attitudes toward ethical codes,10 while the real beneficiaries of the codes are patients,11 and their opinions have to be taken into account in order to improve the quality of care. Moreover, evidence has shown that nurses and patients hold significantly different views about nurses’ adherence to ethical codes. According to one study, while 91.9% of the nurses believed that their performance was satisfactory regarding the ethical codes, only 41.8% of the patients rated their performance as acceptable.9 In addition, although nurse managers are responsible for monitoring nurses’ observance of the ethical codes, their attitudes have been the subjects of few studies. For instance, Aitamaa et al.12 indicated that nurse managers’ main concern about ethical codes was regarding nurses’ provision of high-quality care. Thus, it is important to study managers’ views on observance of ethical codes on the part of their nurses. Furthermore, different perceptions and viewpoints of patients, nurses, and managers may lead to dissatisfaction with nursing care. Therefore, comparison of these three groups can help achieve a common viewpoint. This study aims to compare the patients’, nurses’, and nurse managers’ points of view regarding the extent to which ethical codes are observed in clinical environments.
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Methods Setting This descriptive–comparative study was conducted in the internal and surgical wards of two major educational hospitals in Shiraz, south of Iran in 2014. These hospitals are the largest educational centers in the capital of Fars province and cover other areas in southern part of the country, as well. These two hospitals include a total of 28 internal and surgical wards. This study population included all the patients, nurses, head nurses, and supervisors in these wards.
Data collection Based on the pilot study and probability of loss, the sample size was set at 100 patients, 100 nurses, and 30 managers. It should be noted that the head nurses and supervisors of the internal and surgical wards as well as the matrons at the two hospitals participated in the study as the nurse managers. At first, the researcher visited the 28 wards in the two hospitals and chose four patients from each ward who were qualified for the study via simple random sampling. Besides, the nurses were selected using convenience sampling. In doing so, the researcher visited the wards at different work shifts and the present nurses were given the questionnaires. In case there were more than four nurses present on the shift, they would be randomly sampled. Likewise, the managers were selected by convenience sampling. Since most nurses in Iran work in clinical environments, that is, hospitals and clinics, among the five main parts of ethical codes, the researcher addressed the ‘‘Nurses and Practice’’ which focuses on clinical care. Accordingly, three questionnaires were designed for the three groups under study. Each questionnaire consisted of two sections, the first of which involved the participants’ demographic characteristics. The second section of the questionnaire, on the other hand, included items on the ethical codes. Initially, the items following each code were rephrased so as to fit each target group, that is, patients, nurses, and managers. This section included 16 items scored through a Likert scale including the following options: never (0), occasionally (1), often (2), and always (3). Thus, the minimum and maximum scores of the questionnaires were 0 and 48, respectively. However, 10 code items in the area of clinical care which were related to research and education were omitted from the questionnaire due to the patients’ unfamiliarity with the concepts. The participants’ responses to the items were scaled in the following order: less than satisfactory (0–24), average (24–36), and satisfactory (36–48). To verify the content validity of the questionnaires, five nursing faculty members were consulted. Additionally, test–retest method was employed to verify the reliability of the questionnaires. In doing so, 20 nurses and 20 nurse managers were asked to complete the questionnaires in two stages with an interval of 2 weeks, and the reliability was confirmed with a correlation coefficient of 0.9. The nurses and nurse managers completed the questionnaires themselves, while the researcher interviewed the patients to complete the questionnaires.
Data analysis The collected data were analyzed using the SPSS statistical software (v 15). Descriptive statistics, that is, frequency, percentage, mean, and standard deviation (SD), were used to describe the participants’ demographic characteristics and viewpoints toward adherence to ethical codes. Besides, inferential statistics, namely, analysis of variance (ANOVA), t-test, and chi-square test, were used to describe the relationships between the variables and the differences among the three groups. Pearson’s correlation coefficient was also
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employed to assess the correlation between the participants’ scores and their personal and professional characteristics.
