Barriers to Observance of the Codes of Professional Ethics in Clinical Care: Perspectives of Nurses and Midwifery of Hospitals Affiliated with Qom University of Medical Sciences in 2016

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Health, Spirituality and Medical Ethics - Vol.5, No.1, Mar 2018 33
Barriers to Observance of the Codes of Professional Ethics in Clinical Care:
Perspectives of Nurses and Midwifery of Hospitals Affiliated with Qom University
of Medical Sciences in 2016
Received 31 Jul 2017; Accepted 3 Oct 2017
Imaneh Khaki1, Mohammad Abbasi2, Zohre Khalajinia1*, Somayeh Momenyan3
1 Department of Midwifery, School of nursing and midwifery, Qom University of Medical Sciences Qom, Iran.
2 Department of Nursing, School of nursing and midwifery, Qom University of Medical Sciences, Qom, Iran.
3 Paramedical Sciences Faculty, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
*Correspondence: Should be addressed to Ms. Zohre Khalajinia. Email: zkh6033@yahoo.com
Introduction
rofessional ethics is one of the major
issues in all human communities (1).
Professional ethics is nothing but respect
for the rights of the people and the most
important right of the people is respect for
them (2). Professional ethics is concerned with
a series of shoulds and should nots that address
the professionals of a discipline and are related
to their professional responsibilities (3).
Observance of the codes of professional ethics
is one of the most important expectations from
a health care team that influence treatment
course greatly. Medical ethics is an aspect of
professional ethics, and it is therefore essential
to define and explain it precisely as a
prerequisite for arguments about medical ethics
(4). Medical ethics refers to one’s process of
rational thinking, moral commitment and
conscientiousness to his/her own professional
duties and responsibilities (5,6). Professional
ethics is indeed the observance of patients’
rights and respect for them (6) Professional
ethics is aimed at preserving and disseminating
the appropriate values at propitious times in an
organization (7).
Observance of professional ethics is necessary
in all occupations but it is comparatively more
necessary in the nursing and midwifery
P
Abstract
Background and Objectives: The observance of professional ethics is one of the most important expectations from health care
team whose application has a tremendous effect on treatment course. The aim of this study was to investigate barriers to observance
of the codes of professional ethics in clinical settings from the perspectives of nurses and midwifery in hospitals affiliated with
Qom University of Medical Sciences in 2016.
Methods: This descriptive cross-sectional study was conducted with 246 nurses and midwives working in the public hospitals
affiliated with Qom University of Medical Sciences. The data collection instrument was a questionnaire (developed by Dehghani et
al.) to investigate the observance of professional ethics in the three domains management, environmental and individual care-
related.
Results: In the management domain, the most important barrier to implementing the codes of professional ethics in clinical
settings were lack of in-service training and educational programs from midwives’ perspectives (2.2±0.9) and inappropriate head
nurse-staff communication and lack of in-service training and educational programs from nurses’ perspectives (2.53±1.19, and
2.53±1.06, respectively), in environmental domain, lack of suitable equipment in ward from midwives’ perspectives (2.03±0.94)
and rotational shiftwork from nurses' perspectives (2.32±1.07) and in individual care-related domain, lack of technical skills from
both midwives’ and nurses’ perspectives (2.29±1.21 and 2.65±1.23, respectively).
Conclusion: According to the results of this study, individual care-related factors were among the most important barriers to observing
professional ethics from the perspectives of nurses and midwives working in hospitals.
Keywords: Professional Ethics, Clinical Care, Nurses, Midwives.
Original Article Health, Spirituality and Medical Ethics. 2018;5(1):33-39
Please Cite This Article As: Khaki I, Abbasi M, Khalajinia Z, Momenyan S. Barriers to Observance of the Codes of
Professional Ethics in Clinical Care: Perspectives of Nurses and Midwifery of Hospitals Affiliated with Qom
University of Medical Sciences in 2016. Health Spiritual Med Ethics. 2018;5(1):33-9.
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Khaki I, et al
Health, Spirituality and Medical Ethics - Vol.5, No.1, Mar 2018 34
professions, because treating patients
spiritually while assuming responsibility for
them has an effective role in improving their
health and well-being (8). Ethical commitment
to nurse-patient communication is an important
duty of nurses and the codes of ethical care and
their observance are essential components of
the nursing profession (9).
