8/6/2019 Final NRes

1/39

1

CHAPTER I

INTRODUCTION

Background of the Study

The practice of the nursing profession is interwoven directly or indirectly with the legal

responsibilities in every aspect of service being rendered. It is important for the nurses to

know the legal responsibilities attached to the various phases of her professional practice so

that she is properly guided in the discharge of her duties (Robles and Dionisio, 2001). When

nurses are not aware of ethical standards and the legal responsibilities that they have to be

standards and the legal responsibilities that they have to be accountable for, the practice of

their profession is endangered and because their practice involves human health and

welfare, committing a criminal liability becomes forthcoming.

The fundamental responsibility of the nurse is fourfold: to promote health, to prevent

illness, to restore health, and to alleviate suffering (Robles and Dionisio, 2001). These

functions may seem simple but in the context of the health care system where the well-being

of patients in at stake, there can be instances where nurses find themselves in an ethical

dilemma especially when they are not able to implement effectively the plan of medical care

or treatment of the physicians they work along with.

In order to avoid such a state of ethical dilemma and medical accountability on the

part of the nurses, international and local nursing associations and nursing boards have

spelled out policies and guidelines for the nursing profession, identifying the roles that nurses

have to play, the specific nursing functions that they must do, delineating nursing practices

from those that have to be made or done by medical practitioners.

In order to avoid ethical dilemma and safeguard the nurses against any legal

impediments as they perform their duties, the Nursing Service Department of Saint Anthony

College Hospital, Inc. takes upon itself the responsibility of orienting and refamiliarizing its

nursing service staffs with the specifics of the policies and guidelines as stated in the

8/6/2019 Final NRes

2/39

2

Standard of Safe Nursing Practice. Saint Anthony College Hospital, Inc. is a Christ-Centered

hospital committed to provide innovative, world class and compassionate quality care

preferably to persons living in poverty. Inspired by the Spirit of Saint Vincent de Paul and

Saint Louise de Marillac, we commit ourselves to: vigorously provide value-innovative and

world class healthcare services centered in Christ humanely deliver quality healthcare

services and elegantly leverage resources for viability.

The Nursing Service of Saint Anthony, College Hospital aims to have dynamic

nursing personnel committed to quality nursing care and provide a safe, effective and

comprehensive nursing care. The nursing service constitutes the single largest groups of

hospital employees. It is the mainstay of the organization in supporting administrative

policies, providing effective patient care and promoting good public relations. It is headed by

a Nursing Director who reports directly to the Hospital Administrator and is responsible for

the organization and administration of the Nursing Service. Other than seeing to it that the

Nursing Service Department is managed well, the director is also task to see to it that the

nurses on duty have adequate knowledge and skills, and their behavior and attitudes

conform to the ethical and legal standards set for their profession.

While there seem to be no critical issues where the focus of concern of the Nursing

Service of Saint Anthony College Hospital is concerned, there are no hard data to assure

hospital administration that all aspects of the Nursing Service are delivered efficiently and the

patient care is accordingly undertaken within the parameters of what is ethical and legal. It is

likewise important that every member of the nursing staff of the hospital has adequate

knowledge and skills in the practice of their profession and that all tasks are carried out

accordingly to the ethico-legal standards in nursing practice. It is or the basis of the foregoing

context that this study was undertaken.

Statement of the Problem

8/6/2019 Final NRes

3/39

3

General Objectives

A survey will be conducted to determine the Knowledge, Attitude, and Adherence of Nurses

to the Ethico-Legal Standards on Nursing Practice at St. Anthony College of Roxas City, Inc.(Hospital).

Specific Objectives

Specifically, this study aims to:

1. Determine the demographic profile of the respondents in terms of age, sex, civil

status, educational attainment, employment status, position and length of service.

2. Determine the level of nurses knowledge of ethico-legal standard in nursing practice.

3. Determine the attitude of nurses towards the ethico-legal standard in nursing practice.

4. Determine the nurses level of adherence to the ethico-legal standard in nursing

practice.

5. Determine whether there is a significant relationship between, the nurses

demographic profile and their level of knowledge of ethico-legal standard in nursing

practice.

6. Determine whether there is a significant relationship between the nurses

demographic profile and their attitude towards ethico-legal standard in nursing

practice.

7. Determine whether there is a significant relationship between the nurses

demographic profile and their level of adherence to the ethico-legal standard in

nursing practice.

8/6/2019 Final NRes

4/39

4

8. Determine whether there is a significant relationship between nurses level of

knowledge and their attitude towards the ethico-legal standard in nursing practice.

9. Determine whether there is a significant relationship between nurses level ofknowledge and their adherence to the ethico-legal standard in nursing practice.

10. Determine whether there is a significant relationship between nurses attitude and

their adherence to the ethico-legal standard in nursing practice.

Statement of Hypothesis

This study tested the following null hypothesis:

1. There is no significant relationship between the nurses demographic profile and

their level of knowledge of the ethico- legal standard in nursing practice.

2. There is no significant relationship between the nurses demographic profile and

their attitude towards the ethico- legal standard in nursing practice.

3. There is no significant relationship between the nurses demographic profile and

their level of adherence to the ethico- legal standard in nursing practice.

4. There is no significant relationship between the nurses level of knowledge and

their attitude towards ethico- legal standard in nursing practice.

5. There is no significant relationship between the nurses level of knowledge and

their level of adherence to the ethico- legal standard in nursing practice.

6. There is no significant relationship between the nurses attitude and their level of

adherence to the ethico- legal standard in nursing practice.