Participants Nurses. The inclusion criteria of the study for the nurses were having bachelor or above degrees and having at least 1 month experience of professional practice in an internal or surgical ward. The majority of the nurses under study were female (78%), married (55%), and had bachelor’s degrees (90%). The nurses’ ages ranged from 22 to 40 years, with a mean age of 30.05 + 4.91 years. In addition, their working experience ranged from 1 to 15 years, with a mean of 5.28 + 3.59 years. Moreover, 66% of the nurses had attended continuing education programs on nursing ethics. Patients. The inclusion criteria of the study for the patients were having experienced at least 1 day of hospitalization in an internal or surgical ward, having no cognitive disorders, and being able to talk. In this study, 52% of the patients were female, 75% were married, and 55% had below diploma degrees. Besides, the patients’ ages ranged from 18 to 72 years, with a mean age of 41.71 + 20.65 years. In addition, their length of hospitalization ranged from 2 to 65 days, with a mean of 9.14 + 9.67 days. Nurse managers. The inclusion criteria of the study for the nurse managers were having bachelor or higher degrees and having at least 3 months’ experience of professional practice as a manager. In this study, 80% of the managers were female and 73% were married. The managers’ ages ranged from 25 to 51 years, with a mean age of 36.60 + 6.11 years. Most of the nurse managers (80%) had bachelor’s degrees. Besides, their mean working experience as nurses and nurse managers was 12.30 + 5.98 (ranging from 3 to 28) and 4.56 + 3.64 years, respectively. All the participating managers had attended continuing education programs on nursing ethics.
Ethical considerations This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants received verbal explanation about the study objectives and procedures and then signed written informed consents for taking part in the study. The participants were also reassured about the anonymity and confidentiality of their information.
Results According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses’ adherence to ethical codes in the internal and surgical wards of their hospitals as satisfactory. Additionally, 43.3% of the managers rated adherence to ethical codes as average. The results of chi-square test showed a significant difference among the three groups in this regard (p ¼ 0.001; Table 1). The mean score of nurses’ adherence to ethical codes was 38.44 + 6.91 by the patients, 41.08 + 4.82 by the nurses, and 37.83 + 6.98 by the nurse managers, and the results of ANOVA showed that the differences were statistically significant (p ¼ 0.003; Table 2). In addition, the results of Tukey’s post hoc test demonstrated a significant difference between the patients’ and the nurses’ viewpoints (p ¼ 0.007) as well as between the nurses’ and the managers’ points of view (p ¼ 0.030). However, no significant difference was found between the managers’ and the patients’ viewpoints (p ¼ 0.88). The results of Pearson’s correlation coefficient indicated a weak significant correlation between the nurses’ age and their adherence to ethical codes (p ¼ 0.04, r ¼ 0.077). However, no significant relationship
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Table 1. Viewpoints of patients, nurses, and nurse managers toward nurses’ adherence to ethical codes. Group
Satisfactory, n (%)
Average, n (%)
Less than satisfactory, n (%)
p value
70 (70) 86 (86) 16 (53.3) 172 (74.8)
24 (24) 13 (13) 13 (43.3) 50 (21.7)
6 (6) 1 (1) 1 (3.3) 8 (3.5)
0.001*
Patients Nurses Nurse managers Total *Chi-square.