Currently, health care settings are constantly
changing. Therefore, nurses are currently at
higher risk of experiencing ethical conflicts
during patient care that is an uncomfortable
feeling (10).
The observance or lack of observance of the
codes of professional ethics by nurses and
midwives has been much discussed. Certain
factors such as personality, values, lack of
knowledge, insensitivity to patient rights,
dissatisfaction with working conditions and
limited authority and hospital structure and the
ways of managing it are important in this
regard (6,11-13).
A study on the nurses’ perceptions of ethical
issues in China and Switzerland showed that
Chinese nurses were anxious and unhappy
during and after working and that both
populations experienced certain ethical issues
related to lack of establishing appropriate
communication with patients due to high
workload (14).
Nasiriani et al. have argued that taking into
account and observing nurses’ rights is one of
the important effective factors on patient
rights. Numerous shiftworks, lack of facilities
and understaffing and nurses’ low wage are
considered some issues regarding nurses' rights
(15). Studies have confirmed that the
implementation and observance of professional
ethics in clinical settings are subject to certain
limitations (16,17). Dehghani et al. reported
that the barriers to observance of the codes of
clinical professional ethics were understaffing
and inappropriate shiftwork schedules (16). A
study showed that nurses’ ethical performance
in medication administeration was undesirable
and poor (18). Mohammadi et al. reported that
understaffing, the lack of necessary training on
ethical issues during education, ward
congestion and lack of time were the most
important management barriers to
implementing the codes of professional ethics
(19). The study of Borhani et al. showed that
lack of students’ motivation and interest in
nursing profession, lack of self-awareness, and
lack of trainers were the barriers to acquisition
of professional ethics according to nursing
students’ perceptions (20).
Research findings have demonstrated that there
are certain barriers to observance of the codes
of professional ethics by nurses and barriers,
adversely affecting their abilities to deliver
competent and caring care (3). The lack of
observance of professional ethics in health care
system by nurses and midwives influences
patient satisfaction and treatment, standards for
nursing and midwifery services and
occupational promotion, and awareness of
these barriers helps to promote the professional
level of nursing and midwifery. Due to the lack
of studies on barriers to observance
professional ethics in the nursing and
midwifery professions, this study aimed to
investigate the barriers to observing the codes
of professional ethics in clinical settings from
the perspectives of nurses and midwives in
2016.
Methods
In this descriptive, cross-sectional study to
investigate the barriers to observing
professional ethics in clinical settings from the
perspectives of nurses and midwives in 2016,
the study population consisted of nurses and
midwives working in the public hospitals
affiliated with Qom University of Medical
Sciences (n:250). Participants were selected by
convenience random sampling according to a
formula of sample size calculation for
correlational studies and adjustment to random
number table.
Data collection instrument was a two-section
questionnaire: Demographic questionnaire
consisting of age, gender, ward and work
experience and the items on barriers to
observance of professional ethics in the three
domains management (14 items),
environmental (5 items) and individual care-
related (14 items). This questionnaire was
developed by Dehghani et al. (16). Dehghani et
al. have also investigated the validity and
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Barriers to Observance of the Codes of Professional
35 Health, Spirituality and Medical Ethics - Vol.5, No.1, Mar 2018
reliability of this questionnaire and therefore
we did not investigate these variables in the
current study.
In this questionnaire, items are answered on a
5-point Likert scale; the choices Absolutely
agree and Agree represent that the item in
question is a barrier to observance of the codes
of professional ethics. The choice Disagree
represents that there is no barrier to observing
the codes of professional ethics from the
respondent’s perspective. The choice No idea
represents lack of awareness of the effect of the
variable in question on failure to observe
professional ethics.
After the Research Committee of the
university approved the study protocol
(IR.MUQ.REC.1395.72), the researcher
referred to the selected hospitals, and after the
hospital officials provided confirmation,
certain explanations about the research
objectives were provided to participants in a
suitable location at their own places of work in
the final shiftwork or office hours, and they
were then asked to sign informed consent form
to participate in the study if they volunteered.
