An international publication dealing with medicolegal...

An international publication dealing with medicolegal issues. Articles, court decisions, and legislation on:Medical law, forensic medicine, sexology and law, psychiatry and law, psychology and law, dentistry and law, nursing law, pharmaceutical law, medical ethics, clinical criminology, drugs, alcohol, child abuse, medical experimentation, genetic engineering, organ transplantation, abortion, contraception, sterilization, euthanasia, religion, AIDS, etc.

World Association for Medical Law

Manuscripts should be submitted to the Editorial Office:The International Center for Health, Law and Ethics, University of Haifa, Haifa 31905, IsraelE-Mail: [email protected] and Editor-in-Chief (1980-2010): Prof. Amnon CarmiEditor-in-Chief: Dr. Mohammed S. WattadEditor’s Executive Assistant: Ava Van DamEnglish Editor: Dorothy Fajans, Yehuda LevyLayout: Raul VergaraIndexing: Natali Goldring

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Editorial BoardAbu Ramadan, Dr. MoussaAdlan, Dr. AbdallahAguiar-Guevara, Prof. RafaelBal, Prof. SonnyBeran, Dr. RoyBerger, Dr. KenBeyleveld, Prof. DeryckBlum, Prof. JohnCook, Prof. RebeccaCotler, Prof. MiriamDangata, Prof. YohannaDantas, Prof. Eduardoden Exter, Dr. AndreDickens, Prof. BernardDoron, Dr. IsraelDubinsky, Dr. IsserDuMont, Prof. Janice

Dute, Prof. JosephDutra Dr. CaueEfron, Adv. YaelFerris, Prof. LorraineFimate, Prof. LallukhumFrenkel, Prof. DavidGevers, Prof. SjefHrevtsova, Dr. RadmilaKassim, Dr. Puteri N. J.Kegley, Prof. JacquelynKeidar, Assoc. Prof. Daniella Khalaila, Dr. RabeiLe Blang, Prof. TheodoreLevy, Ms. SharonLupton, Prof. MichaelMartens, Dr. WillemMester, Prof. Roberto

Nissim, Dr. SaraNoguchi, Prof. ThomasPiga, Prof. AntonioRudnick Dr. AbrahamShalata, Dr. AbedSlovenko, Prof. RalphStrous, Prof. RaelTabak, Prof. NiliTalib, Prof. NorchayaVan Wyk, Prof. ChristaVergallo, Asst. Prof. Gianluca MontanariWilbur, Dr. RichardWolfman, Dr. SamuelWood, Dr. DavidZaremski, Mr. Miles

Vice PresidentsBerna Arda (Turkey)Kenneth Berger (Canada)Eduardo Dantas (Brazil)Muh Nasser (Indonesia) Chongqi Wu (China)

Berna Arda (Turkey)Oren Asman (Israel) Roy G. Beran (Australia)Kenneth Berger (Canada)David Collins (New Zealand)Eduardo Dantas (Brazil)Sanjin Dekovic (Bosnia and Herzegovina)Anne-Marie Duguet (France)Terhi Hermanson (Finland)

R. Dierkens WAML Medalion (2002)Hon Secretary General and Founder (2004)

Koichi BaiWAML Medalion (2006)

Arthur LewisHonorary Governor (2004)

Kali Sonderland Honorary Governor (2004)

Antonio PigaHonorary Governor (2006)

Jose Pinto De Costa Honorary Governor (2006)

Amnon Carmi Honorary President (2010)

Bernard DickensHonorary Vice President (2010)

Radmyla Hrevtsova (Ukraine)Mitsuyasu Kurosu (Japan)Vugar Mammadov (Azerbaijan)Muh Nasser (Indonesia)Thomas T. Noguchi (United States)Andre G. Dias Pereira (Portugal)Yuriy Sergeyev (Russian Federation)Chongqi Wu (China)

Executive CommitteeOren Asman (Israel)Roy G. Beran (Australia)Thomas T. Noguchi (United States)Andre G. Dias Pereira (Portugal)

WORLD ASSOCIATION FOR MEDICAL LAWBoard of Governors

PresidentThomas T. Noguchi (United States)

Executive Vice PresidentOren Asman (Israel)

Secretary GeneralRoy G. Beran (Australia)

TreasurerAndre G. Dias Pereira (Portugal)

Board of Governors

Members of Honor

Ethics: Submission of a manuscript for publication in this Journal confirms that all standard ethics procedures were conducted; such as but not restricted to, voluntary informed consent of research participants when applicable and approval of the responsible Research Ethics Board(s).

Medicine and Law Dr. Rabia Khalaila 1 Message from the Guest Editor

Ilya Kagan et al 5 Sexual Harassment by Patients: The Difference Experience of Female Doctors, Nurses and Nurse Aides

Oya Ogenler et al 21 The Options of Hospitalized Patients about Exposed Discrimination based on Hospitals or Health Personnel

Şükran Sevimli, et al 39 Health Professionals of Emergency Service: An Evaluation of Disaster Medicine and Ethical Values

Amira Daher et al 55 Adoption Law, Dilemmas, Attitudes and Barriers to Adoption among Infertility Patients in Israel

Salam Hadid and Mohammad Khatib 69 The Public’s Perception of the Status and Image of the Nursing Profession

Rabia Khalaila 91 Academic Dishonesty among Nursing College Students: Attitudes, Perceptions and Dishonest Activities

LIST OF CONTENTS

THEME ISSUE

VOLUME 34 NUMBER 1

I

Isabel Amélia Costa Mendes et al 109 Research Ethics Committees’ Analysis of Nursing Projects in Brazil

Tal Ilsar 121 Differences in the Interpretation of “DNR” among Physicians and Nurses on Internal Medicine Wards

Dorit Rubinstein 135 “End-of-Life” Decisions: DNR vs. AND

Rabia Khalaila and Zipi Avraham 177 Family Presence During Resuscitation: Professional Considerations and Ethical Issues

Index ?

LIST OF CONTENTS (Continued)

II

Medicine and Law

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Health Law (2014) 33:1-2


Medicine and Law

MESSAgE FROM THE gUEST EDITOR

I am very pleased to present the present issue of Medicine and Law, a special issue on nursing, ethics and the law, with original research and review articles on nursing practice, education and research.

Dr. Ilya Kagan and Prof. Nili Tabak and colleagues’ article engages the major issue of sexual harassment by patients. The aim of their article is to investigate the incidence of sexual harassment of women staff by male hospital patients, and how the experience of harassment differs between doctors, nurses and nurse aides. They found that sexual harassment by male patients is common in the sample, while findings point to the need for radical treatment of this problem and enacting proper legislation on patient rights, which would also deter patients from aggressive sexual acts against their care providers.

The article by Oya Ogenler, Gulcin Yapici, and Nursel Bilgin examines “The Opinions of Hospitalized Patients about Exposed Discrimination Based on Hospitals or Health Personnel in Turkey.” The authors found that patients are negatively affected by the hospital’s infrastructure physical characteristics and are uncomfortable with some negative attitudes expressed by the healthcare staff. Conclusions indicate how necessary it is to increase ethics education and sensitivity training for the healthcare staff, to reinforce existing positive properties and remove any age, gender, race and education related negative aspects.

Another research from Turkey by Şükran Sevimli, Recep Dursun, and Sevdegul Karadas, explores the health professionals’ opinions who work in the emergency medical services in Turkey about the application of basic attitudes like triage, ethics, legal rules to popularize problems experienced during healthcare delivery following natural disasters (such as earthquakes). Results show that triage and legal regulations play an essential role in resource allocation and medical service presentation, while ethical principles are less considered in medical services after natural disasters. Their results suggest including ethical training in medicine and nursing education during natural disasters.

A different topic is addressed by Amira Daher, Yaakov Rosenfeld, and Lital Keinan-Boker, who have researched “Adoption Law, Dilemmas, Attitudes and Barriers to Adoption among Infertility Patients in Israel.” Findings show that the percentage of Muslim couples who adopt or contact adoption authorities in Israel is lower than among Jewish adoptive parents. The major conclusion is that certain contradictions between the religious laws of Islam and laws of the

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land constitute a certain barrier to adoption among Muslim couples receiving fertility treatment over an extended period of time.

The article by Dr. Salam Hadid and Dr. Mohammad Khatib discusses “The Public’s Perception of the Status and Image of the Nursing Profession.” Their study examines the existing knowledge among the general population regarding the nursing profession. The results show that the existing knowledge among the general public regarding the nursing profession is flawed and lacking. Most consider it a care profession based mainly on the performance of skilled and basic techniques. They suggest different steps that should be taken to improve the image of the roles of registered nurses on several levels and on various fronts, such as by distinguishing it from “nursing care,” which is a general concept; the academization of nurses; and the proposed Nurse’s Law, which would make nurses into more independent professionals.

Dr. Rabia Khalaila’s article engages in an important issue in nursing education: academic dishonesty. The worrying results show that academic dishonesty is prevalent among undergraduate nursing students in this Israeli sample. This issue should be of very high concern for nursing educators, and the thought that students do not consider copying, cheating, or plagiarism unethical behavior is a source of profound disquiet. The author suggests that early socialization into the profession of nursing, such as values of nursing practice, ethics of caring, integrity, respect, and responsibility, are critical components of nursing education and a responsibility of all nurse educators.