Table 2. Mean scores of adherence to ethical codes from the three groups’ viewpoints. Group Patients Nurses Nurse managers
N
Minimum
Maximum
Mean
df
p value
100 100 30
16 18 16
48 48 48
38.44 41.8 37.83
6.91 4.82 6.98
0.003*
*Analysis of variance (ANOVA).
was observed between their other demographic characteristics and the scores of adherence to ethical codes given by the three groups (p > 0.05). Considering the patients’ points of view regarding different items in the questionnaire, ‘‘The nurse provides all the nursing interventions with respect to the patient and preserving his or her dignity’’ was the most observed code, while ‘‘The nurse reports any objection or problem of the patient to the ward supervisor’’ got the lowest score. The nurses, on the other hand, gave the highest score to ‘‘The nurse avoids any action, even at the patient’s request, that requires ethical, legal, or religious violation.’’ From the managers’ viewpoint, the most observed code by the nurses was ‘‘The nurse performs the nursing care based on current knowledge and common sense.’’ Both nurses and managers gave the lowest score to observation of the code ‘‘The nurse introduces himself or herself with name, title, and his or her professional role to the patient’’ (Table 3). Based on the results of ANOVA, significant differences were found among the patients’, nurses’, and managers’ viewpoints with respect to 4 out of the 16 questionnaire items. There was a significant difference between the nurses’ and patients’ viewpoints regarding the item ‘‘The nurse, in order to empower the patient, educates him or her and his or her family based on the care plan and discharge program’’ (p ¼ 0.0001). In addition, a significant difference was found between the nurses’ and managers’ points of view concerning ‘‘The nurse respects the patient’s privacy when performing any nursing intervention’’ (p ¼ 0.004). Considering the item ‘‘The nurse reports any objection or problem of the patient to the ward supervisor,’’ the patients’ viewpoints differed significantly from those of the nurses and the managers (p ¼ 0.001). Finally, a significant difference was observed between the nurses’ and managers’ points of views regarding the item ‘‘The nurse avoids any action, even at the patient’s request, that requires ethical, legal, or religious violation’’ (p ¼ 0.04; Table 3).
Discussion Based on the results of this study, the nurses’ adherence to ethical codes in internal and surgical wards was satisfactory from the patients’, nurses’, and nurse managers’ points of view. This finding agrees with the results of another study in which 77.1% of the patients in a hospital in south of Iran rated the nurses’ performance with regard to ethical codes as satisfactory.8 However, another research revealed that 51.8% and 41.8% of the patients rated the nurses’ adherence to ethical codes as average and satisfactory, respectively.9
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Table 3. Comparison of the mean scores of adherence to each ethical code from the three groups’ viewpoints. Mean + SD Ethical codes The nurse: 1. Introduces himself or herself with name, title, and his or her professional role to the patient 2. Provides all the nursing interventions with respect to the patient and preserving his or her dignity 3. Considers the patient’s demands regardless of their age, sex, race, economic status, lifestyle, culture, religion, political beliefs, and physical abilities 4. Performs the nursing care based on the current knowledge and common sense 5. Produces a gentle behavioral and verbal communication, in a way that by attracting the patient’s trust, his or her needs and concerns could be understood 6. Before performing any nursing interventions, obtains the patient’s or his or her legal guardian’s informed consent 7. Provides sufficient information about nursing interventions to the patient 8. When presenting or applying a new product in clinical practice, has a complete knowledge of its risks 9. In order to empower the patient, educates him or her and his or her family based on the care plan and discharge program 10. Considers all the information given or obtained during the care process as the professional secrets and does not reveal them without patient’s permission except in legally permissible cases 11. Informs the patients that part of his or her medical record might be disclosed to other team members for medical consultation 12. Uses the medical information of the patients in research or education with their permission. Presentation of the results is done without mentioning the name, address, or any other information that could lead to identification of the patient 13. Respects the patient’s privacy when performing any nursing intervention 14. In case of patient dissatisfaction or other problems, respects their right to change the charged nurse or other healthcare providers and, to the extent possible, tries to satisfy the patient 15. Reports any objection or problem to the ward supervisor 16. Avoids any action, even in patient’s request, that requires ethical, legal, or religious violation