8/6/2019 Final NRes

5/39

5

Theoretical Framework

This study is anchored on the theory of reasoned action by Martin Fishbein and Leck Ajzen

(1998) According to this theory, the most important determinant of a persons behavior is the

intention to perform it. The intention to perform a behavior is a combination of attitudes

towards performing the behavior and a subjective norm. If a person perceives that the

outcome of performing a behavior is positive , he will have a positive attitude towards

performing that behavior; and if significant others see that the performed behavior is positive

and the individual is motivated to meet the acceptance of significant others, then a positive

subjective norm is expected. The theory further argues that in order for a person to perform a

given behavior, the person must have a strong intention or make a commitment to perform

the behavior. The strength of an attitude is indicated by the amount of knowledge on which it

is based and how that knowledge was acquired. People tend to behave in ways that are

consistent with their attitude when they are well-informed. Studies of Davidson, Kallgren and

Wood suggest that the more informed the respondents are the more consistent their attitudes

will be with their behavior. Fishbein asserts that a change in beliefs can produce changes in

attitudes toward the act, leading to changes in behavioral intentions and finally, changes the

behavior. It can also be argued that when a person believes that the advantages of

performing a behavior, because he expects to gain somehow from the action.

In the context of this study, it is assumed that nurses who understand the importance

of the standards in nursing practice will develop a favorable attitude towards the necessity of

adhering to the ethico-legal standard in their practice, however, this expected link between

8/6/2019 Final NRes

6/39

6

knowing about the practicing it, maybe affected by external factors. In this study, factors

which are assumed to affect adherence are the nurses personal profile, knowledge and

attitudes. It is assumed that matured, married, highly educated nurses and those with regular

status and belong to a higher position may have better understanding of the legal and

ethical, implications of non-adherence. It is also assumed that nurses with better

understanding of the legal, as well as the ethical standard will have positive attitudes toward

adherence to avoid legal consequences.

Conceptual Framework

DemographicProfile:

Age

Sex

Civil Status

Educational

Attainment

Employment Status

Position

Length of Service

Nurses

Adherence to

Ethico-Legal

Standards

In

Nursing

Practice

Independent

Variables

Intervening

Variables

Dependent Variables

Knowledg

e of

Staff

Nurses

Attitude

of

Staff

Nurses

8/6/2019 Final NRes

7/39

Figure 1. A schematic diagram showing the flow of

relationships between variables covered in the study.

7

Significance of the Study

Hospital Administration and the Nursing Service. Results of the study will

provide the SACH administration, specifically the Nursing Service Department

with information that can be the basis of improvement in the over-all delivery of

efficient nursing service. These data can serve in the formulation of specific

hospital policies and guidelines that will continue to maintain the standard of

care being delivered to protect its nursing staff from any ethico-legal problems.

Nursing Managers. Data obtained will provide nurse managers with insights

about their nurses profile, their knowledge, attitude and adherence to the ethico-

legal standards set for the practice of the nursing profession. These data can also

provide the basis of planning and implementation of in-house training for

continuing education that can focus on information dissemination on the

implications of non-adherence to the ethico-legal standards and other strategies

that can help not only in improving the delivery of nursing care but in

empowering nurses and protecting them from any adverse effects of non-

adherence to such standards as they perform their specific tasks.

Nurse Practitioners. Results of the study can develop in them an awareness of

their own adequacy of knowledge, attitude towards, and adherence to the ethico-

legal standards set in nursing practice. This can help them reflect on what they

actually do as they perform their tasks as nurses.

College of Nursing. Results of the study can provide the curriculum planners

and implementers with information that can become the basis of emphasis and

8/6/2019 Final NRes

8/39

8

improvement on the subject such that even while in school, future nurses can

already develop in them the necessary knowledge and attitudes towards their

ethical and legal responsibilities as professionals.

Scope and Limitation of the Study

This focused on nurses employed at Saint Anthony College of Roxas City,

Inc. (Hospital) from June to September of 2011, their professional characteristics

such as age, sex, civil status, educational attainment, employment status,

position, and length of service; their knowledge of the ethical and legal standards

in nursing practice; and their attitudes towards, and adherence to said standards

as stipulated in the Nursing Code of Ethics and the provisions of the Nursing Law.

Results obtained from the study were derived from nurses responses to

the different items in the questionnaire to include those that pertain to their

personal characteristics, their knowledge of, attitude towards, and adherence to

the ethico-legal standards set in the practice of the nursing profession.

Interpretations are based on results of analysis made on descriptive and

statistical data tested at a .05 level of significance.

Definition of Terms

For purposes of clarity, the following terms are defined as they are used in this

study.

Dependent Variables

8/6/2019 Final NRes

9/39

9

Adherence refers to compliance of nurses to the ethico-legal policies, rules and

regulations set by the governing body of the nursing profession. The standards of

the nursing practice are stipulated in RA 9173 of the Nursing Act of 2002. In this

study it is measured by a 15 items questionnaire on how frequent they adhere to

the practices. To prevent respondents from answering in a patterned way, all the

statements except items number 2 and 8 were stated in negative forms.

However, scoring for these negative questions was reversed.

To measure the level of adherence of the respondents, the average score

from all items was computed and classified as follows,

Category Mean Score

High 13-15

`` Moderate 10-12

Low below 10

Intervening Variables

Knowledge refers to the nurses understanding of the legal and ethical

standards in the practice of nursing. This was measured by a 15-item

questionnaire. The respondents answer with either true, false or I dont

know. Their knowledge depended on the number of correct scores obtained.

Every correct answer is given a one (1) point score, and a wrong and I dont

know answer were given a zero (0) score. To measure the respondents level of

knowledge of the with legal standards in nursing practice, the average score from

all items were computed and categorized as follows,

8/6/2019 Final NRes

10/39

10

Category Mean Score

High 13-15

`` Moderate 10-12

Low below 10

Attitude In this study attitude towards the ethico-legal standards in nursing

practice refers to the nurses position or feeling on the ethico-legal standards in

nursing practice. It is measured by a 15-item questionnaire, which sought their

position and how they feel about the standards. To prevent the respondents from

answering the question in a patterned way, items number 3, 4, 5, 6, 7, 12, 13 and

14 were stated negative forms. However, scoring was reversed on these items.

