Journal of Health Sciences and Medicine, Vol. 1 No. 2, September 2017

16

The Determinants of Ethical Principle Implementation in Nursing

Ni Putu Emy Darma Yanti1, Hanny Handiyani2, Kuntarti2

  • 1.    Master of Nursing Program, The Faculty of Nursing, University of Indonesia, West Java, Indonesia

  • 2.    Basic Nursing Department, The Faculty of Nursing, University of Indonesia, West Java, Indonesia

E-mail: [email protected]

Abstract.

The determinant of nursing ethics practice is not identified yet. This problem affects the ethical behavior of nurses in performing nursing care. According to that, it was influencing satisfaction and patient well-being. This study aims to identify the determinants of the ethical principles application in nursing. Descriptive, correlation, cross-sectional design was applied, through simple random sampling to 120 nurses. Data collecting used questionnaires, with univariate, bivariate, and multivariate analyzes. Determinants of nursing ethic application principle were job characteristics, nurses knowledge related to nursing ethics, supervision by supervisor, relationship with colleagues, awards, the role of head nurse, and tenure (p= <0,001-0,049). The most dominant variable was job characteristics (p <0,001). These factors need an attention by hospital manager to keep evaluating the other factors in order to improve the application of ethical principles in nursing.

Keywords: Ethical principles, Knowledge, Nurse, Organizational factor

  • I.    INTRODUCTION

The nursing ethical behaviour is one of the main influential factors for the value of nurses in the society. Nursing ethics may be also required to improve the quality of health services (Numminen, Van, & Leino-Kilpi, 2009). Based on patients’ perception, nursing is a profession with competences in taking a good care of patients depend on their basic human needs (Vanlaere, & Gastmans, 2007). Lanchman (2012) concluded that ethics of care is based on an idea that caring is a foundation for human life and it also demonstrates humanism and equality principles for others.

Tronto (1993) explained four elements of the ethics of care, namely attentiveness, responsibility, competence, and responsiveness. Attentiveness is the principle of human needs fulfilment based on individuals’ perception about their needs, whereas the fulfilment is implemented with high responsibility (Tronto, 1993). Responsibility in nursing practice is influenced by how nurses are taking care of patients with humanity principles (Inga-Britt Lindh, Severinsson, & Berg, 2007). Nursing responsibilities are devided into two categories, namely professional objectives and professional obligations (Snellman & Gedda, 2012). Nurses will only able to do those responsibilities if they have moral competences and moreover apply moral consistently

as their personal value (Zhang, Luk, Arthur, & Wang, 2001). Responsiveness is pointed out in the evaluation of nursing process and the fulfilment of patient’s needs (Tronto, 1998).

Ethical principles seem to be neglected by some nurses, and this may lead to increase the number of ethical problems. A study of knowledge and behaviour of nurses and midwives regarding ethical problems in Zanjan, Iran showed 70.8% of study participants need further training and continuing education about ethical cases (Negarandeh & Gobady, 2001). McKinstry (2000) identified that the neglecting of patient autonomy in health services and the lack of nurse focus on ethical problems. The determinants of ethical principle implementation in nursing have not been identified yet; thus, this study aims to identify the determinants of nursing ethical principle implementation in a hospital in Jakarta.

  • II.    METHODS

This is a descriptive correlation study with cross sectional design. The study involved 120 nurses from 18 hospital wards selected with rule of thumb method and simple random sampling. Data collected from the fourth week of April 2015 to the second week of May 2015. The study evaluated nurses’ knowledge about nursing ethics,

organisational factors, and nursing ethical principle implementation developed based on a Tronto concept theory of ethics of care using questionnaires. The validity and reliability test of the questionnaire involved 30 nurses, and it resulted the Cronbach’s alpha 0.733, 0.914, and 0.957. This study was ethically appraised by the ethical research committee of the University of Indonesia.

The univariate analysis aimed to evaluate the distribution and mean of each variable. Pearson correlation and Spearman applied to identify the correlation of variables. Independent T Test and One Way Anova analysed mean difference of groups. Multiple regression was also applied with 95% standard deviation (α= 0,05).