Patients
Nurses
1.54 + 1.1
1.81 + 0.85
1.7 + 0.91
0.15
2.73 + 0.5
2.67 + 0.55
2.4 + 0.56
0.13
2.72 + 0.55 2.76 + 0.49
2.58 + 0.56
0.29
2.7 + 0.52 2.68 + 0.51
2.66 + 0.47
0.91
2.67 + 0.65 2.64 + 0.52
2.5 + 0.5
0.39
2.51 + 0.74 2.56 + 0.71
2.46 + 0.68
0.76
2.45 + 0.79 2.59 + 0.6
2.34 + 0.55
0.16
2.17 + 0.98 2.54 + 0.59
2.3 + 0.59
0.08
2.32 + 0.96 2.73 + 0.46
2.44 + 0.63
0.001
2.69 + 0.61
2.51 + 0.57
0.41
2.47 + 0.89 2.61 + 0.54
2.5 + 0.62
0.76
2.57 + 0.78 2.58 + 0.55
2.55 + 0.57
0.97
2.64 + 0.67 2.78 + 0.45
2.37 + 0.62
0.004
2.56 + 0.89
2.6 + 0.6
2.48 + 0.63
0.72
2.77 + 0.44
2.33 + 0.66
0.001
2.64 + 0.73 2.79 + 0.43
2.5 + 0.62
0.04
2.6 + 0.8
0 + 0.0
SD: standard deviation.
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Nurse managers p value
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One other study also demonstrated that nurses rated the observance of ethical codes as average.10 In Iran, few studies have addressed patients’ level of satisfaction with observance of ethical codes in hospitals. However, based on the results of the studies on the patients’ level of satisfaction with nursing services, it can be estimated that patients’ satisfaction depends on the factors addressed in the ethical codes. For instance, Joolaee et al.’s13 study showed that the patients were most satisfied with factors such as nurses’ accessibility, the manner of their relationship with the patients, and the timely performance of the interventions, all of which were mentioned in the codes. In this study, the nurses rated their adherence to the ethical codes more satisfactory compared to the patients and mangers. Similarly, a previous study indicated a difference between the viewpoints of the patients and nurses concerning the nurses’ adherence to ethical codes.9 One reason for this difference can be the nurses’ imperfect awareness of the applications of the ethical codes in practice. In a study in the United States, only half of the nurses acted according to the ethical codes or other ethical frameworks. This showed a need for continuing educational programs on ethical codes so that nurses would use ethical codes as a framework for their practice.14 The results of a study in Ghana also demonstrated that the nurses’ reactions to ethical issues did not always agree with the codes set by the International Council of Nurses. The nurses in that study acted based on the local ethical codes, and both their awareness and practice of the standard codes were imperfect.15 Evidently, there is an increasing concern regarding the nurses’ ethical competence. The studies conducted on nurses’ observance of ethical codes have also disclosed that the nurses were not highly competent with respect to the knowledge and practice of ethical codes.16,17 In general, there seems to be three common reasons for nurses’ failure to observe the ethical codes: ineffectiveness of the codes in daily clinical practices, disparity between the codes and the realities in clinical environments, and nurses’ unawareness of the codes.18 Moreover, the differences between the nurses’ and patients’ viewpoints regarding nurses’ adherence to ethical codes in Iran imply that although the ethical codes for nurses have been set in accordance with the Iranian culture, it is essential to hold more educational programs for the staff as well as nursing students and monitor nurses’ ethical performance more carefully.9 In fact, more informed nurses can respect and protect their patients’ rights more effectively.19 Factors, such as disproportion between the number of nurses and patients, can affect nurses’ ethical performance, as well. Bennett et al.20 also mentioned insufficient time and staff, compared to the large number of patients, as the main barriers to nurses’ observance of professional ethics at work. The findings of this study indicated no significant difference between the managers’ and the patients’ viewpoints. However, the difference between those of the managers and the nurses was statistically significant. A possible explanation for these results can be the managers’ critical view toward nurses’ ethical performance as a part of their supervisory responsibilities. The managers monitoring of nurses’ adherence to ethical codes is important because the patients’ rights are not protected solely by ethical regulations, and some strategies must be considered for constant evaluation and monitoring of nurses’ performance in this regard.19,21 It is also possible that patients or their relatives report cases to managers that eventually affects their attitude and causes them to have different opinions from nurses. Since a limited number of studies have been carried out in this area, especially on nurse managers’ viewpoints, future researches are recommended to investigate the nurse managers’ viewpoints concerning observance of ethical codes in the units that they are responsible for. Besides, the differences between the nurses’ and managers’ points of view should be examined in larger sample sizes. In this study, the patients rated the nurses’ performance with regard to reporting their complaints and problems to supervisors as unsatisfactory. However, both the nurses and managers rated the nurses’ observance of this code as satisfactory. Consistently, the findings of a study in Greece showed that the patients believed that their right to complain was not properly respected by nurses.22 Upon entering the new environment of the hospital and experiencing unfamiliar situations, patients need more support and expect nurses to perform their advocating role more efficiently.21 According to the results of a qualitative study,
