Patients’ Knowledge and Perception on Nurses’ Adherence to Nurses’ Professional Code of Ethics in Ghana: A Cross- Sectional Survey

Public Health, Centre of Excellence in Reproductive Health Innovation (CERHI), University of Benin, Nigeria Accident and Emergency, Sacred Heart Hospital, Abor, Ghana Research, Monitoring and Evaluation, Korle-Bu Teaching Hospital, Ghana Nursing Administration, Margret Marquart Catholic Hospital, Kpando, Ghana Child Health, Krachi West District Hospital, Kete-Krachi, Ghana Nursing, Nursing Training College, Ho, Ghana


Introduction
In recent times, the showcasing of professional ethical standards at workplaces has become an imperative issue of interest in almost all professions including the health profession. Within the nursing practice, the Code of ethics is a set of normative principles that underlie a nurse's purpose and associated values. Creasia and Parker (2001) define ethics as an expected standard and behaviour of a group as described in a professional group's code of conduct. Van Rensburg (2011) corroborate this by describing ethics as being focused on words such as right, wrong, good, bad, ought and duty. To the latter, some individuals within a professional or occupational arena would come together to define what should be and what should not be, what duties are bad and even good and these would have to be the standard way of doing things amongst them. These ethics are often codified into a body of knowledge and referred to as the professions' code of ethics. It has been noted that the nursing profession is of vital importance in terms of ensuring strict adherence to ethical professional standards. These codes of ethics basically aim to ensure that nurses perform their duties diligently in such a manner that could meet the highest ethical standards in their professional practice. This, when properly enforced, would ensure that patients are treated well.
Over time, the demand for the need to strictly adhere to such professional ethical standards has manifested in various ways depending on the profession. Typically, several countries and professions worldwide, including the Ghanaian nursing profession has not been an exception to the need to adhere to professional ethical standards. This is partly due to people's in-depth knowledge of their basic rights and responsibilities (Plange-Rhule, 2013;Seneadza and Plange-Rhule, 2009). This stems from the argument that people who visit health facilities have been criticizing the health professionals on their inability to adequately adhere to ethical standards in line with their professional practice (Plange-Rhule, 2013). Behrens and Fellingham (2014) argued that in contributing to the well-being of patients, the respect of their privileges is the basic obligations expected of nurses to perform. Nurses should have respect for human rights as a goal for transforming their profession and the broader society at large. They must be committed to high ethical and professional standards and are expected to instill in themselves high moral values at the various health facilities.
Although nurses are projected to be ethical when dealing with patients in their facilities, studies have shown that they have not been able to do that. It has been discovered that a major area in which nurses often come into conflict or disagreement is ethics (Plange-Rhule, 2013). In Ghana, the issue of nursing ethics has attracted great concern. There have been a lot of calls for debates from stakeholders on the need to streamline the professional practice of nursing in the country (Plange-Rhule, 2013). Plange-Rhule argues that the question of nurses' adherence to ethical issues has brought to the limelight the awareness of the ethical issues in nursing practice and the expectations of people from nurses. Some of the several issues that have been raised by stakeholders include limited information on medication given to patients, failure to seek informed consent before administering medication, treatment or performing surgery and the use of undue influence to obtain patients' consent in order to administer medication.
Studies have shown that, lack of proper adherence to the code of ethics leads to poor quality of care provided by nurses in Ghana and this has been found to be one of the integral reasons behind the unwillingness of people to seek healthcare from health facilities (Atinga et al., 2011;Abekah-Nkrumah et al., 2010;Turkson, 2009). Non-adherence to ethical standards in nursing practice has huge rippling effects. Apart from trampling on the rights and dignity of the patients leading to costly lawsuits and other legal charges, it may also result in irreparable damage to patients.
Many studies in recent times have emphasized the poor quality of healthcare including lack of adherence to ethical standards resulting in loss of lives of patients. These studies indicate that hospitals also lose revenue, material resources, time, morale, staff recognition, trust and respect (Turkson, 2010;Offei et al., 2010;Doyle and Haran, 2001). To many of these scholars, the loss of lives of patients and decline in the credibility of the healthcare providers results in individual and community apathy towards health services contributing to reduced effectiveness and efficiency in health care systems.
Even though, today's clients are much more informed and sensitive to poor medical treatments and services which make them often walk away and never return for repeated services, the economic hardships, lack of education, proximity and other challenging circumstances confronting many Ghanaian health seekers are more than enough to render them vulnerable. These make it difficult for the patients to argue out the circumstances under which their rights are violated, hence discouraging patients from accessing healthcare at the right places.