Then, questionnaires were delivered to
participants and certain explanations about the
two sections of the questionnaire and the
method of answering the items were given to
them, and then the participants began to answer
the items. Participants were told that they
would be allowed two days to return the
completed questionnaires (at work or home at
their convenience). Throughout the study,
ethical considerations were taken into account
including not forcing samples to respond to all
items, not disclosing participants’ answers to
the items, developing the study protocol
according to the guidelines of Qom University
of Medical Sciences and obtaining the consent
of the Health Center Head to conduct the
study, explaining the study procedure to
participants, confidentiality of the collected
information to comply with the regulations and
the codes of ethics and to ensure the officials
and participants to make the results available to
them if they asked.
Data analysis was conducted by SPSS version
20 using the descriptive statistics frequency,
percentage and mean(±standard deviation) and
the inferential statistics t-test.
Result
Out of 250 distributed questionnaires, 246
were completely filled out. Of the completely
filled-out questionnaires, 140 (56.9%) were
completed by female participants. Of the total
number of participants, 62 were midwives who
worked in maternity and postpartum wards and
were being monitored and 184 nurses who
worked in all wards of the hospitals.
Participants’ mean age and duration of work
experience were 34.12±7.69 and 10.04±7.03,
respectively.
Table 1. The mean (±standard deviation)
scores on the items, in management,
environmental and individual care-related
domains, regarding barriers to observing
professional ethics in clinical settings from
nurses’ and midwives’ perspectives.
Table 1. The mean(±standard deviation) scores on the items, in
management, environmental and individual care-related
domains, regarding barriers to observing professional ethics
from the perspectives of nurses and midwifes
P
Standard
deviation
Mean
Post
Barriers
0.005
8.08
31.43
Nurses
Management
6.71
27.15
Midwifes
0.007
3.47
10.47
Nurses
Environmental
3.18
9.11
Midwifes
0.016
8.43
31.33
Nurses
Individual care-
related
8.14
28.35
Midwifes
0.001
17.27
73.23
Nurses
Total
14.57
62.64
Midwifes
The mean scores on the items, in
management, environmental and individual
care-related domains, regarding barriers to
observing professional ethics in clinical
settings from nurses’ and midwives’
perspectives, indicated significant difference in
all three domains between nurses and
midwives (p=0.001).
Table 2 shows the mean (±standard
deviation) scores on the items, in management,
environmental and individual care-related
domains, regarding barriers to observing
professional ethics. In management domain,
the scores on the items lack of efficient control
and supervision by managers, inefficient
management of crisis in ward, inappropriate
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Khaki I, et al
Health, Spirituality and Medical Ethics - Vol.5, No.1, Mar 2018 36
scheduling of shiftworks (disproportion
between personnel's working hours and
numerous shifts), understaffing, lack of written
policies or standards of nursing care
legislation, lack of in-service training and
educational programs on the codes of
professional ethics and inappropriate nurse
head nurse-staff communication (distrust, etc.)
were significantly different between nurses and
midwives.
In this domain, the most important
management barriers to observing the codes of
professional ethics in clinical settings were
lack of in-service training and educational
programs on the codes of professional ethics
from midwives’ perspectives (mean score:
2.2±0.9) and inappropriate head nurse-staff
communication (distrust, etc.) and lack of in-
service training and educational programs on
the codes of professional ethics from nurses’
perspectives (mean scores: 2.53±1.19 and
2.53±1.06, respectively).
In environmental domain, there was a
significant difference in the mean scores on the
items lack of suitable equipment in ward and
rotational shiftwork between midwives and
Table 2. The mean scores on the items, in management, environmental and individual care-related domains, regarding barriers to
observing professional ethics
P-Value
Nurses
Midwifes
Barriers to observing the codes of professional ethics (Items)
Domains
Mean±SD
Mean±SD
0.17
2.16±1.12
1.03±1.77
Lack of paying attention to staff’s abilities and skills at division of duties
Management
0.007
2.30±1.06
0.86±1.9
Lack of efficient control and supervision by managers
0.072
2.33±1
1.06±2.09
Lack of paying attention to staff’s educational needs and planning for meeting
these needs
0.23
2.32±0.99
0.88±2.15
Lack of ethical codes
0.003
2.92±0.96
0.84±1.9
Inefficient management of crisis in ward
0.004
2.07±1.05
0.83±1.64
Scheduling shiftworks inappropriately (disproportion between staff’s working
hours and working numerous shifts)
0.04
1.77±0.86
0.96±1.53
Understaffing
0.11
2±1
0.81±1.77
Extended working hours
0.01
2.53±1.19
0.97±2.14
Inappropriate head nurse-staff communication (distrust, etc.)