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however, patients viewed nurses as excessively task-focused, interested in their routine duties, and indifferent to their patients’ higher needs, especially their emotional and psychological needs, which resulted in patients’ dissatisfaction.19 Traditional paternalism, another prevalent phenomenon in our clinical environments, prevents patients from being fully aware of their diseases and treatments and from participating in clinical decision-making, which can result in patients’ dissatisfaction.21 Therefore, providing patients with sufficient information about their treatment procedures and attending to their emotional–psychological needs can lead to fewer complaints on the part of the patients. In our study, none of the three groups regarded introduction of nurses to patients as satisfactory, which is in agreement with the results of the study by Maarefi et al.8 However, these results were in contrast to those obtained by Sawada et al.23 in Brazil. This contradiction can be justified by the differences between the participants’ cultural backgrounds. The present study researchers’ own clinical experiences confirm that due to cultural reasons, nurses are not willing to introduce themselves to patients and introduce themselves as ‘‘your nurse!’’ upon the first meeting with their patients. Nevertheless, a proper introduction is the first step in establishment of an effective relationship and encourages the two sides to trust each other.24 According to the results of a qualitative study, patients maintained that nurses’ introduction to patients promoted a good relationship and was a sign of respect for patients’ dignity.25 Sometimes, an effective relationship is more important than physical care to patients and can improve the quality of the care provided by the nurse as well as patient satisfaction.21 In this study, all the three groups rated nurses’ respect for patients’ privacy during nursing interventions as satisfactory. This was in contrast to the findings of the study by Ebrahimi et al.,26 where invasion of privacy formed a main theme and was frequently stated by the patients. Likewise, another study revealed a significant difference between the nurses’ and patients’ attitudes regarding respect for patients’ privacy during nursing interventions.27 Since privacy includes physical, social, and informational dimensions,8 the aforementioned contradictions can be explained by the fact that privacy was used in its general sense in this study and the participants might have had different interpretations based on their backgrounds. Therefore, their general attitude toward nurses’ observance of this code was positive. Furthermore, the managers rated nurses’ observance of this code less satisfactory compared to the nurses and patients, which stresses the need for paying more attention to patients’ privacy. Since the majority (99.4%) of Iranians are Muslim28 and respecting people’s privacy is a key tenet in Islam,29 this cultural–religious code should be taken into account more. Thus, it is essential to provide educational programs on patients’ privacy for the staff and to continually evaluate the observance of this code. The patients, nurses, and nurse managers in the two hospitals in this study reported the observance of the ethical codes for nurses as satisfactory. Yet, it is necessary to keep providing educational programs, both at the professional level and for the public, to inform patients about their rights, encourage nurses to respect patients’ rights more properly, and help managers enhance the quality of care through continual evaluation. Although this study was conducted in two of the largest hospitals in the largest city in south of Iran, the study population was rather small, making the results less generalizable. Hence, more comprehensive studies with larger sample sizes are recommended to be conducted across the country so that more accurate plans can be designed. In this study, the nurses’ adherence to ethical codes was assessed by self-report. Although selfreport might be an appropriate method for evaluation, based on the findings and the significant difference between the nurses’ and other groups’ perceptions, future studies are recommended to observe nurses’ performance for assessing this issue. Qualitative approaches might be helpful, as well.