Methods
A cross-sectional survey was conducted among 400 patients at the Eastern Regional Hospital, Koforidua using a simple random sampling in selecting participants. The sample size was estimated using Leslie Kish formula and given that there were no previous studies on the knowledge and perspective of patients on nurses' adherence to their professional code of ethics, prevalence of 50% (P = 0.5) and a margin of error of 5% at a 95% confidence interval were used. All patients who were terminally ill and could not communicate with the researcher were excluded from the study.
A structured questionnaire was used to collect data on socio-demographic variables, patient's knowledge on nurse's professional code ethics in nursing practice and patient's perception of nurses' adherence to their professional code of ethics. Ethical clearance was obtained from the Ethical Review Committee of the Ensign College of Public Health and the Ethical review committee of the Eastern regional hospital, Koforidua. Results were analyzed using SPSS version 20 and data presented using tables and graphs. Statistical significance was set at P<0.05.

Ethical Considerations
Ethical approval was obtained from the Ghana Health Service Ethical and the Ensign College of Public Health Ethical Review committees. However, local permission was obtained from the Hospital management of the Eastern Regional Hospital and its research ethics committee. Consent was also sorted from the participants. Participation was voluntary and respondents could withdraw from the study at any stage without any penalty.

Results
Females dominated the study (66.8%) and the majority (44.0) were between the age cohort 21-30 years as presented in Table 1. A proportion of 24.5% was within the age group 31-40 and only 6.5% were above the age of 60. The dominant religious group was Christianity (80.5%), unmarried people were more (52.5%) and most (42.3%) had attended basic school. Tertiary graduates were (18.9%) and only (9.0%) had no formal education.
The study has shown that the majority (83.3%) of the respondents do not have any knowledge on nurses' professional code ethics while 16.8% of respondents have knowledge on nurse's professional code of ethics as presented in Fig. 1.
Out of the total percentage of respondents who had knowledge of nurses' professional code of ethics, 66.0% indicated health workers as the source of knowledge. Others were television (9.4%), school (9.4%), observation (9.4%) and radio (5.8%) as presented in Table 2.    Several perceptual statements were outlined in relation to nurses' adherence to a professional code of ethics for patients to indicate their views. This is presented in Table 3.
Regarding nurses introducing themselves with name, title and professional rank to patients, 59.8% said no, 20.3% indicated sometimes and (20.0%) said yes, always. Nurses' carry out all their nursing interventions and procedures with respect to preserving patients' dignity, (60.3%) said yes always, 30.3% said sometimes and only (9.5%) said no. On the issue of nurses considering patients demands regardless of age, sex, race, economic status, lifestyle and physical abilities, 45.3% indicated yes always, 30.8% said sometimes and 24.0 said no. 78.5% of patients said to refuse treatment based on age, sex, or income level, 9.8% said sometimes and 11.8% said yes always. The majority (58.8%) of respondents said yes always to nurses producing gentle behavioural and verbal communication, 34.0 said sometimes and 7.3% said no.