  • III.    RESULTS

Table 1. The distribution of nurses based on gender, level of education, and marital status (n=120)

Variable           f         %

Gender

- Male

12

10

- Female

Level of education

108

90

- Vocational school

6

5

- Nursing diplome

110

91,7

- Ners

Marital status

4

3,3

- Sigle

5

4,2

- Married

115

95,8

Table 2. The distribution of participants based on age and length of working experience (n=120)

Variable

Median

Min – Max

95% CI

Age

35

25-59

35,49; 38,06

Length of working

10

2-35

11,63; 14,17

experience

Table 3. Mean of score of nurses’ knowledge about nursing ethic (n=120)

Variable

Mean (SD)

95% CI

Knowledge   about

nursing ethic

3,06 (1,12)

2,85; 3,26

Table 4. Mean of score of nurses’ preception about organisational factors (n=120)

Variable         Mean#         95% CI

Job characteristics

6,00 (2-8)

5,84; 6,23

Structure of

2,73 (0,84)

2,58; 2,88

organisation

Supervision

6,00 (3-8)

6,02; 6,43

Reward

6,32 (1,07)

6,12; 6,51

Colleagueship

12,33 (1,57)

12,05; 12,62

Role of head of

30,00 (25-40)

30,88; 32,02

nurses

- Interpersonal

9,76 (1,20)

9,54; 9,98

role

- Source of

9,00 (6-12)

8,90; 9,32

information

- Decision

12,58 (1,58)

12,30; 12,87

making

#normal distributed: mean (SD), not normal: median (minmax)

Table 5. Mean of score of nurses’ perceptions of nursing ethic principles implementation (n=120)

Variable

Total

Mean#

95% CI

Nursing ethic principles

42-168

147,41

145,23;

implementation

(12,03)

149,58

- Attentiveness

10-40

35,00

33,80;

(24-40)

35,12

- Responsibility

10-40

36,00 (26-40)

35,30;

36,60

- Competence

14-56

49,29

48,51;

(4,35)

50,08

- Responsiveness

8-32

27,71

27,18;

(2,91)

28,23

#normal distributed: mean (SD), not normal: median (min-maks)

Although the majority of study participants are female (90%), the average score of nursing ethical principles implementation among male participants is higher than the females, where the difference of the average score is 1.58. The difference of the ethical principle implementation between male and female is not significant (p= 0,667). The result shows that the majority of study partcipants has nursing diplome degree (91,7%). The ethical principle implementation among three groups is not different (p= 0,435). The majority of study participants is married (95,8%). The mean difference of ethical implementation between not married and married groups is 6.04. Ethical principles implementation between not married and married participants is not significantly difference (p= 0,273).

The average of respondents’ age was 35 years old, which the youngest respondent was 25 years old and the oldest one

was 59 years old. Respondents’ age was not correlated with ethical principles implementation (p= 0,063). The mean of length of work experience among participants was 10 years, the shortherst was two years and the longest was 35 years. The length of work experience was significantly associated with ethical principles implementation (p= 0,049), this factor had positive correlation but it was weak (r= 0,180).

The median of score of nurses’ knowledge about nursing ethic is 51% of total score (3,06; SD 1,12). There is a significant correlation between nurses’ knowledge about nursing ethic and the ethical principle implementation (p< 0,001), which the correlation is positive and weak (r= 0,318).

The component of organisational factors, which has average score that is the closest to total score, is the variable of head of nurse’s interpersonal role (9,67; SD 0,84); whether the smallest score is variable of structure of organisation (2,73; SD 0,84). There is a significant correlation among all of organisational factors with ethical principles implementation except factor of structure of organisation (p< 0,05), the association is positive but weak (r= 0,20-0,399).

The data analysis of respondents’ perception about the implementation of ethical principles in nursing showed average score 147,41 (SD 12,03). The lowest mean score was subvariable responsiveness (27,71; SD 2,91). The multivariate analyses have resulted the determinants of ethical principles implementation which are nurses’ knowledge about nursing ethics, job characteristics, and supervision of nursing managers; the main predictor is job characteristic (β= 0,41). All of independent variables included in latest model could describe the variables of ethical principles implementation with 33.1% (Rsquare= 0,331), and the rest is explained by other variables.

  • IV.    DISCUSSION

Age with nursing ethical principles implementation

The result showed that age is not associated with nursing ethical principles implementation. Leuter, Petrucci, Mattei, Tabassi, and Lancia (2013) explained that age of nurses did not influence nurses’ consideration on ethical problems. However, Mohajjel-Aghdam, Hassankhani, Zamanzadeh, Khameneh, & Moghaddam (2013) asserted that there was improvement of ethical behaviour among older nurses. Rest (1979) described that age does not significantly influence individual behaviour, but more importantly it is influenced by the opportunity of individuals to be involved in reflection and assimilation of moral development process.