Conclusion The results of this study which aimed to compare the viewpoints of the patients, nurses, and nurse managers regarding the observance of ethical codes in the internal and surgical wards of two hospitals showed that the
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three groups rated the observance of the codes as satisfactory. Nurses, however, rated their performance more satisfactory compared to the other two groups. Moreover, differences were observed among the three groups’ viewpoints concerning certain codes, which can result in dissatisfaction with nursing services. Overall, by increasing the awareness of the staff and nurse managers and providing educational programs for the public, we can enhance the general knowledge of the ethical codes and patients’ rights and, consequently, increase satisfaction with clinical care. Acknowledgements This article was extracted from the thesis written by Afifeh Rahmanian Kooshkaki. The MSc thesis in nursing was approved by the Research Vice-chancellor of Shiraz University of Medical Sciences. Hereby, the authors would like to thank Ms A. Keivanshekouh at the Research Improvement Center of Shiraz University of Medical Sciences for improving the use of English in the manuscript. They are also grateful for all the participants who kindly allocated their time to cooperation in this study. Conflict of interest None declared. Funding The study was financially supported by the Research Vice-chancellor of Shiraz University of Medical Sciences (grant no. 92-6921). References 1. Liaschenko J and Elizabeth P. Nursing ethics and conceptualizations of nursing: profession, practice and work. J Adv Nurs 2004; 46(5): 488–495. 2. Butts JB and Rich KL. Nursing ethics: across the curriculum and into practice. Jones & Bartlett Learning, 2013, pp. 146–149. 3. Corley M. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650. 4. Doane G. Am I still ethical? The socially-mediated process of nurses’ moral identity. Nurs Ethics 2002; 9(6): 623–635. 5. Varcoe C, Doane G, Pauly B, et al. Ethical practice in nursing: working the in-betweens. J Adv Nurs 2004; 45: 316–325. 6. Heikkinen A, Lemonidou C, Petsios K, et al. Ethical codes in nursing practice: the viewpoint of Finnish, Greek and Italian nurses. J Adv Nurs 2006; 55: 310–319. 7. Zahedi F, Sanjary M, Cheraghi M, et al. The code of ethics for nurses. Iran J Public Health 2013; 42(Suppl. 1): 1–8. 8. Maarefi F, Ashktorab T, Abbaszadah A, et al. Review of the patients in relation to respecting the codes of ethics the nurses. Bioethics Quart 2013; 3(10): 36–56 (in Farsi, English abstract). 9. Mohajjel A, Hassankhani H and Moghaddam S. Knowledge and performance about nursing ethic codes from nurses and patients perspective in Tabriz teaching hospitals Iran. J Caring Sci 2013; 2(3): 219–227 (in Farsi, English abstract). 10. Ghobadifar MA and Mosalanejad L. Evaluation of staff adherence to professionalism in Jahrom University of Medical Sciences. J Educ Ethics Nurs 2013; 2(2): 1–7 (in Farsi, English abstract). 11. Madani G. Patient satisfaction from medical and nursing care. J Nurs Midwifery Res 2004; 3(24): 15. 12. Aitamaa E, Leino-Kilpi H, Puukka P, et al. Ethical problems in nursing management: the role of codes of ethics. Nurs Ethics 2010; 17(4): 469–482. 13. Joolaee S, Givari A, Taavoni S, et al. Patients’ satisfaction with provided nursing care. Iran J Nurs Res 2008; 2(6): 37–44.
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