To measure the respondents level of attitude towards ethico-legal

standards, the average score form all the items were computed and classified as

follows;

Category Mean Score

Unfavorable 1-1.5

Neutral 1.6-2.5

Favorable 2.6-3.0

Independent Variables

8/6/2019 Final NRes

11/39

11

Age refers to the number of years of the respondents life as of their last

birthday. This categorized as young to include those who are below 30 years,

and old for those who are 30 years and above.

Sex refers to the biological classification of the nurses categorized into male and

female.

Civil Status refers to whether nurses are single and married.

Educational attainment refers to the highest education completed by the

nurses categorized into bachelors degree and bachelors degree with masteral

units.

Employment status refers to the employment specification of nurses

categorized as probationary, a licensed nurse who is on 3-6 months probationary

period of trial and observation; and regular, one who is employed permanently

and enjoying the benefits afforded by the law.

Position refers to items in the organizational structure which includes the

following:

Staff nurse refers to a nurse employed with the primary responsibility of

providing bedside nursing care.

Head nurse refers to a nurse employed with the primary responsibility of

managing the unit or department.

Supervisor refers to a nurse employed with the primary responsibility of

supervising the personnel in the nursing department.

Length of service refers to the number of years the nurses have worked at

Saint Anthony College of Roxas City, Inc. (Hospital). It is categorized as long for

8/6/2019 Final NRes

12/39

12

those who have served the hospital for 2 years and above, and short for those

who have served below 2 years.

Ethico-legal standards refer to the prescribed rules and regulations embodied

in the Nursing Law and the Nursing Code of Ethics governing the practice of

Nursing.

Standards in nursing practice refer to the written documents outlining

minimum expectations for safe nursing care.

CHAPTER II

REVIEW OF RELATED LITERATURE

This chapter presents a review of literature related to the present study. Included are

concepts about ethical and legal standards in nursing practice and results of studies that

were deemed related to the concerns of the study. These literatures have provided the

researchers with insights and information that guide them in the formulation of their research

objectives and later on the interpretation of some of their findings.

Nursing Practice Standards

Webster (2004) defines a standard as any established measure of extent, quantity, or

quality, or value; a criterion of excellence or example for comparisons. Marquins (2000)

further adds that for an individual nurse, a standard is the sum total of what she believes is

8/6/2019 Final NRes

13/39

13

desirable patient outcomes and the priorities she assigns to her nursing activities. As stated,

standards are necessary to demonstrate to the public, to government and other stakeholders

that a profession is dedicated to maintaining public trust and upholding the criteria of the

professional practice.

Alberta Association of Registered Nurses has emphasized that standards are

essential for a self- regulating profession. They represent acceptable requirements for

determining the quality of nursing care a patient or clients receives. Among the functions of

nursing practice standards are (1) guide and direct nursing practice; (2) promote professional

nursing practice; (3) facilitate evaluation of nursing practice; (4) enable the patient/ client to judge the adequacy of nursing care; (5) provide guidelines to the nurse researchers in

identifying and explaining relationship between nursing practice and patient care outcomes;

(6) provide guidelines for the nurse administrators to support and facilitate safe, competent,

and ethical nursing practice within their agencies; (7) provide guidelines for the nurse

educators in setting objectives of educational program; (8) facilitate articulation of the role of

nursing within the health care team.

These standards represent the criteria against which the practice of all registered

nurses will be measured by the public, clients, employees, colleagues and themselves. It

also reflects values of the profession. As stressed by Canadian Nurses Association, (CNA)

nurses as professionals, are committed to the development and implementation of nursing

standards through the on- going acquisition.

The following are the components of the standards in the nursing profession:

(1)Assessment; (2) diagnosis; (3) outcomes identification; (4) planning; (50 implementation

which includes coordination of care, health teaching and health promotion, consultation and

prescriptive authority and treatment; (6) evaluation; (7) quality of practice; (8) education; (9)

8/6/2019 Final NRes

14/39

14

professional practice evaluation; (10) collegiality; (11) collaboration; (12) ethics; (13)

research; (140 resource utilization; and (15) leadership.

The nursing profession has been leader in the field of standards development. As thelargest health profession providing care to individuals, families, groups, communities and

population and a multiplicity of settings, these standards have an important role in guiding

the nursing practice.

All standards of practice provide a guide to the knowledge, skills, judgment and attitudes

that are needed to practice safely. They describe what each nurse is accountable and

responsible for in practice. Standards represent performance criteria for nurses and can

interpret nursing scope of practice to the public and other health care professionals.

Standards can be used to validate practice and generate research questions that lead to

improvement of health care delivery. Finally, standards aid in developing a better

understanding and respect for the various and complementary roles that nurses have

(htt://www.nurses.ab.ca/profconduct/npa.html/November 25, 2006).

Ethical Standards in Nursing Practice

The ethical standards in nursing practice are explicitly spelled out in the Code of Ethics

for Nurses. This code provides nurse practitioners a guide that they must conform to as they

perform their or especially in a hospital setting.

The term ethical is defined by Swansburg as conforming to professional standards of

conduct. In this definition, they have included such concepts as privacy and confidentiality in

the context of a nurse- patient relationship. This is further followed up by CAN where

consideration of ethical issues is stressed to be an essential component of providing care

within the therapeutic nurse- client relationship. Nurses encounter ethical conflict, uncertainty

and distress in their everyday practice. Continuous changes in the health care system, in

8/6/2019 Final NRes

15/39

15

areas such as technology, and changes in values contribute to these ethical dilemmas.

Understanding and communicating beliefs and values help nurses to prevent ethical conflicts

and work through them when they occur.