Gender and nursing ethical principles implementation

The result shows that there is not significant difference between male and female nurses on the implementation of ethical principles. Gender has significant role in ethic. Gilligan (1977) explained that female perception about moral is related to the people responsibility on helping others. This perception shows that feminist theory based on moral and sacrification which may be needed while women have to decide about something in their life. The moral of women may be based on dilemma between the affection and the autonomy or power. Gilligan (1982) explained that the women wisdom is contextual and narrative model with communication skill to maintain harmonisation, whether men adopt impersonal model in which mainly focuses on justice based on regulations and abstract concepts as perimeters for interpersonal relation (Gould, 1988). The result of this study is difference with previous studies, it may be caused by the domination of women as the participants in this study, which is 90% of total respondents. This may result on the low of variability of the data.

The level of education with ethical principles implementation

The study resulted that there was no significant difference among three groups of participants based on their level of education. Habaghery, Salsali, and Ahmadi (2004) explained that several nurses feel that nursing educations do not fully prepare them as effective clinical decision makers and also less prepare them how to act based on professional ethical principles. Nursing education should develop ethical sensibility as part of nursing. The education should be focused on the development of nursing care based on humanity (Gastmans, 2002). McFadzean and McFadzean (2005) concluded that in order to improve ethic among nurses it needs ethical learning at organisation, continuing education and work evaluation.

The length of work experience with ethical principles implementation

The study showed that the length of working experience was significantly associated with ethical principles implementation among nurses. Robbins and Judge (2013) asserted that the previous experience dealing with ethical problems has positive influence on the way nurses making ethical decision. Nurses ability in making internalisation of their working experiences allows them in gathering values of their work (Kim Lützén, Dahlqvist, Eriksson, & Norberg, 2006). Nurses with longer working experience could better adapt with their working environment and be more aware on potential problems of their works (Denier, Dierckx de Casterle, De Bal, & Gastmans, 2010).

Marital status and ethical principles implementation

This study result showed that there was no association between marital status of nurses with their ethical principles implementation. This may be because of the variance of characteristic among participants specifically moral development and cognitive. Irani, Rudd, Gallo, Ricketts, Friedel, and Rhoades (2007) explained cognitive and critical thinking ability are the main influental factors for behaviour. The uniqeness of individual characteristics and the ability of critical thinking can influence individual moral development which this further influences their behaviour (Chikering & Reisser, 1993).

Nurses’ knowledge about ethical principles and the implementation of the ethical principles

The nurses’ knowledge about ethical principles has significant correlation with the application of ethical principles in nursing practice. The study by Lin, Lu, Chung, and Yang (2010) showed the significant difference of the students’ ability on distinguish cases of nursing ethical problems between groups of study by case based learning method and conventional learning method. Van der Arend and Remmers-van den Hurk (1999) explained the lack of knowledge among nurses tend to become the cause of ethical problems. Knowledge is one of the main components to build individual behaviour; however, the ability of critical thinking will improve individual awareness and objectivity (Irani, Rudd, Gallo, Ricketts, Friedel, & Rhoades, 2007).

Job characteristics with ethical principles implementation

This study showed that there was significant association between job characteristics with ethical principle implementation among nurses. Nurses with higher perception about their job characteristics will also have higher implementation of ethical principles. Nurses with better understanding about their responsibilities will also implement ethical principles better than those with lower understanding. The component of responsibility uses as ethical obligations and becoming the essential element in developing nursing (Snellman & Gedda, 2012). The moral responsibility of nurses in becoming humanist and helping others are coming within themselves or coming from the discussion with others (Inga-Britt Lindh, Severinsson & Berg, 2007). Fakl-Rafael (2005) asserts that nurses have responsibility to taking care of people and the environment.

Structure of organisation with ethical principles implementation

Structure of organisation is not associated with ethical principles implementation among nurses. Job structure and interpersonal will reduce affiliation resulted from formal and

social gap of job hierarchy and principles (Stringer, 2002). Effective communication on stucture of organisation will allow nursing ethical principles implementation. Studies by Balcanoff (2013), Buchan, Ball, and Rafferty (2003) showed that communication influences nursing ethic implementation. Their study result also have been supported by other studies which indicate that ineffective communication influence the decreasing moral among nurses (Cottingham, DiBartolo, Battistoni, & Brown, 2011; Friedman, Cooper, Click, & Fitzpatrick, 2011; Harrison, Lambiase, & Zhao, 2010; Hayes, Bonner, & Pryor, 2010).

