an investigation on cognition and ethical practice of nurses at national hospital of pediatrics and results of some interventions

Hence, we carried out a project: “An investigation on cognition and ethical practice of nurses at National Hospital of Pediatrics and results of some interventions”.. In this study, mora

INTRODUCTION

According to World Health Organization in 2006, there was high percentage

of nurses per 10,0000 people in developed countries For example, in Netherlands

it was 137,3; UK 122; Japan 77,9; Singapore 42; in Vietnam the rate was low at 6,7 [4]

Nurses are the people who frequently contact with patients in nursing care process The relationship between nurses and patients not only lies in nursing technique but in moral issue as well At present, moral rules have been built at some nursing associations such as International Council of Nurses (ICN) and National Nursing Organizations In Vietnam, a moral standard has been built for nurses by Vietnam Nursing Association [32],[106],[123]

A study done at Phu Tho General Hospital showed that 12,5% of medical staff caused troubles for patients [69] At Ninh Thuan hospital, there was 13,6% of medical staff shouting, threatening and being frigid with patients [43] At Viet Duc hospital in 2009, 13,9% of medical staff shout at patients and care givers, in which nurses accounted for the highest rate of 59,5% [46] Therefore, moral issues of nurses are attracting lots of attentions from medical practitioners [41]

National Hospital of Pediatrics (NHP) is the highest referral hospital giving intensive care for children, which belongs to the Ministry of Health It is hospital overloading, communication attitude, behavior of nurses that makes some customers unsatisfied A research carried out in 2009 at the hospital showed that dissatisfaction accounted for 18,3% [23]

However, the above researches only took a survey on morality of medical staff as

an element while it is fact that nurses are the people who directly contact with patients

at NHP and other hospitals Their attitude and morality will have the first and thorough effect on customers’ satisfaction as well as reveal health care quality of the hospital In order to improve the two elements, we need to evaluate morality of

nurses and find the solution to the problem Hence, we carried out a project: “An investigation on cognition and ethical practice of nurses at National Hospital of Pediatrics and results of some interventions”

In this study, moral issues are considered and evaluated from two sides for the first time: from nurses and from customers (patient’s family include: father, mother, grandfather, grandmother and care givers) with subjective questionnaire and interviews Some reasons causing violating medical ethics were carefully analysed, even including sensitive reasons Therefore, researchers gained detailed, subjective data and then some effective interventions, which were being applied, were evaluated thoroughly

so that practical recommendations can be made and carried out at many hospitals

NEW FINDINGS AND SOME CONTRIBUTIONS OF THE THESIS

- This is the first time the nurses’ cognition and ethical practice have been described from different point of views (nurses and customers)

- The research result has shown some remaining drawbacks in terms of cognition and ethical practice of nurses in relation to customers (shouting, receiving money/ taking bribe, differentiating, ect.), with colleagues and in nursing practice

- Some nurses’ violation of morality has been pointed out; however, these issues have not been regulated or stated clearly in legislative documents or in some regulations of medical ethics for medical staff in general and for nurses in particular

- Some factors relating to medical ethics practice of nurses include knowledge, experience, career passion, the number of patients, working extra hours

- Medical ethics of nurses have been improved by applying interventions including training, observation, discussion, professional support

STRUCTURE OF THESIS

This thesis consists of 126 pages (not including index), 4 chapters, 13 tables,

24 graphs, 17 bar charts, 159 references (96 documents in Vietnamese; 63 documents

in English; > 70% of documents have been published in the last 5 years)

Here is the detailed structure: Introduction: 02 pages; Literature review: 35 pages; Research objective and methodology: 20 pages; Research result: 36 pages; Discussion: 30 pages; Recommendation: 02 pages; Conclusion: 01 page

CHAPTER 1 LITERATURE REVIEW

1.1 Position, function and roles of nurses

Nursing is an art and a science that studies the way to take care of oneself when necessary and take care of others when they could not care for themselves Nevertheless, the definition of nursing is given differently depending on different periods in history Nursing theory includes grand nursing theory, nursing theory relating to people’s basic need, nursing theory about health and health care, psychological & social theory, Nightingale theory, Henderson theory, and so on Nurses play an important role in giving care for patients, recognizing patient’s condition, limitations and demands for care Their main functions include dependent function, cooperative function and independent function Like other medical staff, nurses have responsibilities of nursing care, leadership in hospitals, community and doing research

1.2 Definition of medical ethics and moral standards

Medical ethics is an issue belonging to the scope of morality It is a branch of morality mentioning about moral issue in medical practice Medical ethics are regulations or standards that are expected to obey by medical workers According to WHO, like other careers, medical ethics is reflected through passion, ability and self-decision However, medical workers are expected to have higher moral standard than others The present regulation of medical ethics was declared by WHO in 1999

Nursing profession was built and developed at the end of 19th century Nurses’ moral regulations were inherited and developed from moral rules Nevertheless, their regulations have unique characteristics which are suitable to the requirement of nursing practice At the moment, the moral regulations being applied consist of the ones by ICN, the ones at each country and area