According to Pierce, registered professional nurses are in the best position to advocate

for the rights of their patients and this being so; they are frequently involved in ethical issues

and ethical decision- making processes. Ethical dilemmas arise daily when the nurse is

confronted with a choice, in which ethical reasons both for and against the choice are equally

desirable. These issues are often emotionally charged.

Recent studies (Donovan and Redman, and Cassels and Gaul,Clark,2002; Dinc,

20030 have identified some of the more frequently occurring ethical issues confronting

nurses today. Among these are staffing patterns that limit a patients access to care;

management/ administration participation in down-sizing that reduces patient services and

staff while maintaining quality care and access to that care; the protection of patients rights

and human dignity; the right to refuse treatment; the prolongation of the living and dying

process, and the need to consider the impact on the patients quality of life. Other equally

important concerns are informed consent; whether or not to use physical or chemical

restraints; providing care that may be a risk to a nurses health; potential differences between

nurse and patients belief systems regarding issues such as abortion, euthanasia, and organ

and tissue donation; and bioethical issues raised by medical technologies and treatment

such as the use of stem cells from human embryos.

At the center of this multiplicity of issues and concerns is the registered professional

nurse who, in facilitating the ethical decision- making process, can utilize different

frameworks and models. First and foremost, is the American Nurses association Code of

Ethics (ANA, 2001) which states every professional nurses ethical obligations and duties,

8/6/2019 Final NRes

16/39

8/6/2019 Final NRes

17/39

17

associated with automated information management. They should not hold as fact the belief

that clinical decision- making based upon the use of technology results in better patient care.

In a survey made by LaDuke (2000) on the Effects of Professional Discipline on Nurses,she mentioned that in the United States, over 5,000 nurses are disciplined annually because

of misconduct that these nurses were not prepared to defend themselves legally with some

taking the blame for system failures. Among the types of misconduct mentioned were

medication error (27 percent0, documentation error (11percent), and medical treatment

without physicians order (8 percent). Among the penalties meted out were, on the extreme,

revocation or surrender of license; and on the lightest, censure and reprimand. About 66percent of the 177 nurses disciplined in 1998 were penalized with stayed suspension.

In the Philippines, in consonance with RA 7164, protocols for specific nursing activity

are being designed and disseminated in order to deliver excellent and quality nursing care in

the interest of patient welfare. An example is the Board of Nursing Resolution no. 08, series

of 1994 that concerns the administration of intravenous injection. As provided for, a

registered nurse is proscribed or prohibited from administering intravenous injections to a

patient unless he/she has undergone a special training at least under a nursing administrator

who is a member of Association of Nursing Service Administrator of the Philippines (ANSAP)

that any registered nurse without such training who administers injections to patient

whether causing or not an injury or death to the patient shall be held liable either criminally

(Sec.30, Art VII) or administratively (Sec 21, art III) or both.

Since nursing is a practice- based profession, it becomes necessary that nurses are

aware of what is ethical and legal in regard to what they do as they perform their tasks in

their job. However nurses prepare for the risks in their jobs, Jarvis states that the basic

professional education is no longer sufficient for training on going safe practice. As adult

8/6/2019 Final NRes

18/39

18

learner, nurses are expected to take primary responsibility for their own continuous

education. Legally and morally, health professionals have the duty to update themselves with

the knowledge regarding their particular specialty or field of service, particularly on the area

of risk management. As Carpentino claims, no course fully prepares a professional for a

lifetime of practice.

Several factors have complicated the process of extracting risk management

guidelines for nurses in managed care. These include the relative newness of managed

care, the limited volume of litigation to a foundation of legal precedence, and the complex

contractual agreements among the parties involved (Faulkner & Gray). A number of suitsinvolving managed care organizations are starting to wind their way trough the appellate

courts. As a result, liability issues are becoming clearer. For instance, failure to process

claims appropriately, denial of claims, and undue delay of treatment can lead to liability

(Fiesta). Most of these issues have a common theme: Who should be held liable when

things go wrong? (Faulkner & Gray).

The courts have addressed several cases related to poor outcomes alleged to have

resulted from care received from or through managed care organizations. Traditionally, these

claims would have been treated as malpractice claims. However, due to the intricate

contractual arrangements between the many stakeholders, it is quite challenging to delineate

the legal responsibilities (Faulkner & Gray).

Knowledge or Awareness of Ethico-Legal Standards

The following literature does not specifically pertain to nurses knowledge of the

ethico- legal standards in nursing practices. As stressed, the rapidly increasing body of

knowledge relative to the practice of the nursing profession makes it mandatory for nurses to

maintain competence in both theory and practice (Verhey).

8/6/2019 Final NRes

19/39

19

As mentioned by Spitzer, the roles emerging in managed care emphasized the need for

nurses to maintain a thirst for learning, ongoing persistence, keen awareness, and

willingness to be flexible. Innovative roles imply emerging areas of responsibility, including

legal, ethical and clinical accountability. As financial risk is shared by providers, including

nurses, new areas of risk and risk management are also emerging. For instance, in triage

and utilization- management, nurses now have obligations to ensure that the appropriate

care is given. Difficulties may arise when nurses are trying to manage resources frugally and

with allegiance to their employers, yet also trying to act in the patients best interest. These

circumstances put the nurse practitioner in dilemma and ensuing decision can impact on

nursing practice (Fiesta)

Nursing is the therapeutic relationship that enables the client to attain, maintain or regain

optimal function by promoting the clients health assessing, providing care for and treating

the client's health condition. This is achieved by supportive, preventive, therapeutic, palliative

and rehabilitative means. The therapeutic relationship is established and maintained by the

nurse and the client through the nurses use of professional nursing knowledge, skill and

caring attitudes and behaviors to providing nursing that contribute to the clients health and

well- being. The relationship is based on trust, respect and intimacy and requires the

appropriate power inherent in the care providers role. Clients values and choices are of

primary consideration when planning and providing care, and nurse own personal values

never interfere with the clients right to receive care. Regardless of the role, whether directly

or indirectly involved with individual clients, all nurses are responsible for providing ethical

care services.