Isabel Amélia Costa Mendes and her coauthors from Brazil present an “Analysis of Research Ethics Committees of Nursing Projects in Brazil.” This research presents a general view of nurses and the nursing profession’s demand for research ethics committees in nursing institutions. The results demonstrate that nurse researchers in Brazil increasingly submit their projects to Research Ethics Committees for evaluation. The study reveals the importance nursing attributes to the ethical analysis of projects involving human beings, in compliance with the principles of respect for human dignity that support this science and its practice.

Tal Ilsar discusses the definition of DNR (Do Not Resuscitate) held by the medical and nursing staff in Internal Medicine wards in a leading hospital in Israel. Findings show a lack of uniformity in various staff members’ understanding of the concept, and which nursing procedures may be performed and which should not. Consequently, she proposes structuring a uniform protocol and guidelines for all health professionals referring to DNR.

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In addition to the research articles, the Special Issue proposes two surveys of the literature clinical spheres associated with end-of-life issues. The first is Dr. Dorit Rubinstein’s article on the meanings and differences between “End-of- Life” options including euthanasia, DNR (Do Not Resuscitate), and AND (Allowing Natural Death), and the implications of these decisions on the nurses’ role.

A second article by Dr. Rabia Khalaila with Dr. Zipi Avraham discusses ethical and professional considerations for patient family presence during resuscitation (FPDR). The literature shows an increasing worldwide trend of allowing close family members to be present during resuscitation of their loved one, according to the wishes of the patients and their families, but at present is far from being implemented in Israel because of various ethical, cultural and professional issues discussed in the article.

I sincerely hope, and firmly believe, that the current issue will contribute to the discourse and stimulate further discussion of the issues among the general public, nursing professionals and policymakers.

The wide variety of articles in this Special Issue reflects the broad spectrum of mutual relations between the world of law and ethics and the nursing profession.

I wish to take this opportunity to extend deepest thanks to Dr. Mohammed S. Wattad, Editor-in-Chief, and to Ava Van Dam, Executive Assistant to the Editor, Medicine and Law, for their devoted labors and continued support for producing this Special Issue. Thanks, as well, to all authors and coauthors, from Israel and abroad, for their efforts and willingness to publish their research as part of this Special Issue.

Rabia Khalaila, PhD, RNDirector, Nursing DepartmentZefat Academic College,Zefat, [email protected]

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Medicine and Law

SEXUAL HARASSMENT BY PATIENTS: THE DIFFERENCE EXPERIENCE OF FEMALE DOCTORS, NURSES AND NURSE AIDES

Ilya Kagan RN PhD* , Tami gaash RN MA ** , Sasha grigorash RN B***, Michal Sela RN BA****, Yaffa Maximov RN MA*****, Shosh Cohen******, Prof. Nili Tabak RN PhD LL.B*******

Abstract: Study Aim: To examine the incidence of sexual harassment of women staff by male hospital patients, and how experiencing it differs between doctors, nurses and nurse aides.

Methods: 434 women staff in three large Israeli hospitals completed an anonymous self-administered questionnaire on (a) the frequency of sexual harassment by patients, (b) the emotional effect of a described instance of harassment, (c) what action respondents would take if confronted by the same incident.

* Lecturer, Nursing Department, Steyer School of Health Professions, Sackler School of Medicine, Tel Aviv University, Israel; Quality & Patient Safety Coordinator, Nursing Administration, Rabin Medical Center, Clalit Health Services, Israel. E-mail: [email protected]

** Nursing Supervisor, Hasharon Hospital, Rabin Medical Center, Clalit Health Services, Israel. E-mail: [email protected]

*** Surgical Department A, Beilinson Hospital, Rabin Medical Center, Clalit Health Services, Israel. E-mail: [email protected]

**** Internal Medicine Department ‘Vav’, Beilinson Hospital, Rabin Medical Center, Clalit Health Services, Israel. E-mail: [email protected]

***** Deputy Nurse Manager, Otolaryngology Department, Hasharon Hospital, Rabin Medical Center, Clalit Health Services, Israel. E-mail: [email protected]

****** Nursing Administration, Beit Rivka Geriatric Medical Center, Clalit Health Services, Israel. E-mail: [email protected]

******* Director, Steyer School of Health Professions, Sackler School of Medicine, Tel Aviv University, Tel Aviv, 69978, Israel. E-mail: [email protected]

Health Law (2015) 34:5-20

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Results: Sexual harassment by male patients is common, ranges from mild innuendo to threats of rape, and creates great emotional distress. The younger the staff the more the harassment. Women doctors—the youngest staff group—were beset more than nurses and nurse aides and voiced the most negative emotional and behavioral reactions.

Conclusions: The Israeli healthcare system is unprepared to deal with the phenomenon. Five measures are recommended as a minimum response.

Keywords: Sexual Harassment; Hospital Patients; Healthcare Providers; Women.

BACKGROuNDSexual harassment in the workplace has severe impacts on the worker’s mood, wellbeing and performance. Absenteeism and even quitting the job are further outcomes. In hospitals harassment impacts on staff-patient relations. It is worse when aggravated by signs of contempt or a wish to humiliate or exploit, particularly of new young staff who may hesitate to complain out of fearing the consequences on their employment. It can even hurt a nurse’s physical and mental health (Finnis, Robbis & Bender, 1993).

Yet, despite widespread discussion of the sexual harassment of female staff by male colleagues at work, the issue of sexual harassment by patients and their family members has received little coverage and research, both in Israel and elsewhere. The subject seems to be ‘taboo’ among researchers of inpatient behavior. Yet, on the ward, in the experience of the authors of the present study the problem raises its head every few months in the wake of some distressing incident of verbal or physical sexual harassment by a patient or relative. And the harrassed’s discomfort is added to by the fact that hospital norms and regulations give her little help (Hibino, Hitomi, Kambayashi & Nakamura, 2009).

Just as patients have every right to expect the staff to treat them correctly and with consideration for their dignity, so does staff have similar rights. That should be the unspoken consensus, yet no such consensus seems to operate in practice. Take for instance: S., a 63-year-old man with severe diabetes, father of three and grandfather of six, a double amputee confined to a wheel-chair. In the three months after his admission to a geriatric nursing home he became notorious for the lewd and crude way he would talk to female staff and where

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he would put his hands when taken to be showered. Threats that if he persisted he would not be showered and that his family would be called in had no effect and eventually the family members were asked to remove him.

Madison and Minichiello (2004) have defined sexual harassment as unwanted remarks, jokes, touching and invitations to sexual activity. Bronner et al. (2003) define it as sexual acts, which insult and disturb a staffer’s work. DeMayo (1997) reports a survey of 750 female psychotherapists who stated their determination to root out sexual harassment from their work, saying that it had become a significant nuisance, which threatened the balance of power between therapist and patient. Philips and Schneider (1993) report that, of a 599-strong sample of female hospital doctors, no less than 75% had suffered sexual harassment from patients at some time. Frank (1998) reported that 37% of her sample of younger female doctors had suffered sexual harassment. Harassment was also frequent when they received patients in a private consulting room. In a multi-staff clinic, or emergency room, the hazard was much less. Naturally, the more frequent and the more severe the harassment, the more disturbing women doctors found it. The overall conclusion was that it was sufficiently frequent to merit a place in the medical school curriculum.

Most of the published studies on the issue have investigated both the nature of the harassment and the staffers’ response. For instance, Hibino, Ogino and Inagaki (2006), who surveyed a sample of 473 hospital nurses in Japan, found that 55% had suffered from sexual harassment at varying degrees, some severe. In most cases, they remained passive and did not take any firm physical steps to halt the behavior. In the UK, Ferns and Meerrabeau (2008) reported a high degree of verbal and physical sexual harassment of student nurses by patients, family members and visitors during the nurses’ practical experience sessions. Though Bronner et al.’s 2003 study found that the rate of sexual harassment of nurses and student nurses was rising and that they were trying to confront it by more defensive and assertive conduct, many found it hard to respond assertively.

In Israel, the few reports on sexual harassment by patients confine themselves to assessing the character and frequency of harassment only among nurses, without going into its outcome in the staff’s emotional and behavioral response.

The aim of this study was to examine the incidence and characteristics of harassing sexual behavior by patients and their relatives towards female doctors, nurses and nurse aides, and its emotional and behavioral impact on them.

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Methods

Sample

411 female nurse aides, nurses and doctors working in medical, surgical and geriatric wards in three hospitals in central Israel, participated in the study (42% in Beilinson Hospital, 40% in Hasharon Hospital and 18% in Beit Rivka Geriatric Medical Center). 30% worked in general surgical departments, 31% in internal medicine departments, 18% in geriatric departments and the rest in medical-surgical or geriatric rehabilitation units. Average age was 44 (SD=11.72; range 21-64). Average period of employment in healthcare was 16.85 years (SD=11.21). Doctors were, overall, younger than nurses and nurse aides and had correspondingly less seniority (see Table 1). 64% of the sample were Israeli-born, 26% had emigrated from the former USSR. 75% worked full-time. Additional socio-demographic characteristics of the sample are given in Table 2.

Procedure

The Helsinki Committee (Ethics Board) of Rabin Medical Center authorized the study, validating all three hospitals. Staff members voluntarily agreed to participate in the study with no inducements offered. The study was supported by a grant from the Keisariya Fund in partnership with the Rabin Medical Center’s Research Council.

