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

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


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 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)(12)(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

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 carerelated (14 items).This questionnaire was developed by Dehghani et al. (16).Dehghani et al. have also investigated the validity and Downloaded from jhsme.muq.ac.ir at 1:52 IRST on Saturday December 15th 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 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±7.69and 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.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 Downloaded from jhsme.muq.ac.ir at 1:52 IRST on Saturday December 15th 2018 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 inservice 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 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.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 carerelated 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.

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

Table 2 .
The mean scores on the items, in management, environmental and individual care-related domains, regarding barriers to Downloaded from jhsme.muq.ac.ir at 1:52 IRST on Saturday December 15th 2018 Downloaded from jhsme.muq.ac.ir at 1:52 IRST on Saturday December 15th 2018