The discipline of nursing is its strong knowledge base coupled with a fine tradition of

community- based care. In many ways, the emergence of managed care represents

opportunities for nursing to influence the future of health care delivery. However, nurses must

8/6/2019 Final NRes

20/39

20

be poised to face this challenge by acquiring and using accurate information, responsible

strategies, and a strong clinical foundation (Britt, Schraeder & Shelton).

In the study of Hariharan (2006) about the knowledge, attitude and practice of ethics andlaw of physicians and nurses, it was found out that the majority of the respondents did not

know enough of the law pertaining to their workplace. Most of the respondents agreed to the

importance of ethical knowledge, although one- tenth of the staff nurses did not think that it is

important. Those respondents, who thought that the knowledge of ethics and law was

unimportant, also responded that they never saw problems. Perhaps due to poor awareness

regarding ethics and ethical situations, many of these respondents would not have possiblyrecognized the problems art the workplace.

Another major finding of this study was that majority of the physician and nurses did not

know the contents of their respective codes. Physician and nurses commonly encounter

ethical and legal issues in their workplace. However, many of these professionals were either

unaware of their importance or unable to appropriately deal with these issues.

The paper by Britain provides an account of a course developed by the Department

of Midwifery Studies at the University of Central Lancashire (UCLAN) in response to a

request for the North West Regional Health Authority. UCLAN developed a 3-day program to

provide family planning nurses with the specific skills and knowledge to provide emergency

extension of the family planning program. The nurse role is particularly significant for public

health as one third of live births in the UK are unintended.

The need for providing adequate education and the necessary safeguards when

expanding the current role of nurses is also highlighted by a qualitative study by Jowett,

Peters, Reynolds and Wilson-Barnett (2001). This study consisted of a questionnaire

examining three main areas, namely; respondents awareness of the scope of professional

8/6/2019 Final NRes

21/39

21

practice for nurses, midwives and health visitors; activities that the respondents would like

these professionals to do but were currently part of their role; and respondents; concerns

about these professionals expecting to do. The questionnaire was distributed to medical

organizations, professional bodies, consumer groups, government departments, health

authorities, social service departments, community health councils, private health care

providers and centers for nursing and midwifery educations. A total of 212 responses were

received. Responses revealed that there was high degree of awareness about the scope

document (85 percent), 25 percent of respondents described prescribing as a desirable

component of expanded practice, 40 percent were concerned that staff required adequate

training and 23 percent identified the need of safeguard patients.

Attitude toward the Standard in Nursing Practice

Cormack describes attitude simply as what is liked and disliked. For Oppenheim,

attitude is considered as a state of readiness, a tendency to respond in a certain manner

when confronted with a certain stimuli. Oppenheim continued that attitude statements

express a point of view, a belief, a preference, a judgment, an emotional feeling and a

position for or against something. He is considers that attitudes are usually dormant and are

expressed in speech or behavior only when the object of attitude is perceived. For Schoen,

an attitude is equivalent to a lasting opinion or disposition. However, Oppenheim considers

opinion to be the product of attitudes, which in turn are the product of values. His study holds

that a sound and health educational attitude in nursing desires ongoing and further education

which is considered a positive and worthwhile experience, thus leading to personal growth,

fulfillment and enhanced self-esteem. This attitude is considered a profitable outlook to the

learner and a prerequisite for teachability.

8/6/2019 Final NRes

22/39

22

Quinn considers attitudes as having three basic components: cognitive (belief,

thoughts), affective (feelings), and a motor (action) behavior component. In measuring

attitudes, one might also predict behavior that follows convictions. However the link between

attitudes and behavior is not always clear according to Cormack Schoen even denies any

relationship between attitudes and behavior. She states that behavior does not indicate

attitudes, nor do attitudes predict behavior. He further explains that consistent with common

observation, what people say is often quite different from what they do.

Several methods of changing the attitudes of others can be used. Communication,

education and advertising are acceptable forms in a democratic and liberal environmentmore forceful means can, however like propaganda, brainwashing, and infliction of pain or

pleasure and even by medication. It appears that for any change in attitudes to occur, there

must be an input of knowledge (Bason). However, information giving alone does not

automatically lead to change in recipient, which may even have an opposing effect. Thus,

Knowles claims that mandatory attendance to adult teaching programs, such as in in-service

training, does not guarantee that the educational experience is valued, or that learning

occurs. Carpenito states that mandatory continuing education is specifically intended for

laggards and violates the voluntary nature of adult education. Laggards have fixed ideas;

their skills have deteriorated and adapt few new ones. Moreover, she claimed that mandatory

continuing education is only considered important for the protection of the public and its

benefits were never proven. Carpenito further elaborates that forced nursing education

insults nurses and the mere presentation of a certificate does not imply that learning has

occurred,

Several studies have been commissioned to highlight the change in attitudes that can

result form continuing nursing education. Harrison and Novak studied the effects of a

voluntary gerontological course to nurse already working in gerontology. These authors

8/6/2019 Final NRes

23/39

8/6/2019 Final NRes

24/39

24

In Malta, the Ministry of Home Affairs and Social Development (MHASD) in its policy

document for Our Lady of Mount Carmel Hospital (MCH) and mental health had commented

on the motivation of several general nurses working in the psychiatric practice in MCH. They

appeared motivated enough to further their nursing knowledge and obtain better

qualifications when the right educational opportunities arise. The following comments were

however, based on an opinion rather than the results of an actual study: although by

international standards, the complement of the nurses is sufficient to cope with the nursing

standards, their level of training is inadequate to offer effective psychiatric nursing care

notwithstanding that a good number of nurses are motivated and make an effort.