Before collecting the data, a pilot study was conducted (N=30) to evaluate the data-collection procedure and respondents’ understanding of the questionnaire. Some items were altered in the light of comments received. The researchers distributed the final questionnaires together with a letter explaining the aim of the study and guaranteeing the respondent’s anonymity and data confidentiality. In all, 521 female staff in the selected departments of the three hospitals received a questionnaire and the overall response rate was 78.9% (73.7%, 85.5% and 75.4% in Beit Rivka, Hasharon and Beilinson hospitals, respectively). The return of the completed questionnaire was construed as consent to participate. The questionnaire took about 15 minutes to complete.

Tools

The structured self-administered questionnaire constructed by the authors comprised four sections which measured (a) the incidence and characteristics of female healthcare workers’ (HCWs) exposure to sexual harassment by

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patients, (b) the emotional effect of a described instance of harassment on the HCWs, (c) the behavioral response the HCWs anticipated from themselves to the same hypothetical instance of harassment and (d) the respondent’s socio-demographic data. To develop the tool, the authors set up a multidisciplinary focus group, consisting of five senior nurses, two doctors and one senior ethics expert. The group was asked to define the domains pertinent to sexual harassment by patients and to set out the possible emotional and behavioral reactions of female staff to these behaviors. 56 items addressing the three study domains (incidence of sexual harassment, nurses’ emotional reactions and behavioral responses) were identified. All eight members of the focus group reviewed the questionnaire for face validity, feasibility and comprehensibility and had to be in full agreement for any item to be included. For avoidance of any misunderstanding in discussing the issue of coping with harassment by mentally ill, unconscious and confused patients, it was decided to focus the study on the sexual harassment by conscious patients. Their comments were incorporated into the construction of the final questionnaire, which was pilot-tested among 35 female HCWs working at a different hospital.

The variable Incidence of HCWs’ exposure to sexual harassment by patients was measured by a 13-item section (see Table 3), whose items escalated from verbal harassment through physical contact of a sexual nature, to proposals of intimate relationships and threats of rape. Respondents were asked to reply to each item on a Likert scale of 1 (Never) to 6 (Several times a day). The overall score was represented by the mean. The Cronbach alpha score for this section of the questionnaire was .92.

The variable Emotional response to the patients’ sexual harassment was measured by a 15-item section (see Table 4), which was preceded by a short account on a sexual harassment by a patient: ‘A fully conscious 65-year-old inpatient sexually touches a female HCW’s intimate body parts. The patient has been in hospital for two weeks due to exacerbation of his chronic illness and is due to be discharged in two days.’ Respondents were asked to describe the intensity of their emotions and feelings in response to the narrative, the questionnaire items ranging through positive and negative emotions, such as anger, helplessness, encouragement, frustration, embarrassment, happiness, professional satisfaction, pleasure, disgust, guilt and fear. They rated their response to each item on a scale from 1 (Not at all) to 6 (Very much). The overall score was represented by the mean. The Cronbach alpha score for this section of the questionnaire was .81.

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The variable Behavioral response to the patients’ sexual harassment was measured by a 15-item section (see Table 5). With respect to the same narrative described above, respondents were asked to describe the behavioral response they anticipated from themselves. The possible reactions they were offered ranged from ignoring the abusive act to much more forceful and active reactions. Respondents had to rate each possibility on a scale from 1 (Not at all) to 6 (Very much). The overall score was represented by the mean. The Cronbach alpha score for this section of the questionnaire was .75.

Respondent socio-demographic data were collected on 11 items including gender, age, work experience (seniority), religion, religiosity, place of birth, managerial position, place of work, whether they had attended a training course on sexuality in illness, and hours of work.

Data analysis

Descriptive statistics were used to analyze the nurses’ socio-demographic data and describe the study variables. Factor analysis was performed by the Principal Axis Factoring Method (Oblimin Rotation), which explained 45.5-54.9% of the variance. This resulted in an accepted rule of thumb (Pett et al., 2003) rates as ‘practically significant’. Pearson correlation coefficients were used to test relationships between variables, and t-tests were used to compare group means. Multiple regression analysis was used to measure the unique contribution of independent variables to dependent variables. The level of significance employed throughout was 0.05. The data analysis package was SPSS 21.0.

Imputing socio-demographic data: 434 of the distributed questionnaires were returned. Some of the socio-demographic items were not completed by 4-8 respondents, but no respondent failed to answer all of these items. In these cases we deployed Stochastic Regression Imputation (Enders, 2010) to impute that a failure to fill in certain items (but not all items) meant that the answer was ‘No’ or ‘Not applicable’. (Where the respondent’s answer is missing, Stochastic Regression Imputation uses a regression model to impute an expected value by extrapolation and the spread of values around the regression line. It is assumed that the dependent variable is a normally distributed function of a linear combination of predictor variables) yi~N(xiβ, Iσ2) when i=1,2,..,411 ((Enders, 2010). With regard to analyses for which this was a requisite datum, only those respondents who did not state their ‘Professional Status’ were removed from the sample. 16 respondents answered less than half the questions, a further six did not answer the Emotional Reaction items, and

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one missed all the Exposure to Sexual Remarks items. Stochastic Regression Imputation was again used to impute answers to the Exposure and Behavioral Reaction items but not to the Emotional Reaction items.

Results

One-way ANOVA on age and seniority in healthcare (see Table 1) found statistically significant differences in age and seniority by professional status (F = 11.66, p<, 001: F =22.32, p<, 001). Practical nurses were the oldest professional status group and had the longest seniority while female doctors were the youngest. No significant differences were found in ‘training in sexuality in illness’ by professional status (x2 = 6.39, p = .094). Some 80% of registered nurses and about 60% of practical nurses had not received such training.

Exposure to sexual harassment by patients (Table 3): Factor analysis was used to group examples of sexual harassment into three main categories: Sexual Remarks, Unwanted Sexual Contact, and Indecent Advances, which also represent an ascending order of importunity. Table 3 shows that more than half the respondents had been the object of sexual remarks, with doctors and registered nurses being the most frequent sufferers. The doctors also reported more Crude Comments and Unwanted Sexual Attention than the other professional groups. The more severe manifestations of sexual harassment were less frequent, mostly ranging from 10-15% of respondents, but Attempts to Start Romantic/ Sexual Relations were markedly more frequent, at over 20% for registered nurses and nurse aides and climbing to 37% for female physicians. Indeed, ANOVA found that, overall; doctors were harassed significantly more than any other professional groups.

Emotional response to hypothetical cases of sexual harassment by patients (Table 4): Factor analysis generated the following three factors:

• Revulsion (items 1, 4, 5, 8, 14) with a Cronbach alpha reliability score of .82, a mean of 2.81, SD=1.11.

• Attraction (items 3, 6, 10, 11, 15) with a Cronbach alpha reliability score of 0.78, a mean of 0.12, SD=0.44.

• Anxiety (items 2, 7, 9, 12, 13) with a Cronbach alpha reliability score of 0.75, a mean of 1.41, SD=1.09.

It should be emphasized that 100% of the physicians said that their emotional response was one of anger and 97% - one of disgust. Similar high percentages

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were the case with registered nurses but the frequency was somewhat lower among practical nurses and nurse aides. By contrast, very small percentages, mostly less than 5%, uniformly across all professional groups, reported any sort of positive response. The doctors stand out: not a single one admitted to a positive response. Whereas the “Revulsion” scores were significantly different from professional group to professional group on all items, the only significant between-group differences on the Attraction and Anxiety variables were found on the Happiness and Threat items. Bonferroni post hoc tests indicated wide gaps on Revulsion scores between registered nurses and nurse aides and also between doctors and nurse aides. Similar differences were found on the Attraction items but not on the Anxiety items. One-way ANOVA found a significant difference in the frequency of feelings of Revulsion and Attraction (F=7.83, p<.001; F=4.57, p=.004, respectively) across all professional groups but no such differences with respect to Anxiety scores (F=0.33, p=.801).

Behavioral response to hypothetical cases of sexual harassment by patients (Table 5): Factor analysis generated two factors:

• Balanced behavioral response, in which the respondent, while deploring the patient’s behavior, wanted to maintain personal interaction with him (Cronbach alpha reliability score = .77).

• Extreme behavioral response, characterized by a wish to end and to avoid any further personal interaction with the patient (Cronbach alpha reliability score = .73).

Only few statistically significant or important differences were found between the professional groups’ anticipated behavioral response to sexual harassment by a patient.

Association between variables: The Pearson correlations between the study variables for the whole sample are shown in Table 6. As shown, the higher the emotional burden related to sexual harassment was, the more extreme an active reaction and response was expected.

Discussion and Conclusions

The first thing to say is that this study has established the frequency and emotional sensitivity of the problem in Israeli hospitals. The sexual harassment of female staff by male patients is very common, creates great emotional distress and behavioral reactions that are difficult for caregivers. This confirms Schneider and Philips’ (1993) findings in Canada and DeMayo in (1997) and

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Hibino, Ogino and Inagaki’s (2006) in Japan. The present study finds that female HCWs are exposed to every form of sexual harassment from mild insinuation to threats of rape. It expands on previous studies by comparing the severity of the problem as between different professional status groups and age/seniority groups. While it is not surprising that the younger the HCW, the more harassment she has to face, it is more surprising that women doctors, who are also the youngest professional group, are beset more than nurses and nurse aides. Perhaps their combination of high status, gender and relative youthfulness is taken by some male patients as a particular challenge. Doctors, too, were the most negatively emotional in their reactions to a description of sexual harassment and the most vehement in their demand that their hypothetical contact with the harasser be halted at once, either by his being removed and/or punished or by other means (although registered nurses were not far behind them on this issue).