0.03
2.53±1.06
0.9±2.2
Lack of in-service training and educational programs on professional ethics
0.003
2.46±0.98
0.97±2.03
lack of written policies or standards of nursing care legislation
0.07
2.36±1.06
0.95±2.09
Lack of adequate experience of educators of ethical and legal issues during
education
0.14
2.27±1.01
0.84±2.06
Lack of necessary education on ethical issues during education
Environmental
0.17
1.97±0.94
0.9±1.79
Inadequate moral and legal support of staff by senior managers
0.04
2.31±0.97
0.94±2.03
Lack of suitable equipment in ward
0.1
1.95±0.9
1.74±0.82
Biological changes due to night shiftwork
0.07
1.85±0.93
1.16±0.77
Ward congestion
0.001
2.32±1.07
1.8±0.84
Rotational shiftworks
0.49
2.02±1.04
1.91±0.98
Improper expectations of patients and their caregivers from staff
0.57
2.24±0.99
2.16±1.02
Lack of knowledge about or awareness of the codes of professional ethics
Individual care-related
0/02
2.2±1.01
1.87±0.93
Lack of time
0.03
2.35±1.03
2.03±1.02
performing entirely new tasks that one does for the first time while he/she does not
have knowledge and skills about them
0.05
1.92±1.03
1.64±0.18
Lack of staff’s paying adequate attention and sufficient diligence due to high
workload, etc.
0.49
1.86±0.91
1.77±0.83
Patients’ inappropriate treating with staff (Communication with the patients who
do not cooperate)
0.73
2.17±0.93
2.22±0.89
Negative attitudes toward the codes of professional ethics
0.93
2.1±0.92
2.09±1
Dealing with infectious disease patients and fear of acquiring certain diseases such
as AIDS and hepatitis
0.76
2.22±0.99
2.17±1.12
Lack of motivation and interest in profession
0.001
1.89±0.96
1.43±0.64
Lack of staff’s meeting basic needs such as sufficient income or rest
0.04
2.19±1.04
1.88±0.94
Dissatisfaction with ward
0.04
2.65±1.23
2.29±1.21
Lack of technical skills
0.06
2.5±1.09
2.24±0.91
Lack of ability of critical thinking or to make moral decisions
0.23
2.4±1.12
2.2±1.13
Defective establishment of effective and appropriate communication with patient
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Barriers to Observance of the Codes of Professional
37 Health, Spirituality and Medical Ethics - Vol.5, No.1, Mar 2018
nurses. In this domain, the most important
management barrier to observing the codes of
professional ethics in clinical settings was lack
of suitable equipment in ward from midwives’
perspectives (mean score: 94.0±2.03) and
rotational shiftwork from nurses’ perspectives
(mean score: 2.32±1.07).
In individual care-related domain, the mean
scores on the items lack of time, lack of
technical skills, lack of staff’s paying adequate
attention and sufficient diligence due to high
workload, etc., lack of meeting basic needs
such as sufficient income or rest among staff,
dissatisfaction with working in ward,
performing entirely new tasks that one does for
the first time while he/she does not have
knowledge and skills about them, were
significantly different between midwives and
nurses. In this domain, the most important
management barrier to observing the codes of
professional ethics in clinical settings, from
both nurses’ and midwives’ perspectives, was
lack of technical skills (mean scores: 65.2±1.23
and 29.2±1.21, respectively).
Discussion
In the current study, the barriers to observing
the codes of professional ethics in
management, environmental, and individual
care-related domains from nurses’ and
midwives’ perspectives were investigated. The
nurses and midwives reported that in
management domain, the lack of in-service
training and educational programs on the codes
of professional ethics was the most important
barrier to observing these codes in health care
delivery. The study of Nasiriani et al. on the
association between nurses’ awareness of
patient rights and the observance rate of these
rights, showed that patient rights were more
respected with increasing the nurses’
awareness (12).
The study of Rudi Rasht Abadi et al. revealed
that nurses who were unaware of patient rights
could seriously violate their rights and
contributed to their dissatisfaction with the
health care system. On the other hand, the
effect of education on awareness score and
managers education and request for the
observance of patient rights on observance
score, can be one of the effective strategies to
further observing patient rights in hospitals
(20).