A study employing the pre and post-test design examines the effects of an

educational program on Hispanic physicians attitude towards and knowledge of HIV/ AIDS

was conducted by Stanton and Johnson (2000). A convenient sample of physicians

participated which limits the generalizability of the results to other groups. However, it does

not point out that a training program can alter physicians screening and testing practices as

well as their attitudes towards clients with HIV/ AIDS. This has implications for providers in

remote rural areas or in medically underserved communities where access to formalized

continuing education may be limited or offered at times not compatible with a busy practice.

The study suggests that one kind of training and education need to be planned and

developed to facilitate provider participation. Perhaps, on line courses or programs might be

most effective of providing this one on one approach.

There is no conclusive evidence from the literature concerning the degree to which

education can affect a change in the attitudes towards psychiatric nursing. There is some

support in the research findings for the notion that educational exposure can create more

positive attitudes towards the care of the mentally ill and the practice of psychiatric nursing

(Hafner & Proctor).

8/6/2019 Final NRes

25/39

25

Harrison describes student attitudes towards the psychiatric nursing practice as

based on fear, primarily resulting from misconceptions about the mentally ill. While the main

focus of this paper concerned clinical experience, the results are nevertheless relevant

towards all aspects of teaching psychiatric nursing in general. This article supports the

findings of Stevens and Dulhunty that neophyte-nursing students tend to view the mentally ill

with fear and mistrust. Stevens and Dulhunty argued that neophyte-nursing students are

reflecting the views of the boarder society towards the mentally ill. That society holds

negative views towards the mentally ill as being dangerous and unpredictable is well

supported (Southgate). In the light of such evidence there is no reason to believe that people

about to commence a nursing program would hold substantially different views. Furthermore,

such views would undoubtedly influence the attitudes of undergraduate student nurses

towards a career in psychiatric nursing.

Adherence to the Standards of Nursing Practice

It is always stressed that nurses should collaborate with physician colleagues to

improve care for specified sub-populations (Graff et al.). Roles and responsibilities for the

expanded role of nurses in Graffs study included: identification of an at-risk population;

development of interventions to reduce risk factors; establishment of care coordination

system; resource networks and critical linkages for patients and staff to assure access to

needed services; data collection, monitoring, and analysis; identification of strategies to

reduce hospital length of stay; a focus on outcomes and a review of variances from

standards of care; and use of data to improve care and outcomes across the population.

In Malta, locally registered nurses are not exempt from such updating needs.

Although, this legal framework has not been introduced in Malta, all registered nurses are

entitled for two days, paid study-leave per year (Health Department Circular no. 206/ 91).

8/6/2019 Final NRes

26/39

26

In the Philippines, policies regarding the delivery of safe nursing care are spelled out

in the standards of nursing practice, in general, and in care pathways for specific

specializations, in particular. The most common is the carrying out of doctors orders and

prescriptions to the letter. Restrictions like in the case of intravenous practice are also

defined to be administered only by those who have undergone and completed the training for

the purpose.

It is common practice that before a newly hired nurse is allowed to practice in a

healthcare facility like the hospital, an orientation on rules and policies is being administered.

His orientation includes provisions for ethical concerns like consultations with supervisors,getting informed consent from patients, keeping and safeguarding the confidentiality of

patients records; and also procedural policies such as endorsements of cases, wearing the

proper uniform, maintaining and protecting the sterility of equipment, and similar concerns

(CEH Code of Ethics Handbook).

All of these provisions from part of the hospital rule that when violated by the nurse

becomes a legal or ethical question.

8/6/2019 Final NRes

27/39

27

SYNTHESIS

The nursing profession is one of the largest industries here in the Philippines and

in the United States. Since the Philippines is the number one exporters of health service providers

especially nurses, it is assumed that the nursing profession being in demand profession

internationally has established rules governed by excellent and acceptable standards. These

standards of nursing practice measure the quality and the status, as well as the values of theprofession (CNA), and nurses as professionals should be committed to adhere to these standards.

The ethical standards in nursing practice are explicitly spelled out in the Code of

Ethics for Nurses. This code provides nurse practitioners a guide that they must conform to as they

perform their work especially in a hospital setting. Just like other profession, the nursing profession

is not exempted from issues, conflicts, and dilemma. It too has its ups and downs. Since nursing is

a licensing profession, nurses must be fully aware of the legal implications of their practice. They

are handling lives thus their practice is tantamount to public safety. Britain and Jowett, et al (2001)

supported this claim. However, in the study of Hariharan (2006), he found out that some nurses

have poor awareness of the problems in their workplace and worse, they did not even know the

law affecting their job.

Since nursing is a practice-based profession, it becomes necessary that nurses

are aware of what is ethical and legal in regards to what they do as they perform their tasks in their

job. As stressed by Swansburg, nurses should be capable of assessing and managing the legal

risks associated with their profession. The study of La Dule (2000) however stated that

5,000nurses in the United States are disciplined annually because of misconduct, due to

8/6/2019 Final NRes

28/39

28

medication errors, documentations errors and giving medical treatment without doctors order.

Because of this issue, Jarvis opined that since basic education for nurses is no longer sufficient for

training of ongoing safe practice, nurses must update themselves with knowledge regarding areas

of risk management. Carpenito supported this contention that continuing education for nurses must

be mandatory. However, Schoen and Knowles, strongly opposed the idea of claiming that,

trainings, attendance to programs and seminars-workshops do not5 guarantee that learning for

nurses occur. As claimed by Oppenheim, the real change must be in the attitude of nurses.