Another finding is that both beforehand and afterwards, the system, at least in Israel and we suspect elsewhere too, is rather unprepared to deal with the phenomenon. Few staff have been given proper guidance and training on how to prepare themselves and the administrative procedures and norms are not sufficiently firmly in place to support women staff once an ‘assault’ has occurred. The wide variances in possible behavioral responses among all three professional groups are to support the confusion and ambiguity among HCWs due to the absence of policy and guidance how to respond and to cope at work with the sexual harassment by patients. From the authors’ own experience and the senior experts consulted for this study, the following steps are recommended as a minimum response to the problem:

1. Permissible patient behavior should be codified. Patients should be allowed no leniency to importune or insult staff.

2. When conducting a physical examination of a male patient a female doctor should have a nurse alongside her.

3. The patient should, beforehand, receive an explanation as to what sort of examination is to be performed.

4. Unacceptable patient behavior should be reported immediately to the staffers’ superiors.

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5. All incidents of sexual harassment should be documented and discussed in real time so that evidence is available for any judicial procedure.

6. To formulate, both at the national and at the hospital’s levels, a policy to deal with sexual harassment by patients.

References

Brogan, F.E. & Schiffman, M. (1998). Prevalence and correlates of harassment among US women doctors. Archives of Internal Medicine, 158, 352-358.

Bronner, G., Peretz, C., & Ehrenfeld, M. (2003). Sexual harassment of nurses and nursing students. Journal of Advanced Nursing, 42(6), 637-644.

Cook, D.J., Liutkus, J.F, Risdon, C.L., Griffith, L.E., Gordon, G.H & Walter, S.D. (1996). Residents’ experience of abuse, discrimination, and sexual harassment during residency training. Journal of the Canadian Medical Association, 154(11), 1657-1665.

DeMayo, R.A. (1997). Patient sexual behavior and sexual harassment: A national survey of female psychologists. Professional Psychology, 28(1), 58-62.

Enders, C.K. (2010). Applied Missing Data Analysis, The Guilford Press, New York, NY.

Ferns, T. & Meerrabeau, L. (2008). Verbal abuse experienced by nursing students. Journal of Advanced Nursing, 61(4), 436–444.

Finnis, S.J., Robbins, I., & Bender, M. (1993). A pilot study of the prevalence and psychological sequelae of sexual harassment of nursing staff. Journal of Clinical Nursing, 2, 23-27.

Hibino, Y., Hitomi, Y., Kambayashi, Y., & Nakamura, H. (2009). Exploring factors associated with the incidence of sexual harassment of hospital nurses by patients. Journal of Nursing Scholarship, 41(2), 124-131.

Hibino, Y., Ogino, K., & Inagaki, M. (2006) Sexual harassment of female nurses by patients in Japan. Journal of Nursing Scholarship, 38(4), 400-405.

Madison, J., & Minichiello, V. (2004). The contextual issues associated with sexual harassment experiences reported by registered nurses [online]. Australian Journal of Advanced Nursing, 22(2), 8-13.

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Pett, M. A., Lackey, N. R., & Sullivan, J. J. (2003). Making sense of factor analysis: the use of factor analysis for instrument development in care research. Sage Publications, London.

Phillips, S.P., & Schneider, M.S. (1993). Sexual harassment of female doctors by patients. New England Journal of Medicine, 329(26), 1936-1939.

Robbins, I., Bener, M., & Finnis S.J. (1997). Sexual Harassment in nursing. Journal of Advanced Nursing, 25, 163-169.

Table 1. Study sample by professional status, age and seniority: Two-way ANOVA (n=396)

(%)

All MD RN PN NA

N 396 35 245 34 82 P µ2 F

Age M 44.09 37.89 43.18 52.91 45.82

SD 11.72 8.65 11.90 8.02 11.41 <.001 .08 11.66

Seniority M 16.85 8.84 17.50 27.85 13.78 <.001 .15 22.32

SD 11.21 8.58 11.47 8.51 8.15

MD – medical doctor/physician RN - Registered nurse PN - Practical Nurse NA - Nurse Aide

16 Medicine and Law

Table 2. Study sample by professional status and socio-demographic characteristics: χ2 analysis (in %)

Variable NAll MD RN PN NA

P χ2 Df396 35 245 34 82

Religion

Jewish 81.9 94.1 77.6 90.6 86.2

.046 17.25 9Muslim 14.0 2.9 18.3 3.1 10.0

Christian 2.6 - 2.1 6.3 3.8

Other 1.6 2.9 2.1 - -

Religious practice

Religious 18.9 14.3 19.2 17.6 20.7

.009 17.10 6Traditional 35.6 22.9 33.1 29.4 51.2

Secular 45.5 62.9 47.8 52.9 28.0

Marital Status

Single 15.5 31.4 17.6 2.9 7.4

.005 28.59 12

Married 72.9 60.0 73.9 73.5 75.3

Divorced 7.7 5.7 5.5 20.6 9.9

Widowed 2.3 2.9 1.7 2.9 3.7

Other 1.5 - 1.3 - 3.7

Hours of work

100% 75.0 91.4 73.1 64.7 78.0

077 15.57 970% 18.7 2.9 19.6 23.5 20.7

50% 5.3 5.7 6.1 11.8 -

25% 1.0 - 1.2 - 1.2

Place of Birth

Israel 63.6 68.6 62.3 58.1 67.5

.406 6.15 6USSR 26.4 25.7 28.0 35.5 18.2

Other 10.0 5.7 9.7 6.5 14.3

Managerial Position

Yes 18.4 5.7 26.5 - 7.3<.001 28.87 3

No 81.6 94.3 73.5 100 92.7

Trained on sexuality in Illness

Yes 22.0 17.1 21.6 38.2 18.3.094 6.39 3

No 78.0 82.9 78.4 61.8 81.7

MD – medical doctor/physician RN - Registered nurse PN - Practical Nurse NA - Nurse Aide

17Medicine and Law

Table 3. Exposure to sexual harassment by patients, by professional status (n=411) (%)

Sexual Remarks All MD RN PN NA Df X2 P

Mild remarks 54.5 68.0 62.0 32.4 35.4 3 27.25 001.>

Innuendo, crude jokes 55.1 65.7 62.4 23.5 41.5 3 26.80 001.>

Crude remarks 30.8 42.9 30.6 23.5 29.3 3 3.32 344.

Unwanted sexual attention 35.9 65.7 38.8 14.7 23.2 3 26.82 001.>

Discomforting touch 38.4 45.7 44.5 26.5 22.0 3 16.06 001.

Using instruments for innuendo 13.4 11.4 13.9 5.9 15.9 3 2.25 522.

Unwanted Sexual Contact

Touched in intimate parts 7.6 2.9 7.8 2.9 11.0 3 3.52 318.

Rape threat 1.5 0 1.2 0.0 3.7 3 3.73 293.

Unwanted stroking, cuddling 15.2 8.6 15.1 14.7 18.3 3 1.81 612.

Unwanted kiss 12.1 17.1 12.2 8.8 11.0 3 1.28 734.

Sexual touch 13.1 14.3 13.9 2.9 14.6 3 3.42 332.

Indecent Advances

Proposed sexual relations 10.4 17.1 10.2 2.9 11.0 3 3.79 285.

Attempt to start romantic/ sexual relations 23.5 37.1 24.9 5.9 20.7 3 10.11 018.

18 Medicine and Law

Table 4. Emotional response to hypothetical case of sexual harassment by patient (%)

All MD RN PN NA Df X2 P

N 396 35 245 34 82

Revulsion

Repulsion 83.2 90.6 85.8 82.4 71.8 3,363 8.97 030.

Anger 93.5 100 97.9 82.4 82.7 3,387 32.59 <.001

Disgust 86.1 97.0 89.8 79.4 73.1 3,380 18.20 <.001

Embarrassment 88.1 100 91.5 79.4 76.3 3,377 19.36 <.001

Frustration 67.8 90.6 67.4 71.0 57.9 3,369 11.20 011.

Attraction

Happiness 3.8 0.0 2.2 5.9 9.3 3,370 9.64 022.

Envy 3.8 0.0 3.5 5.9 5.6 3,365 2.38 497.

Professional satisfaction 5.5 0.0 4.9 9.1 8.5 3,363 4.10 251.

Pleasure 3.0 0.0 2.2 5.9 5.4 3,369 3.98 264.

Encouragement 8.1 0.0 7.2 6.5 14.9 3,359 7.67 053.

Anxiety

Fear 51.1 67.6 51.3 36.4 49.4 3,376 6.69 082.

Threat 52.9 82.4 55.2 40.6 38.2 3,374 20.88 <.001

Guilt 18.4 27.3 15.3 21.9 22.5 3,365 4.29 232.

Shame 71.8 66.7 73.0 74.2 69.2 3,372 0.95 814.

Helplessness 66.6 80.6 68.0 63.6 57.9 3,365 5.67 129.