Manager supervision with ethical principles implementation

This study showed a significant correlation between manager supervision with ethical principles implementation. Nurses with higher perception about supervision have showed higher ethical principles implementation as well. McKnight, Ahmad, and Schroeder (2001) study about the effect of staff-manager relationship with staff’s moral concluded that staff’s moral is significantly influenced by control of manager and the positive staff-manager relationship. Gatot and Adisasmito (2005) asserted that the main influencing factor of job satisfaction among nurses is the relation with nursing managers. A study by McFadzean and McFadzean (2005) showed that the manager supervision influence nurses’ moral significantly. Supervisors who can build effective communication allow positive effect on moral of nurses.

Rewards with ethical principles implementation

Reward has significant association with ethical principles implementation. Nurses with higher perception about reward showed higher implementation of ethical principles. A study by Callaghan (2003) in the United Kingdom also supports this study, her study showed that the low of moral among nurses is influenced by the lack of support for continuing education among them and also the lack of promotion opportunities. Huitt (2003) explained that the support from management improve internal motivation among nurses, and it will lead to ethical professional development directed by nurses’ self-reflection.

Colleagueship with ethical principles implementation

The study resulted a significant association between colleagueship with ethical principles implementation. It means that nurses with higher peception about colleageship also showed higher implementation of ethical principles. Desphande and Joseph (2008) explained that good relationship with colleagues will improve ethical principles application among nurses. Rosenstein (2002) have also identified the effect of nurse-doctor relationship on nurses’

moral. The main influencing factor of nurses’ moral is medical staff behaviours. The effective communication between junior and senior nurses as well as managers and staff nurses should be maintained to improve nurses’ moral (Gulliver, Rowell, & Peck 2003).

Role of head nurses with ethical principles implementation

There is significant association between role of head nurses with ethical principles implementation. Leadership is one of main factors for the transforming of nurses’ ethical working attitude toward clients (Chaousis, 2000).

Managers have essential roles on the development of organisational culture including influencing value, knowledge, attitude, skill and organisational behaviour; as well as on continuing establishment of ethical standard (Kane-Urrabazo, 2006). American Organization of Nurse Executives (2005) explained that nurse managers should be able to matriculate the application of ethical principles in nursing, as well as to integrate ethical standard and essential values in nursing practice; this will lead to establishment of high quality of ethical standard implementation in nursing practice.

The main influencing factor of ethical principles implementation

The multiple regression analysis resulted the model, which can estimate ethical principles implementation, include variable of nursing knowledge about nursing ethic, job characteristics, and manager supervision. Specifically, job characteristic is the most dominant influencing predictor from those three main influencing factors of the ethical principle implementation.

  • V.    CONCLUSION

The main influencing variables for the implementation of ethical principles in nursing are nurses’ knowledge about nursing ethics, job characteristics, and manager supervision. The strongest influencing factor for those three main factors is job characteristics.

Based on demographic, participants were mainly married, female, and nursing diploma. The median of participants age was 35 years old, which the youngest respondent was 25 years old and the oldest one was 59 years old. The mean of length of work experience among participants was 10 years, the shortherst was two years and the longest was 35 years.

The median score of nurses’ knowledge about nursing ethic was 51% from maximum of total score. Furthermore, the average score of organisational factors, which was the closest to total score, was the variable of head of nurse’s

interpersonal role. While the lowest averaged score of organisational factors was structure of organisation.

The respondents’ perception about the implementation of ethical principles in nursing shows average score which is near with the expectation of maximum total score. Responsiveness is the sub variable of the participants’ perception with the lowest average score.

The demographic characteristics of participants including gender, marital status, and level of education do not have significant   differences on   the   ethical principle

implementation between male and female nurses, unmarried and married nurses, and among three groups of level of

education. The age of participants does not associate with nursing ethical principle implementation, while the length of working experience does.

The nurses’ knowledge about ethical principles has significant correlation with the application of ethical principles in nursing practice; more specifically the correlation is positive but weak. Organisational factors except structure of organisation have significant correlation with ethical principle implementation; and specifically the correlation is positive but weak.

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