Discussion
The study has shown that the majority (83.3%) of the respondents do not have any knowledge on nurses' professional code ethics. This is not surprising because the daily health education of patients is limited to disease conditions and does not include education on nurse's professional code of ethics. Also, there were no Information, Education and Communication (IEC) materials on nurse's professional code of ethics displayed in the wards or the hospital environment for patients to read. Knowledge is central to the practical exhibition of professional work ethics and knowledge predisposes a person to be efficient, reliable and consistent in professional work delivery (Cannaerts et al., 2014;Smith et al., 2012).
Gaining knowledge on nurses' professional code of ethics was mostly from health workers. This phenomenon is possible because over the years the government of Ghana has prioritized the nursing sector especially the community health nursing system. This has facilitated the enlightenment of communities on nurses' work through outreach programmes by nurses from these institutions. It is part of the curricula of the community nurses to educate and hold communitybased discussions with people and through that many people have gained ample knowledge on the activities of nurses, hence accounting for it being the major source of knowledge on nurses' professional code of ethics by patients. Television and radio did not constitute the major sources of knowledge possibly because the study found most of the respondents to be females with a lower level of education.
In nursing, standards are imperative to safeguard against loss of human lives. The personal behaviour of nurses can also promote satisfaction of service delivery and reduces stress and depression associated with illness (Lin et al., 2010;Kurban et al., 2010). For instance, (Brecher, 2014) found more patients to be hopeful of their health conditions in the United States of America due to the role of nurses. Most patients observe how nurses demonstrate professionalism with regards to how they introduce themselves, carry out all nursing interventions and consider patients' demands regardless of social class among others respondents stated that the majority of the nurses did not exhibit professionalism in terms of introducing themselves with name, title and profession to patients. Yeboah et al. (2014) argue that the ratio of a nurse to a patient in Africa is about 1-20 making difficult or almost impossible for a nurse to introduce him/herself to every patient in a day. With the pressure emanating from large number of patients, nurses cannot spare the time but rather use the time provide quicker services to patients. This possibly accounted for a smaller number of patients indicating yes to nurses introducing themselves. In every circumstance, nurses uphold human dignity as the core peripheral of their profession. Nurses ensure that all their actions are geared towards protecting human life and solving human problems as their oath of office demands hence not strange that most of the respondents indicated that the nurses carry out their nursing interventions and procedures with respect to preserving patients' dignity. This finding is in line with (Yeboah et al., 2014). Respondents indicated that most nurses (78.5%) did not discriminate in attending to patients. In recent times, discrimination in a society based on age, gender or social class has been widely spoken against. The media and Non-Governmental Organizations globally have made several efforts to address discrimination among human race (FRA/UNDP, 2013). This has attracted attention in all fields including nursing. The nurses' profession is a profession that is open to all people of different ages, gender, race, class, among others. Nurses in Ghana have been trained to eschew all forms of discrimination in the delivery of services accounting for most patients were not refused treatment based on their age, sex, or income level. Nurses however provided tailored services to meet patients' demands regardless of age, sex, race, economic status, or physical disabilities.
The majority (61.3%) of respondents are of the view that nurses respected their privacy, prevented you from other harm and displayed gentle behavioural and verbal communication when performing any nursing intervention. This view expressed agrees with the view of (Poikkeus et al., 2014), that the general behaviour of nurses is paramount in providing care and attention to patients. Nurses require modesty, patience and love to be able to provide the necessary care and behaviour to patients. In some Ghanaian hospitals, it has been observed that nurses do not exhibit the best of behaviour. Patients held the view that nurses disrespected them and talked to them in a way that was not appreciated (Abekah-Nkrumah et al., 2010). Some patients even become afraid to approach a nurse when they have issues of concern based on fear of public ridicule. This study, however, found a contrary view as respondents indicated nurses discharged a gentle behavioural and verbal communication. Likewise, patients acknowledged nurses obtained their consent before performing any nursing intervention, provided information about interventions rendered and informed patients about disease condition, outcomes and expectations which affirms the finding of (Sherwood and Barnsteiner, 2013).

Conclusion
Majority of patients (83.3%) do not have knowledge of the nurses' professional code of ethics in Ghana. Greater knowledge of professional ethics is needed for patients to understand and know what is expected of nurses so they can be able to put nurses in check. Also, continuing nursing education in ethics and addressing health system deficiencies in that regard will enhance nurses' professional development and their ethical decisionmaking and practice.

Recommendation
The Ministry of Health should educate and sensitize Ghanaians on the activities and the professional code of ethics of health workers especially nurses so that they can have knowledge of it and know what to expect of nurses when services are rendered to them. This can be in the form of information on the notice boards in the health facilities. This will help more people understand the roles of their health service providers and by extension promotes good patient-nurse relationships. Secondly, the Nurses and Midwifery Council of Ghana (NMC) should put in place periodic supervision and monitoring activities for nurses in the country to ensure that nurses adhere to their code of ethics after completion of training.

Ethics
Ethical approval was obtained from the Ghana Health Service Ethical and the Ensign College of Public Health Ethical Review committees. Local permission was obtained from the Hospital management of the Eastern Regional Hospital and its research ethics committee. The main ethical issues related to the protection of participant information, consent, autonomy and confidentiality were addressed. Consent was obtained from the participants. Participation was voluntary and respondents could withdraw from the study at any stage without any penalty.