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Table 5. Behavioral response to hypothetical case of sexual harassment by patient (%)

All MD RN PN NA Df X2 P

N 396 35 245 34 82

Extreme behavioral response

Try to get patient removed from ward 32.3 45.7 32.2 34.0 28.0 3 3.69 297.

Make police complaint 34.8 40.0 39.2 26.5 23.2 3 8.41 038.

Remove the patient from female patients 67.4 71.4 69.4 29.4 63.4 3 2.43 488.

Slap his face 15.9 14.3 17.6 26.5 13.4 3 1.38 710.

Give drugs to reduce his libido 17.4 11.4 16.3. 58.8 20.7 3 2.58 460.

Try to avoid all care contact with him

76.0 80.0 80.0 11.8 64.6 3 8.81 032.

Talk to family to reprimand them

40.9 34.3 45.3 23.5 35.4 3 5.50 139.

Have him put in bed restraints

15.4 20.0 12.2 70.6 24.4 3 7.87 049.

Balanced behavioral response

Tell him off 90.7 97.1 91.0 29.4 90.2 3 4.56 207.

Put a quick firm stop to it 93.7 100 94.3 11.8 91.5 3 4.90 179.

Raise it at staff meeting 83.3 80.0 83.7 84.8 86.6 3 2.08 556.

Warn other staff of the danger 92.7 91.4 93.9 88.2 91.5 3 1.77 622.

Complain to my superiors 84.8 88.6 83.7 76.5 90.2 3 4.35 226.

Ignore it 34.6 34.3 29.0 88.2 52.4 3 15.03 002.

20 Medicine and Law

Table 6. Pearson Correlation matrix for study variables (N=411)

Sexual remarks

Unwanted touching

Indecent proposals Revulsion Attraction Anxiety


Exposure to sexual remarks

-

Unwanted touching **33. -

Indecent proposals **24. **25. -

Revulsion 08. 03. 004. -

Attraction 004. *14. 05. **15.- -

Anxiety 10. 10. 02. **39. *12. -


06. *10. *10. **32. 09. **36. -

Balanced behavioral response

04.- 06.- 002. **45. **17.- **19. **37.

* - p<.05; ** for p<.01

21


Medicine and Law

THE OPINIONS OF HOSPITALIZED PATIENTS ABOUT EXPOSED DISCRIMINATION BASED ON HOSPITALS OR HEALTH PERSONNEL

Oya Ogenler*, gulcin Yapici**, and Nursel Bilgin***

Abstract:

Objective: The aim of this paper is to determine whether age discrimination exists for hospitalized patients.

Methods: This study was conducted on 298 hospitalized patients at the Mersin University Medical Faculty Hospital in Mersin, Turkey, in May 2012. The questionnaire consisted of 8 questions trying to determine patients’ socio-demographic attitudes and consisted of 22 items prepared by the authors.

Results: It was determined that 54.9% of the patients included in the study were male, 73.3% of them were married, 80.9% were subject to the social security system. A total of 87 participants reported that the physical conditions of the hospital were not appropriate. Approximately half of the patients mentioned that health care personnel explained what needed to be done to their relatives instead of the patients themselves.

Conclusion: Patients were negatively affected by the physical characteristics of the hospital and were uncomfortable with some negative attitudes of the health staff.

Keywords: Age Discrimination; Medical Ethics; Hospitalized Patients; Human Rights; Equitableness.

* Mersin University Medical Faculty, Department of History of Medicine and Ethics** Mersin University Medical Faculty, Department of Public Health*** Mersin University Medical Faculty, Department of Forensic Medicine

Health Law (2015) 34:21-38

22 Medicine and Law

IntroductionOne of the most important human rights is the right to health. Obtaining this basic right and basic health services is everyone’s right.1 Inequalities in any society affect the right to health. The factors that create inequality in life quality such as illnesses, different characteristics or disabilities can prevent access to medical services.2

Provision of appropriate health services to patients and distribution of equal medical services among patients are possible only when ethical issues are taken into consideration.3,4

Women, children, the elderly, disabled individuals and people who live under inappropriate life conditions, constitute the group most affected by this inequality. Application of different or unfair procedures to people because of their characteristics, or due to the social groups to which they belong, is known as “discrimination”. Discrimination based on age is also a type of discrimination. When individuals are subjected to unfair judgments in their daily lives, these judgments affect them negatively. Discrimination can be inadvertent and/or unintentional. It is very hard to determine discrimination without any clear criteria.2,5,6

Interactions between medical staff and patients play a key role in medical care and these interactions affect patients’ commitment to treatment regimens.7

Additionally, if medical staff displays any discriminating attitude or behavior, this situation affects the equilibrium of medical service delivery and can result in its unfairness.7,8 In terms of patient practices in medical facilities, some implementations, such as “giving the priority to young and acute patients” and “overlooking age related diseases in the elderly due to age during patient care and service delivery”, can cause unsolved medical problems and loss of traditional holistic doctor care.2,8,9,10

Prior to this study, during our research on the medical faculty, 6th year students and physicians identified practices of age discrimination by these groups.11,12 In this context, this study was planned to determine whether hospitalized patients thought they were discriminated against or not. This study aimed to investigate the existence of age discrimination for patients at hospitals.

METHODS

This cross-sectional study was carried out in May 2012 with the participation of 298 in-patients at Mersin University Medical Faculty Hospital in Mersin,

23Medicine and Law

Turkey. The survey form was prepared after ageism studies in literature were analyzed by the authors and then was applied on ten patients staying at the university hospital. The survey questions were finalized as a result of the pilot study.

The questionnaire covered information about age, sex, education level, occupation, marital status, social insurance, place of birth and monthly income and included 22 statements about age discrimination. Two statements were not evaluated since a sufficient number of patients did not respond to those statements.

Statements regarding discrimination against in-patients were composed of four sections. The section about “Limitations on Life at the Hospital” includes statements about difficulties in finding the clinic or the patient room, appropriateness of the physical structure of the hospital, taking assistance from relatives while keeping track of hospital procedures and getting tired during these procedures. Statements in the section related to “Negative Behavior of Health Staff” are related to negative comments of the staff about patients’ physical appearance or disability, physical maltreatment, show of anger by shouting, displays of exasperation and arguments with patients. Statements in “Age Discrimination” are related to giving precedence to the elderly while waiting for clinics, spending less time with elderly patients compared to young patients, giving precedence to young patients in procedures done at the hospital and behaving more genially towards young patients. Statements regarding talking about the procedures with patients’ relatives instead of the patient, disinterest of the staff regarding the patient’s problems other than diseases, the desire to be called by their names and giving the patient’s bed to someone younger are included in “Patient Autonomy” section.

Since most of the patients did not state their monthly income, income status was not included in the assessment. Patient’s social security status was collected under three headings: patients with social security, patients with no social security and patients with only health insurance (green medicare card). During analyses, patients with green cards and patients with no social security were combined together and the patients were classified under two headings as patients with social security and patients with no social security.

Individuals under 18 or hospitalized in the emergency department and intensive care unit were not included in the study. After explaining the purpose of the study and obtaining approval, data collection forms were filled out by patients themselves, or the forms were filled out by researchers during face to face interviews. The patients were informed that they were free not to answer any of the questions if they chose not to do so.

24 Medicine and Law

The research protocol was approved by the Ethical Commission of the Medical Faculty at Mersin University.

The study was limited to the small group size of patients hospitalized during a month period at one university hospital.

Descriptive statistics (percentages, mean, standard deviation, and range) were used for summarizing the data. Chi-square test was used to compare categorical variables. Comparisons of continuous variables were done using Student’s t-test. A p value smaller than 0.05 was considered statistically significant.

RESULTS

The study sample consisted of 298 in-patients. The sample included 162 (54.9%) male and 133 (45.1%) female participants. The average age of the participants was 53.1±17.4 (range 19 to 93). 217 participants (73.3%) were married, 33 participants (11.1%) were single and 46 patients (15.5%) were widowed, while 237 patients (80.9%) had health insurance from the social security system and 56 patients (19.1%) reported that they had no social insurance. In terms of educational status of the patients, 180 (63.4%) of them were elementary school graduates, 66 (23.2 %) were high school graduates and 38 (13.4%) were university graduates (Table 1).

Table 2 presents the responses of in-patients to the statements.

Older patients were compared to younger ones, patients who were primary school or lower level graduates were compared to high school or university graduates and widowed patients were compared to married or single patients who had difficulties finding the clinic for their treatments (p=0.001, p=0.035, p<0.0001 respectively). Older patients and widowed patients had difficulty finding their hospital rooms as well (p=0.001, p=0.016 respectively). A total of 87 (29.2%) participants reported that the physical conditions of the hospital were not appropriate. Patients with primary school or lower education levels, patients who were workers, retired or unemployed and widowed/divorced patients required assistance from their relatives during hospital procedures such as paperwork (p=0.016, p=0.002, p=0.046 respectively). Approximately half of the patients (49.7%) mentioned that health care personnel explained what needed to be done to their relatives instead of themselves. This was especially observed in elderly patients, patients with low levels of education and widowed/divorced patients (p<0.0001, p=0.005, p= 0.043 respectively). Elderly patients reported that health care staff displayed annoyance during

25Medicine and Law

care, yelled at them and paid more attention to younger patients (p=0.009, p=0.039, p=0.026 respectively). Widowed/divorced patients also reported that health care personnel showed annoyance during care (p=0.010) (Table 3).