However, the link between attitudes and behavior is not always clear (Cornack). To change

attitude, there must be input of knowledge or may have an opposite effect. According to MHASD,

based on international standards, nurses level of training is inadequate to offer effective nursing

care. In response to these findings, RCN encourages education and training of nurses in order to

motivate them to live up to international standards. Stanton and Johnson (2000) supported this

idea by saying that training programs and exposure can alter views and practices, as well as

attitudes of nurses towards clients. They emphasized that motivating nurses is of most importance.

Motivation plays a major role for nurse to continually update themselves and keep abreast

with rapid change and challenges of the profession. This claim is supported by DeSilets saying that

if nurses wanted to stay professionally competent, they should attend conferences and lectures.

Constants exposure to other fields of their profession could undoubtedly influence their views and

definitely, their practice (Southgate). However, the study of Proctor and Hafner found out that there

is no conclusive evidence that education can affect a change in the attitude of nurses toward these

fields.

Because of this dilemma, nurse educators have been exploring various strategies in

maintaining the quality of nursing and the delivery of health care. Graduates must be competent

enough to face intimidating threats to the tasks, of the giving compassion to our fellow human

8/6/2019 Final NRes

29/39

29

being, without deviating from ethical and moral standards of nursing practice is vital role and of

great importance to health care practitioners like nurses.

Chapter III

METHODOLOGY

This chapter deals with the research design, place of the study, respondents of the

study, research instrument, validity of the questionnaire, reliability of the questionnaire, data

gathering procedure, scoring of responses data processing and analysis.

The Research Design

This is a descriptive-relational type of research that employed the one-shot survey

design. According to David (2002), this design can be used to objectively describe a

situation/condition of the study population and determine the characteristics of said

population/respondents. This type of r4esearch is also appropriate in determining the

relationships of variables being studied.

Place of the Study

This study was conducted at Saint Anthony College of Roxas City, Inc. (Hospital)

Respondents of the Study

The respondents of the study were 70 registered nurses during the year 2011. There

were staff nurses, head nurses and supervisors, assigned in all nursing units of the hospital,

those probationary and regular nurses employed on regular status.

8/6/2019 Final NRes

30/39

30

The Research Instrument

Researcher-made questionnaires were used in this study.

Part I includes items which are required information about the personal profile of

respondents, particularly age, sex, civil status, educational attainment, employment status,

position, and length of service.

Part II is a 15-item statement about nurses knowledge of ethico-legal standard of

nursing practice with the corresponding three choices response categories of true false

and I dont know. Respondents were asked to check the column of their choice relative to

their individual response to every item.

Part III is a 15-item statement related to respondents attitude towards ethico-legal

standards in nursing practice. Three-column response categories namely agree, neutral

and disagree are included, with respective column and respondents were asked to check

the column of their choice based on what is true to their individual circumstances.

Part IV is a 15-item statement which dealt with respondents adherence to the ethico-

legal standards in nursing practice. A two-column response category was included and

respondents were asked to check the column of their choice based on what they actually do

in the hospital. The response categories include; yes and no.

Validity of the Questionnaire

For face and content validation of the questionnaire, three consultants in research

were requested to give comments and suggestions to assure the researcher that all items in

the questionnaire was relevant to the objectives of the study. The suggestions and

8/6/2019 Final NRes

31/39

31

comments made by these consultants were incorporated in the final revision of the

questionnaire.

Reliability of the Questionnaire

To test the reliability of the questionnaire, it was subjected to a pre-test to 30 nurses

chosen by convenience a month before the actual survey. The pre-test respondents did not

participate in the actual survey. Data from the pre-test were tabulated and reliability

coefficient was computed using the spit-half method. The items in the questionnaire were

splitted into odd and even numbers. The result of the odd-numbered items was correlated

with that of the even-numbered items.

To get the reliability coefficient of of the questionnaire, the Pearson Product-

moment correlation coefficient was used. The formula is:

r= So2 + SE2 SD2

2So2 SE2

Where:

R= reliability of of the questionnaire

So2 = variance of odd numbers

SE2= variance of even numbers

SD2= variance of the difference between odd and even numbers

To get the reliability coefficient of the whole questionnaire, the spearman Brown

Prophecy Formula was used. The formula is:

8/6/2019 Final NRes

32/39

32

11 = 2 1/2

1+ 1/11

Where:

11= is the reliability coefficient of the whole questionnaire

1/11 = is the reliability coefficient of of the questionnaire

The reliability result was reported to the researchers adviser, Mr. Mark Alvin Alisasis,

RN who after ascertaining the reliability of the research instrument gave permission to use

the questionnaire. The questionnaires were reproduced and administered accordingly.

Data Gathering Procedure

A letter of request to conduct the study at St. Anthony College Hospital, Inc. made

and submitted to the hospital administrator for approval. When request was granted, the

researcher personally distributed the questionnaire. It had a cover letter stating the purpose

of the study. The researcher assured the respondents that all information gathered will be

held in utmost confidentiality.

The respondents were given five days to answer the questionnaires. This gave the

respondents time to understand the question and answer every item included. The

questionnaires were distributed to all nurses who were on duty in the morning and afternoon,

and night shift with the help of the supervisor on duty. After a week, the questionnaires were

returned personally to the researcher with the assistance of the supervisors and head nurses

on duty.

The researcher checked for the completeness of the gathered data. Retrieval of the

questionnaires was 100 percent.

8/6/2019 Final NRes

33/39

33

Scoring the Responses in the Questionnaire

Scoring was made only to parts II, III, and IV of the questionnaire. For part II wher

items dealt with nurses knowledge of the ethico-legal standards of the nursing practice and wher

response categories consisted of three, namely True, False, and I dont know, every correc

answer was given a score of 1, while a wrong or I dont know answer was given a score of 0. The

level of knowledge was categorized as High when they were familiar with most of the standards

Average when they were familiar with many of the standards, and Low when they were familia

with only a few of the standards.

Part III, assigned scores for positive items were 3, 2 and 1 for agree, neutral and

disagree respectively; and for negative items, the opposite, namely 1, 2, 3, respectively.