However, lack of knowledge about and
awareness of the codes of professional ethics
among nurses and nursing students has been
reported. Khalili et al. reported that the levels
of the nursing students’ knowledge about
professional ethics were undesirable and that
additional education on professional ethics was
necessary (6). The study of Mohammadi et al.
indicated that nursing teachers reported the
lack of training on ethical issues during the
undergraduate nursing education to be the most
important management barrier to observance of
the codes of professional ethics. This
highlights the emphasis of nursing teachers on
education as a practical and effective approach
to eliminate existing barriers (19).
It is therefore essential to hire authorities on
nursing professional ethics to teach ethical
issues to nursing students. Available findings
indicate that correct and continuous education
of ethics, including its education to health care
staff, instructors and students in health care
systems is necessary. From the perspectives of
sociologists, professional ethics can be easily
modified by education. Individuals can achieve
self-control if they receive proper and strong
training (17).
Inappropriate head nurse staff communication
was another important management barrier to
observing professional ethics from the nurses'
perspectives. This is concerned with the roles
of nursing managers in creating a work
environment for nurses suitable enough to
deliver efficient care, leading to clients’
satisfaction, enhancement of care quality, and
nurses’ autonomy and accountability (21).
Robin acknowledges that nursing managers are
responsible for creating and maintaining a
work environment for nurses, and their
leadership style to reinforce an effective
environment is particularly important to
promote the clinical competence of nurses
(22). Therefore, inappropriate staff-head nurse
communication prevents the creation of a
suitable work environment, and consequently
the provision of quality services to patients will
be distorted.
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Khaki I, et al
Health, Spirituality and Medical Ethics - Vol.5, No.1, Mar 2018 38
The most important environmental barrier to
implementing the codes of professional ethics,
from the nurses’ perspectives, was rotational
shiftwork. The general health of the nurses
working on rotational shiftwork is lower than
that of the nurses working on fixed shiftwork.
It is clear that the nurses who do not have
acceptable levels of health cannot deliver good
(physical, mental, etc.) care to patients (23).
Wright et al. reported that disruption of sleep
circadian rhythm and subsequently daytime
sleepiness are the most important
consequences of shiftwork (24). A study
demonstrated a clear association between
certain sleep disorders such as sleepiness and
sleep apnea and shiftwork. These disorders can
influence clinical function and represent
important factors for patients’ survival and
health professionals’ well-being. Sleep
disorders not only affect the physical and
mental health of individuals directly and
indirectly, but also affect their functioning and
quality of work. Because a healthy and
dynamic health care system is closely
associated with people's health, any weakness
in functioning and inability of nurses resulting
from sleep disorders can endanger the life of a
human (25).
In our study, lack of appropriate equipment
in ward was reported to be one of the
environmental barriers to implementing the
codes of professional ethics from midwives’
perspectives. Mousavi et al. reported that lack
of equipment in ward and being forced to use
inappropriate devices could affect care. Gurses
and Carayon also demonstrated that the
unavailability of equipment and considerable
time spent searching for equipment were the
main functional barriers (26).
Of the individual care-related factors, lack of
technical skills was reported to be a barrier to
observing professional ethics by both the
nurses and the midwives. Navidian et al.
reported that in individual stressors domain,
the need for high skills caused the highest
levels of stress among the nurses and practical
nurses, with an association between the
severity of stressor-induced stress and the
nurses’ general health such that general health
declined with increase in the severity of
stressor-induced stress (27). Obviously, the
nurses who do not have good levels of health
cannot deliver high quality care to the clients.
Because the observance of the codes of
professional ethics is an integral component of
nursing services, it may generally be
challenged by inefficient delivery of health
care services.
Conclusion
The current study showed that individual care-
related factors were among the most important
barriers to observing professional ethics from the
perspectives of nurses and midwives working in
hospitals. Managers and authorities are thus
recommended to provide continuous and
necessary education on professional ethics for all
staff to eliminate such barriers.
Our study suffered from certain limitations
including insufficient time to complete the
questionnaires. We, therefore, allowed the
participants two days to return the completed
questionnaires so that they could complete the
questionnaires at work or home at their
convenience.
Conflict of interest
The authors have no conflict of interest to
disclose.
Acknowledgements
This article was derived from a research
protocol approved at Qom University of
Medical Sciences. We hereby gratefully
appreciate the participation of the midwives
and nurses as well as the funding for this
research protocol provided by the Research and
Technology Deputy of this university.
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