A total of 147 (49.3%) patients stated that health care personnel did not address them by name and used some adjectives (such as uncle, auntie, grandma, young man etc.) instead. This was mostly observed in the case of elderly patients, women, individuals with low educational levels and individuals with no social security (p=0.001, p=0.023, p=0.032, p=0.030 respectively). Young patients, university graduates, workers and government officials, single and married individuals wanted to be addressed by their names (p=0.001, p=0.019, p=0.002, p=0.029 respectively) (Table 4).

A total of 169 (56.7%) patients did not agree to give up their beds to someone younger than themselves. This was more evident especially in elderly patients and individuals who were born in city centers (p<0.0001, p=0.030 respectively).

Generally, patients reported that health care personnel did not make any negative comments about their physical appearances (83.9%) and physical disabilities (81.2%) nor maltreated them (87.9%). 84.6% of the patients thought that younger individuals were not given priority at hospitals and 79.9% believed that younger individuals were not treated with more geniality than elderly patients were.

DISCUSSION

Although all individuals applying to medical facilities have equal rights in terms of receiving basic health services,13 in-patients in our study stated that they could not, in some respects, equally benefit from health related services.

The right to health is a human right which is guaranteed as a patient right as well. Based on the right to health, tools and opportunities should be provided equally and without any discrimination. Regardless of social and personal characteristics of patients, hospitals should provide physical, technological and environmental equipment to facilitate access to all units.13 However, the hospital in which the current study was conducted was not suitable, especially for the elderly, individuals with low educational levels and widowed individuals. One fourth of the patients stated that they had difficulty finding the clinics and the patient’s rooms, and approximately one third of the patients mentioned that the physical conditions of the hospital did not suit them. Regardless of the social and physical characteristics of patients, the hospitals’ polyclinic and in-

26 Medicine and Law

patient services are the areas, which need to be easily accessed. If patients have difficulty in accessing the basic service departments, it can be thought that the number of patients that will have difficulty in finding disease, or condition specific diagnoses, or treatment areas, will increase as well.14

Requiring a relative’s assistance for any procedure shows that patient autonomy and free patient mobility is restricted and that the patient is dependent on someone for the task at hand. The average age range of the in-patents in our study was over 50 and approximately 40% of the patients stated that they felt exhausted while following the procedures at the hospital. Statements that display exhaustion are signs of lack of comfort at the hospital. Patients and patient relatives should have a comfortable environment during health care delivery. Planning health care suitable to patient characteristics is crucial. Basic criteria and standards for hospital conditions have been identified in the “Accessibility Basic Guide for Disabled Individuals in Health Care Institutions” prepared by the Ministry of Health (2012).14 According to this guide, the width of sidewalks, parking areas, the existence of a hospital settlement map to allow easy mobility of the patients, suitability of building entrances, ramp slopes, suitability of the stair head areas, provision of information at the entrances of emergency, polyclinics and other services, existence of referral systems, existence of warning signs, areas to move about and stairs and elevators should be arranged to meet the needs of the patient’s characteristics thus ensuring service delivery without any problems.14 Statements about negative aspects in the current study show that comfort is not fully provided to the patients. Restrictions that limit accessibility and inappropriate arrangements may cause problems and negative situations.14,15

The main determinants of health are social, economic, cultural and environmental conditions.8,16 The attitudes and behavior of individuals who provide health services also play an important role in the provision of health services. These factors may result in inefficient and imperfect access for services by individuals who should benefit from health services and may create disadvantaged groups with respect to social groups and class.11,12,17 Inequality in the form of opportunity or treatment may result in injustice. Compared to younger individuals, an elderly person runs a higher risk to catch diseases and it is unjust to give priority to young persons by health care personnel.11,12

This may impair the equality between elderly and young patients. Equality does not necessarily mean decreasing health differences to allow everyone to have the same degree and quality level of health, but to decrease or eliminate inequalities caused by preventable and unjust reasons.18

27Medicine and Law

The statements made by the in-patients in our study respecting the effect that younger individuals are given priority over the elderly, support this line of thinking. Similarly, a study by Ögenler etal11 conducted with medical students, identified the existence of age discrimination. The existence of negative attitudes and behaviors may prevent just and equal access to service provisions.2,10-12,18,19 Health care personnel should spend the same amount of effort with high standards and ethical sensitivity in offering equal quality services to all individuals.4,18

Socio-economic inequalities especially affect women, elderly patients, people with low level of education, people with no social security and unemployed.1 The current study identified health care personnel that displayed negative behavior against the elderly and widowed individuals but did not have negative attitudes towards differences in gender, level of education and social security. The very existence of negative behavior towards patients is a rather unpleasant situation for health care personnel as well. As found in our study, patients’ statements that report more exposure to negative behavior due to old age, in addition to their aggravation from their illness, are important. Negative behavior that does not include violence is hard to confirm.8,17,18 Although patients’ reports about negative attitudes are relative, they still need to be taken into consideration.16,20

The fact that the elderly are exposed to more negative behavior may be related to the health education curriculum, which emphasizes that compared to young individuals the elderly are more dependent, more incompetent in physiological terms and are more likely to catch diseases.11,17,21 The health education curriculum should be reviewed and restructured in terms of age discrimination issues.11-13,17

When health professionals are required not to make any statements regarding the outer appearance and physical properties of patients, even one patient’s report that has been exposed to that effect, is important enough to be taken in consideration, both in terms of patients’ rights and human rights.13,17,20 In a relationship that is already unequal due to the patient’s illness, any negative behavior towards the patient’s suffering, will agitate his feelings of trust and respect. The purpose of the relationship between the patient and the physician is to solve problems and meet the requirements and can be fulfilled only when the relationship is based on mutual respect and trust.22 Positive communication with the patient will result in obtaining better outcomes.

The current study found that when addressing individuals with lower levels of education, women patients, elderly patients and individuals with no social

28 Medicine and Law

security, health care personnel addressed them by using adjectives other than their names. The patients identified being addressed to with an adjective instead of their own names, as a negative behavior. It can be argued whether this paternal approach was used towards individuals who needed more compassion and interest when compared to other groups. However, a situation that does not call for compassion may be regarded as disrespect as well.23 In our study, patients with higher levels of education, younger patients and patients who were gainfully employed stated that they preferred to be called by their names. Being addressed by the health care personnel with anything other than their names is equal to disrespect to their autonomy. It is important, in human interactions, to address the other party with his/her name. This behavior honors the individual and makes him/her feel accepted.24 Unwillingness on the part of the elderly to give their bed to a younger patient indicates that their fear of death is higher than the younger’s,25 and they cannot accept it as fair. In terms of autonomy, the elderly who do not want to give their bed to younger patients may fear that some of their other rights could also be taken from them.

As a result, we concluded that there are patients who feel uncomfortable with the physical characteristics of the hospital and the health care personnel negative attitudes and behavior. These conditions negatively affect mainly seniors, people with lower levels of education, widowed individuals and people with no social security. Although patients who reported negative attitudes by health care personnel are scarce, even one such report, from this vulnerable group, is crucial enough to be taken into consideration in terms of the results obtained in this study.

We believe that it is imperative to increase the number of studies that disclose health care personnel’s biased conduct and review the health care curriculum for health care candidates. Furthermore, studies are necessary to increase the ethical sensitivities and awareness of active health care staff, to reinforce existing positive properties and remove negative aspects.

Conflict of interest: The authors declare that they have no conflict of interests.

Funding: None

29Medicine and Law

REFERENCES

1. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978 http://www.who.int/publications/almaata_declaration_en.pdf?ua=1 (accessed 25 Jun 2014)

2. Clark A, Hayes R, Jones K, et al. Ageism and age discrimination in primary and community health care in the United Kingdom. A Review Form the Literature. Centre for Policy on Ageing 2009.http://www.cpa.org.uk/information/reviews/CPA-ageism_and_age_discrimination_in_primary_and_community_health_care-report.pdf (accessed 25 Jun 2014)

3. Uzel İ. Education of Medical Ethics. T Klin Tıbbi Etik 1994;2(3):121-6.

4. Arda B. Evaluation of research ethics committees in Turkey. Journal of Medical Ethics 2000;26:459-61.

5. Neumark D. Reassessing Age Discrimination in the Employment Act. Washington, DC: AARP Public Policy Institute, 2008 http://www.socsci.uci.edu/~dneumark/2008_09_adea.pdf (accessed 25 Jun 2014)

6. Young B. Ageism and London’s Hospitals: A long-overdue and insufficient remedy. UWOMJ 2008;78(1):1-2. http://www.uwomj.com/wp-content/uploads/2013/06/v78n1.1-2.pdf (accessed 25 Jun 2014)

7. Drew P, Chatwin W, Collins S. Conversation analysis: a method for research into interactions between patients and health-care professionals. Health Expectations 2001;4:58-70.

8. Phelan A. Elder abuse, ageism, human rights and citizenship: implications for nursing discourse. Nursing 2008;15(4):320-9.

9. Nobili A, Garattin S, Mannucci P.M. Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium. Journal of Comorbidity 2011;1:28-44.

10. McConatha J.T, Hayta V, Reiser-Danner L, et al. Turkish and U.S. Attitudes Toward Aging. Educ Gerontol 2004;30(3):169-83.