Nurses’ moral regulations in Vietnam are controlled by Prevention of Corruption Act; Law on Medical Examination and Treatment; Nursing capacity standard by Ministry of Health; Nursing moral regulations by Vietnam Nursing Association (VNA)

1.3 Some studies on medical ethics of nurses

In the world: Nightingale did make a big impact on environment and health care

in order to reduce mortality rate among war invalids from 42% to 2% According to Shimaoka Nobuki, there was 67,2% to 70,2% of people desiring to be cared by nurses According to Roderick, who did a research in the US showed that 73% of patients felt satisfied with nursing care It was fact that patient’s complications would reduce from 2% to 25% if nurses were assigned tasks which were suitable to their qualification and

ability Shimzutani in Japan pointed out that there was relation between nurses and exhausted conditions due to stress, bad behavior and attitude toward patients

In Vietnam, many studies showed that most of patients feel satisfied with nursing care, in which the rate is often above 80% Although the matter of shouting, causing troubles for patients accounts for only a low rate, it is frequently seen in researches of medical ethics The researches also reveal that carrying out adequately nursing procedures is very important in nursing care Some studies also believed that nurse’s attitude can be improved and reduce moral violation due to some interventions: training, education, communication lessons, knowledge in law

To sum up, these studies on medical ethics of nurses have not had an overview and seen in different aspects in terms of customers/patients, nurses and management Since this is an sensitive issue, the approach of researches often leaves at training activities without any general evidence – based interventions (basing on customer’s, nurses’ and managers’ recommendations) These studies have not met the demand of improving nursing care quality at present

1.4 Some introductions about National Hospital of Pediatrics (NHP)

Medical examination and treatment at NHP

It is fact that hospital overcrowding tends to increase, in which bed capacity at national hospitals went up from 116% in 2009 to 120% in 2010 and 118% in 2011 There existed high level of overcrowding at NHP with 119.8% in 2011 [6]

The number of outpatients in 2012 at NHP was 672.000, which increased to 8,96% The percentage of outpatients tended to climb up to 34,4% in compared with the year 2011 [6]

Care services bring about effectiveness in reducing the number of inpatients and also make profits for the hospital Patients have got many benefits from this kind

of service in which health care quality is highly ensured The General Pediatric Department A is serving this kind of service with the total of 53.703 turns of treatment; 5.176 inpatients, bed capacity reached 95% (5% increase in compared to the initial plan) These units always consider high quality of health care service as the highest standard in which the patients are the center of the service

Nursing care at NHP

Hospital nursing personnel [3]

The total number of nurses/ medical technicians in the hospital is 749 people,

in which there is 0,9% of master of nursing; 15,5% of bachelor of nursing; 7,3% of associate degree; 75,7% of vocational degree There are 10 bachelors of nursing pursuing nursing specialist I at Research Institute for Child Health There are 46 head nurses

Hospital nursing care [3]

- There are frequently overloading and severe patients at some departments, so nurses have to work under much pressure

- There are many administrative procedures, so many nurses do not have time to

do their nursing care

- There is a shortage of personnel, especially at Neonatology, ICU and Emergency department

- The proactiveness of nurses has not been enhanced; nursing procedures have not been adequate

- Nurses’ communication skill is sometimes unsatisfactory

- The percentage of young female nurses is high, together with hard working hours, so their psychological health is not so good and stable, affecting their work Like other national hospitals, NHP is facing up with hospital overcrowding with low quality infrastructure Besides, personnel capacity, nurse capacity has not met the higher requirement of health examination and treatment Moreover, nurses are dealing with pressure and workload, so they often feel stressed and exhausted This issue has been a big challenge in providing health care treatment for children as well as for meeting customers’ satisfaction

CHAPTER 2 RESEARCH OBJECTIVES AND METHODOLOGY

2.1 Research site, time and subjects

- The study was performed at NHP from June 2012 to June 2013

- Research subject: Nurses, customers (patients’ family: father, mother, grandfather, grandmother, legal representative of children at NHP)

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2.2.3 Sampling method

- Make a random list of 481 nurses having adequate standard who are numbered from 1 to 481 In 7 random nurses, choose 3 consecutive nurses and remove 4 nurses next In case of refusal, continue to make lists until the sample size

is enough

- Choose sample size at outpatient group and inpatient group basing on the percentage of patients at two areas Time of collecting data is 1 week, including weekend At outpatient clinic, choose customers randomly to draw according to frequency of cases in a day (morning, afternoon) Inpatient group is chosen basing on the number of discharge cases, make a list to confirm sample size before interview

2.3 Research content and variables

- Characteristics of research subjects: for customers (hometown, age, relationship with children, kind of healh care service, times of treatment); for nurses (age, gender, marital status, qualification, experience, income, extra working hour, time of working extra hour, average hours of doing procedure, number of patients, other works beside nursing care)

- Cognition and medical ethical practice of nurses:

+ Attitude of nurses towards customers

+ Nurses’ morality in relation with customers

+ Nurses’ morality in performing assigned tasks

+ Nurses’ morality in relation with colleagues

+ Reality of cognition of medical ethics of nurses

- Ethical practice of nurses through customers’ reflection:

+ Customers’ satisfaction with nurses’ attitude at Outpatient clinic

+ Customers’ satisfaction with nurses’ attitude at Inpatient wards

+ Customers’ reflection on nurses’ morality

2.4 Technique and tool of data collection

- Technique of data collection: interview with questionaire, deep interview, observation

- Observation procedure: Descriptive study, finding the relationship between factors and knowledge, ethical practice  Ask for permission and recommend solutions  Make intervention  Evaluate intervention

- Intervention tool and technique: training documents, working schedule, graphs, camera, management

- Research standards were built basing on: Prevention of Corruption Act; Law on Medical Examination and Treatment; Nursing capacity standard by Ministry of Health; Moral issues by WHO, Nursing moral regulations by ICN and by VNA

2.5 Data management

- Use suitable date for data input

- Use SPSS 17.0 and EPI Info 7.0

- The figures are calculated to average value or percentage %

- Compare average values using algorithm T-student

- Compare two or more percentage % using Chi–square algorithm (χ2), test rate (pretest)

- Use OR, CI 95% to identify the relationship between medical ethics of nurses Use performance indicators to evaluate intervention

- Qualitative study is classified according to the matters raised by nurses, customers, combined with N-vivo software to manage data

2.6 Control and correct errors

In order to limit errors, we performed the following steps:

* Process of building toolkit:

- Identify research variables and variable definition, method of variable measurement, method of collection

- Test toolkit to identify unclear variables, variables which are difficult to collect, variables which are easy to be confused and errors to find solution

* Process of data collection:

- Give training in interview technique, observation, data collection for researchers which is done by public health officers

- Observe the process of data collection, re-interview and check accuracy of interviewers

- Each interviewee was identified by different code

* Process of data input, management and data analysis:

- Build Epiinfo 7.0, eliminate variables that are not included in permitted range

- Check and identify unusual variables, validity and logic of data When identifying errors, researchers re-interview according to the code that is only recognized by interviewer and researcher

* Moral issue in research

This study was only performed under the permission of review board at Thai Binh Medical University and participation agreement of NHP as well as voluntary participation of research subjects

The process of data collection and research result will be confidential to research participants, ensuring safety and voluntary participation in the research

* Some limitations of the study

- In order to make sure objectivity in data collection process, questionnaires and checklists answered by nurses are not identified by their names

- Feedbacks on medical ethics- a sensitive issue consist of three elements: cognition, attitude and behavior In order to get objective and accurate feedback, there need different approach and time at each research site However, it is not easy for a short - time doctoral thesis with such a limited budget

- The research subjects before and after intervention are different customers at two different times, so the result can be incorrect due to heterogeneous objectives

To improve these limitations, the thesis combines different ways of collecting data such as combining quantitative with qualitative study; combining subjective opinions of research subjects with objective opinions obtained from parents and caregivers; combining interview, discussion with direct observation; associating fieldwork with expert method

CHAPTER 3 RESEARCH RESULT

3.1 Cognition and ethical practice of nurses and some relating factors 3.1.1 Information about customers and nurses at NHP

The study was conducted on 368 customers, in which 156 were customers of Outpatient clinic and 212 customers were inpatients

Table 3.1.Some features of customers Customers

Feature

Number (No)

Percentage (%) Number % Number %

Information about nurses participating in the study

The study was conducted on 214 nurses, in which there were 22 nurses at outpatient clinic, 192 nurses at inpatient wards

Table 3.2.Some features of nurses at NHP Information

Age

<25 years 5 22,7 70 36,5 75 35,0 25-35 years 15 68,2 102 53,1 117 54,7 35-45 years 1 4,5 15 7,8 16 7,5

Female 19 86,4 165 85,9 184 86,0 Marital

Working

experience

Below 5 years 7 31,8 107 55,7 114 53,3 5-10 years 14 63,6 64 33,3 78 36,5

3.1.2 Cognition and ethical practice of nurses

3.1.2.1 Customers’ feedback on ethical practice

* Ethical practice of nurses in serving care

Most of customers feel satisfied with serving attitude at outpatient clinic; however there exist some unsatisfied feedbacks, especially in explaining for family (63,5%) and in introducing name, giving reasons (34%)

¾ of interviewees supposed that nurses’ attitude is quite satisfactory at inpatient wards

Table 3.3 Customers’ feedback on nurses’ discrimination

Area Feedback

Outpatients Inpatients Total

Outpatients Inpatients Total

for patients

Yes 153 98,1 204 96,2 357 97,0 Suspect of misleading

Table 3.5 Customers’ feedback on nurses’ shouting Information

Table 3.6 Customers’ feedback on nurses’ receiving bride/money

Percentage Information

Outpatients Inpatients Total