Part IV, assigned scores were 1 for Yes, and 0 for No answers. Items included i

the questionnaires were re-stated positively to ethico-legal statements for easy interpretations.

Data Processing and Analysis

As soon as all the questionnaires were retrieved, the researcher coded the data an

entered the coeds in a data sheet prepared for the purpose. After all data have been coded, they

were encoded and subjected to statistical analysis using the statistical package for social science

(SPSS) PC software.

Frequency distribution were used for the description of the personal profile of th

respondents such as age, sex, civil status, educational attainment, employment status, position, an

length of service, and to determine the respondents level of knowledge, attitude, and adherence t

ethico-legal standards in nursing practice; the gamma test was employed to test the significance o

relationship between the ordinal variables; and chi-square was used to test the significan

relationships between nominal and ordinal variables. The alpha level of significance adopted for a

inferential tests was set at 0.05 levels. Statistical results were all computer generated.

8/6/2019 Final NRes

34/39

34

QUESTIONNAIRE

Knowledge, Attitude, and Adherence of Nurses to the

Ethico-Legal Standards in Nursing Practice at Saint

Anthony College of Roxas City, Inc. (Hospital)

This research instrument is intended to gather information from the nurses

employed at Saint Anthony College of Roxas City, Inc. (Hospital). You are in the

best position to supply the information needed for this purpose.

In this regard, please answer the items as honestly as you can. Please

dont leave any item unanswered.

Part I. Personal Profile:

Directions: Kindly provide the necessary information.

a. Name (Optional) ______________________

b. Age ____________

c. Sex

a. Male _______

b. Female _____

d. Civil Status

a. Single______

b. Married____

e. Educational Attainment

a. Baccalaureate Degree ______

b. With masteral units ________

f. Employment Status

a. Probationary ______

b. Regular __________

8/6/2019 Final NRes

35/39

8/6/2019 Final NRes

36/39

36

8. The Nurse Practice Act is a legal statute regulatingnursing; it defines nursing standards for nurses andprotects the domain of nursing.

9. The nurse can perform intubation procedure to savethe life of the patient when the physician failed afterseveral attempts.

10. Informed consent for nursing procedureprovides protection against future litigation.

11. As a certified IV therapist, I can initiate IVtherapy administration.

12. There is no need to write an incident report forerrors committed when the patient is notcomplaining.

13. Nurses are bound not only by their personalvalues but also by the rules governing their

professional conduct.14. Ethical decisions are difficult because there isno right or wrong answers.

15. Being a legal document, the nurses notesshould truly reflect what transpired during thepatients hospitalization.

Part III. Attitudes of Nurses towards Ethico-Legal Standards in

Nursing Practice.

Direction: Please indicate your responses by checking. The following

descriptions are given for each of the following choices:

A- Agree N- Neutral D-Disagree

ITEMS A N D1. I am willing to come for duty anytime my service is

needed even if I am on vacation.2. I can refuse an assignment to float to unfamiliar

setting even if there is no one else available to care forthe patient, than put my patient at risk.3. I reprimand my subordinates in front of the patient

when the error has been committed and ask him/ herto apologize to the patient.

4. I can not leave the department to the nursing aid evenif I am sure that my reliever is coming though I amalready late for an important appointment.

8/6/2019 Final NRes

37/39

37

5. I refuse to do overtime when I am tired even if nobodyis available.

6. I am willing to accept gifts from the medicalrepresentative as long as I will not be required topatronize their products.

7. I can sell left over medicines of discharged patients toother patients provided it is at lesser cost.

8. I can give the medicine even though I thought the doseseemed high because it was clearly written by theattending physician and confirmed by the residentphysician.

9. I can do post mortem care even if there aresubordinates I can delicate.

10. It is not acceptable to commit occasionalmedication error in spite of the heavy workload.

11. I am willing to extend my duty hours because Iknow that my service is needed by my patient.12. I will not refuse when the supervisor assigns me

to other department where my service is needed evenif I am not trained to handle the said department.

13. There is a need to report error in oral medicationeven if it did not significantly harmed the patient.

14. There is no need to document errors in doingprocedures as long as the patient was not harmed.

15. Even if I am preoccupied carrying out thephysicians order, I can not delegate some oral

medications to my nursing aides.

Part IV. Adherence to Ethico-Legal Standards in Nursing

Practice.

Direction: Kindly answer the following by putting a check mark on the

column that corresponds to your answer. Please do not leave any items

unanswered.

ITEMS Adhere Do notadhere1. I do not report for duty in any white dress, if

prescribed uniform is not available.2. For clarification on my patients treatment, I

speak in his behalf to his attending physician.3. I secretly encourage over-staying patients who

cannot pay their hospital bills to leave the hospitalwithout the knowledge of the attending physician.

8/6/2019 Final NRes

38/39

38

4. When my patient refuses treatment, I leave themalone.

5. Upon approval of my visa, I will immediatelyresign from my job because I am afraid that myvisa might be revoked.

6. I do not discuss the affairs of my colleagueswithout their knowledge to my superior eventhough I care for them.

7. I do not discuss my patients ailment to otherpatients/ folks.

8. I give immediate attention to my clients whentheir condition demands for it regardless of theiraccommodation.

9. I do not change the documentation of my co-staffwhen they are wrongly documented in the

patients chart.10. I do not follow the procedure in givingmedication because I have already memorizedthe drug my patient is receiving for several days.

11. I do not insert nasogastric tube to thepatient even with doctors order.

12. I do not carry out verbal orders.13. I restrain restless and violent patient even

without the doctors order.14. I do not perform catheterization even when

the patient is unable to void and is in pain.

15. I update the patients waiver for DNR statusafter it has been signed.

8/6/2019 Final NRes

39/39

39