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11. Ögenler O, Yapici G, Taşdelen B, et al. The Views of Medical Doctors on Elder Discrimination. Iran Red Crescent Med J 2012;14 (5):318-19.

12. Ögenler O, Yapici G, Taşdelen B, et al. Opinions of a Group of Medıcal Doctors on Elder Dıscrımınatıon in Mersin. Turkish Journal of Geriatrics 2012;15(4): 409-15.

13. Nys H, Stultiens L, Borry P, et al. Patient rights in EU Member States after the ratification of the Convention on Human Rights and Biomedicine. Health Policy 2007;83:223-35

14. The Ministry of Health. Accessibility Basic Guide for Disabled Individuals in Health Care Institutions. Ankara, 2012http://thsk.saglik.gov.tr/dosya/kronik_hastaliklar/temel_bilgiler_rehberi.pdf (accessed 25 Jun 2014)

15. Douglas C.H, Douglas M.R. Patient-friendly hospital environments: exploring the patients’ perspective. Health Expectations 2004;7:61-73.

16. Deaton A. Inequalities in income and inequalities in health. 1999. https://www.princeton.edu/rpds/papers/pdfs/deaton_inequalities.pdf (accessed 25 Jun 2014).

17. Morrison E.H, George V, Mosqued L. Primary Care for Adults With Physical Disabilities: Perceptions From Consumer and Provider Focus Groups. Fam Med 2008;40(9):645-51.

18. United Nations. Convention On The Rights Of Persons With Disabilities and Optional Protocol http://www.un.org/disabilities/documents/convention/convoptprot-e.pdf (accessed 25 Jun 2014)

19.Van Delden J.J, Vrakking A.M, van der Heide A. et al. Medical Decision Making in Scarcity situations. J Med Ethics 2004;30(2):207-11.

20. World Health Organization. Disability and Health http://www.who.int/mediacentre/factsheets/fs352/en/ (accessed 25 Jun 2014)

21.Illich I. Limits to Medicine Medical Nemesis: The Expropriation of Health. Translated by: Sertabiboğlu S. İstanbul: Ayrıntı Publications, 1995.

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22. Henzel ZO. Comparison of Turkish and French Physicians in the Context of Perceiving Patients and Providing a Patient Concept. Doctorate Thesis, Çukurova University Medical Sciences Institute Deontology and Medical History Department, Adana, 2009, pp. 1-12

23. Sennet R. Respect in a World of Inequality. İstanbul, Ayrıntı, 2014

24. Gilktte R.D, Filak A, Thorne C. First Name Or Last Name: Which Do Patients Prefer? J Am Board Fam Pract 1992;5:517-22.

25. Yalom I. Staring at the Sun: Overcoming the Terror of Death. Kabalcı Yayınları, İstanbul: 2008.

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Table 1: The socio-demographic characteristics of respondents

Characteristics Number % / Mean±SDSex (n=295)Female 133 45.1Male 162 54.9Education level (n=284)Elementary school 180 63.4High school 66 23.2University 38 13.4Occupation (n=277)Unemployed 97 35.0 Worker 87 31.4 Retired 56 20.2 Officer 37 13.4Marital status (n=296)Married 217 73.3Divorced/widowed 46 15.5 Never married 33 11.2Social Insurance (n=293)Yes 237 80.9No 56 19.1 Place of birth (n=280)City center 119 42.5District 101 36.1Village 60 21.4Age (year) 285 53.1±17.4

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Table 2: The distribution of patient responses to the statements

Statements Yesn(%)

Non(%)

Do not known(%)

1. I had difficulty in finding the examination room by myself 75(25.2) 205(68.8) 18(6.0)

2. I had difficulty in finding my room in hospital 72(24.2) 212(71.1) 14(4.7)

3. Physical characteristics of the hospital do not suit me 87(29.2) 161(54.0) 50(16.8)

4. While pursuing work in the hospital I got help from my relatives

224(75.2) 63(21.1) 11(3.7)

5. Staff explained the procedure to my relative, not to me 136(45.6) 148(49.7) 14(4.7)

6. The priority was given to me rather than younger ones than me during waiting for examination

70(23.5) 192(64.4) 36(12.1)

7. Medical staff made negative comments about my looks 13(4.4) 250(83.9) 35(11.7)

8. Medical staff made negative comments about my physical barriers (hearing, seeing, walking ...)

7(2.3) 242(81.2) 49(16.4)

9. I was physically mistreated by health personnel 10(3.4) 262(87.9) 26(8.7)

10. Medical staff shouted to me for anything he/she got angry 25(8.4) 247(82.9) 26(8.7)

11. Health staff did not consider my problems except my disease 24(8.1) 236(79.2) 38(12.8)

12. Medical staff spent less time with me than with younger ones 13(4.4) 234(78.5) 51(17.1)

13. Hospital staff showed signs of tiredness while they were taking care of me

26(8.7) 236(79.2) 36(12.1)

14. Young people are given higher priority in jobs than me in the hospital

15(5.0) 252(84.6) 31(10.4)

15. Young people are being serviced more with a smile than me in the hospital

27(9.1) 238(79.9) 33(11.1)

16. I'm tired of my job while pursuing at the hospital (?) 119(39.9) 159(53.4) 20(6.7)

17. Staff did not call me by my name 147(49.3) 132(44.3) 19(6.4)

18. I want staff to call me by my name 160(53.7) 88(29.5) 50(16.8)

19. I accept if my bed would be given to any younger patient than me with the same illness

94(31.5) 169(56.7) 35(11.7)

20. I / my relatives have discussed with hospital staff 25(8.4) 256(85.9) 17(5.7)

35Medicine and Law

Table 3a: Comparison of socio-demographic characteristics of participants to responses to the some statements

Statements 1 Statements 2Yes

n(%)No

n(%)Do not known(%)

Yes n(%)

No n(%)

Do not known(%)

Sex

FemaleMale

32(24.1) 43(26.5)

93(69.9) 109(97.3)

8(6.0) 10(6.2)

36(27.1) 36(22.2)

91(68.4) 118(72.8)

6(4.5) 8(4.9)

Marital status *** *MarriedWidowed/divorcedNever married

45(20.7) 18(39.1) 11(33.3)

164(75.6) 21(45.7) 19(57.6)

8(3.7) 7(15.2) 3(9.1)

43(19.8) 18(39.1) 10(30.3)

166(76.5) 24(52.2) 21(63.6)

8(3.7) 4(8.7) 2(6.1)

Educational status *Elementary SchoolHigh SchoolUniversity

54(30.0) 9(13.6) 8(21.1)

115(63.9) 55(83.3) 26(68.4)

11(6.1) 2(3.0) 4(10.5)

51(28.3) 10(15.2) 7(18.4)

121(67.2) 53(80.3) 29(76.3)

8(4.4) 3(4.5) 2(5.3)

Occupation

Unemployed WorkerRetired Officer

28(28.9) 25(28.7) 9(16.1) 9(24.3)

65(67.0) 58(66.7) 44(78.6) 25(67.6)

4(4.1) 4(4.6) 3(5.4) 3(8.1)

30(30.9) 20(23.0) 8(14.3) 9(24.3)

64(66.0) 65(74.7) 43(76.8) 27(70.0)

3(3.1) 2(2.3) 5(8.9) 1(2.7)

Place of birth

City centerDistrictVillage

23(19.3) 30(29.7) 21(35.0)

92(77.3) 63(62.4) 37(61.7)

4(3.4) 8(7.9) 2(3.3)

23(19.3) 33(32.7) 16(26.7)

92(77.3) 62(61.4) 43(71.7)

4(3.4) 6(5.9) 1(1.7)

Social Insurance

YesNo

55(23.2) 18(32.1)

167(70.5) 36(64.3)

15(6.3) 2(3.6)

53(22.4) 17(30.4)

172(72.6) 37(66.1)

12(5.1) 2(3.6)

*p<0.05 **p< 0.0001

36 Medicine and Law

Table 3b: Comparison of socio-demographic characteristics of participants to responses to the some statements

Statements 4 Statements 5 Statements 13

Yes n(%)

No n(%)

Do not known(%)

Yes n(%)

No n(%)

Do not known(%)

Yes n(%)

No n(%)

Do not known(%)

Sex

FemaleMale

104(78.2) 118(72.8)

22(16.5) 40(24.7)

7(5.3) 4(2.5)

61(45.9) 73(45.1)

67(50.4) 80(49.4)

5(3.8) 9(5.6)

9(6.8) 17(10.5)

109(82.0) 125(77.2)

15(11.3) 20(12.3)

Marital status * * *

MarriedWidowed/divorcedNever married

163(75.1) 36(78.3) 24(72.7)

164(75.6) 21(45.7) 19(57.6)

8(3.7) 7(15.2) 3(9.1)

97(44.7) 27(58.7) 12(36.4)

113(52.1) 16(34.8) 17(51.5)

7(3.2) 3(6.5)

4(12.1)

12(5.5) 10(21.7)

3(9.1)

178(82.0) 32(69.6) 25(75.8)

27(12.4) 4(8.7)

5(15.2)

Educational status * *

Elementary SchoolHigh SchoolUniversity

144(80.0) 48(72.7) 21(55.3)

30(16.7) 17(25.8) 14(36.8)

6(3.3) 1(1.5) 3(7.9)

95(52.8) 25(37.9) 12(31.6)

76(42.2) 41(62.1) 22(57.9)

9(5.0) 0(0.0)

4(10.5)

17(9.4) 8(12.1) 0(0.0)

139(77.2) 54(81.8) 33(86.8)

24(13.3) 4(6.1)

5(13.2)

Occupation

Unemployed WorkerRetired Officer

76(78.4) 68(78.2) 43(76.8) 22(59.5)

13(13.4) 19(21.8) 13(23.2) 14(37.8)

8(8.2) 0(0.0) 0(0.0) 1(2.7)

49(50.5) 47(54.0) 22(39.3) 11(29.7)

43(44.3) 40(46.0) 30(53.6) 24(64.9)

5(5.2) 0(0.0) 4(7.1) 2(5.4)

8(8.2) 8(9.2) (8.9)

1(2.7)

76(78.4) 70(80.5) 44(78.6) 33(89.2)

13(13.4) 9(10.3) 7(12.5) 3(8.1)

Place of birth


92(77.3) 73(72.3) 47(78.3)

25(21.0) 23(22.8) 10(16.7)

2(1.7) 5(5.0) 3(5.0)

56(47.1) 39(38.6) 30(50.0)

60(50.4) 56(55.4) 28(46.7)

3(2.5) 6(5.9) 2(3.3)

11(9.2) 10(9.9) 5(8.3)

94(79.0) 80(79.2) 48(80.0)

14(11.8) 11(10.9) 7(11.7)

Social Insurance

YesNo

175(73.8) 45(80.4)

53(22.4) 9(16.1)

9(3.8) 2(3.6)

107(45.1) 27(48.2)

119(50.2) 27(48.2)

11(4.6) 2(3.6)

19(8.0) 7(12.5)

192(81.0) 43(76.8)

26(11.0) 6(10.7)

*p< 0.05**p< 0.0001

37Medicine and Law

Table 4: Comparison of socio-demographic characteristics of participants to responses to the statements 17 and 18

Statements 17 Statements 18Yes

n(%)No

n(%)Do not known(%)

Yes n(%)

No n(%)

Do not known(%)

Sex *FemaleMale

78(58.6) 69(42.6)

48(36.1) 81(50.0)

7(5.3) 12(7.4)

63(47.4) 95(58.6)

48(36.1) 40(24.7)

22(16.5) 27(16.7)

Marital status *MarriedWidowed/divorcedNever married

105(48.4) 29(63.0) 12(36.4)

100(46.1) 14(30.4) 17(51.5)

12(5.5) 3(6.5) 4(12.1)

122(53.2) 17(37.0) 19(57.6)

60(27.6) 22(47.8) 6(18.2)

35(16.1) 7(15.2) 8(24.2)

Educational status *Elementary SchoolHigh SchoolUniversity

96(53.3) 30(45.5) 17(44.7)

68(37.8) 36(54.5) 19(50.0)

16(8.9) 0(0.0) 2(5.3)

91(50.6) 32(48.5) 30(78.9)

57(31.7) 20(30.3) 6(15.8)

32(17.8) 14(21.2) 2(5.3)

Occupation *Unemployed WorkerRetired Officer

54(55.7) 35(40.2) 30(53.6) 17(45.9)

34(31.1) 47(54.0) 23(41.1) 19(51.4)

9(9.3) 5(5.7) 3(5.4) 1(2.7)

41(42.3) 54(62.1) 26(46.4) 29(78.4)

35(36.1) 18(20.7) 22(39.3) 6(16.2)

21(21.6) 15(17.2) 8(14.3) 2(5.4)

Place of birth


68(57.1) 46(45.5) 29(48.3)

43(36.1) 49(48.5) 29(48.3)

8(6.7) 6(5.9) 2(3.3)

68(57.1) 47(46.5) 37(61.7)

32(26.9) 35(34.7) 17(28.3)

19(16.0) 19(18.8) 6(10.0)

Social Insurance

YesNo

109(46.0) 37(66.1)

113(47.7) 17(30.4)

15(6.3) 2(3.6)

132(55.7) 25(44.6)

63(26.6) 24(42.9)

42(17.7) 7(12.5)

*p< 0.05

39


Medicine and Law

HEALTH PROFESSIONALS OF EMERgENCY SERVICE: AN EVALUATıON OF DISASTER MEDICINE AND ETHICAL VALUES

Şükran Sevimli*, Recep Dursun**, Sevdegul Karadas***

Abstract: Aim: To obtain the opinions of health professionals’ who work in emergency medical services on the application of basic attitudes like triage, ethics, legal rules; to popularize problems they have encountered or may experience while giving health services after natural disasters; and to develop further suggestions.

Material and method: In order to evaluate health service problems, laws, triage and ethics applications, a questionnaire tool was formulated. The poll that was taken included 133 emergency service workers, with and without earthquake experiences. Data were analyzed using descriptive statistics with statistical significance set at p<0.001. The frequency distributions taken into account and chi square test were applied to understand the difference between the employees who experienced an earthquake and the employees who did not.

Findings: 57.7% of participants in the survey were males and 42.3% females. Their average age was 29.8 %. 16.8% of them worked in the university hospital, 77.4 % in a state hospital and 5.8% in private hospitals. 51.1% of the participants were doctors, 43.1% nurses and 5.8% emergency medical technicians. 48.2% of the participants had experienced earthquakes, 52.6% had not. 27% of them were consulted on triage, 37.2% on both triage and legal rules, 31.4% on triage, laws and ethics and 4.4% on triage and ethical principles.

* YYÜ Medical Faculty Department of Medical History and Ethics 65080, Van, Turkey. Correspondence author: University, Faculty of Medicine, Department of Medical History and Ethics, 65200, Van, Turkey. E-mail: [email protected]. Mobil-phone: +90 505 888 14 52, Tel-fax: +90 432 216 75 19.

** Dicle University Faculty Department of Emergency Medicine Diyarbakır, Turkey.*** YYÜ Medical Faculty Department of Emergency Medicine 65080, Van, Turkey.

Health Law (2015) 34:39-54

40 Medicine and Law

Conclusion: Results show that while ethical principles are less considered in medical services after natural disasters, triage and legal regulations play an essential role in resource allocation and medical service presentation. The results show that the inclusion of ethical training in natural disaster medicine education and its enhancement through regular rehearsals is essential.

Keywords: Earthquake; Natural Disaster Problems; Triage; Ethical Dilemmas.

INTRODuCTIONNatural and man caused disasters are defined, medically, as mass casualty incidents and emergency conditions. Disasters can, among others, cause massive destruction, collapse or substantial damage to a building, a great deal of human suffering, a number of injured people, excessive demand of medical resources, shortage of time, disorder, security, shelter and emotional problems. Therefore, disasters can lead to triaging decision-making problems, laws- patient rights issues, and ethical challenges that are different from usual medical practices (Karadag and Hakan 2012). Indeed, the Emergency Department (ED) has an important role in managing emergency conditions. The ED’s essential approaches are different from medical practices; triage is an essential function which aim is “the greatest good for the greatest number”. A second approach is patient rights; and a third approach is medical ethics principles that support human rights, ethics codes and democracy.

A natural disaster can result in the loss of approximately 3 to 4 million lives and many wounded and/or traumatized people. According to USGS (Science for a Changing World, 2013) data, between the years 2000-2012, earthquakes have caused the death of 450.000 people. All earthquake reports state that the number of deaths increases in parallel with the intensity of the earthquake, its depth, the compatibility of the architectural structures to the earthquake conditions, and the poverty and density of the disaster area’s population . In parallel, the need for disaster preparations in the medical sector to decrease the number of deaths, has risen. Therefore, this new medicine discipline called “Disaster Medicine” and a number of media organizations on Disaster Medicine and Public Health Preparedness have become part of the agenda (Larkin, 2010 pp.62-73).

Our research topic – earthquake - is a quite familiar term for almost all the individuals who live in Turkey, which is positioned on three main fault lines.

41Medicine and Law

However, due to the buildings incompatibility to withstand earthquakes, the population density, and the deficiency in the necessary disaster medicine preparations, Turkey has experienced massive earthquakes related traumas.

A research to evaluate the post-earthquake problems from the point of view of emergency service health professionals was conducted in the province and districts of Van in eastern Turkey. The earthquakes in question occurred on October 23rd, 2011, at 13.00 p.m., with a magnitude of 7.2 on the Richter scale, and in Van, on November 9th, 2011, at 21.23p.m, with a 5 km depth and a 5.6 magnitude (Turkish Red Crescent Report 2012). Besides the main earthquakes, there have been over 2000 aftershocks. Although their intensity decreased and their intervals prolonged, the aftershocks continued in 2013. These earthquakes have resulted in 612 deaths and many injures in the province and districts of Van (as the hospitals did not perform the registration process adequately and the injured individuals had been discharged emergently, a definite number of injured people could not be obtained) (AFAD Report 2012). The damage to the hospital buildings from the earthquake became a substantial obstacle in providing health services. The health professionals provided services in small tents set up in the hospital yard. In the following days, the health services provided field hospitals positioned in the yard of the state hospital of the province of Van, which was relatively less affected by the earthquake.

The emergency medicine professionals of the province of Van who lived through earthquakes and provided services after the earthquake and the emergency medicine professionals from other provinces have participated in our research. Since the research findings include the views of the health professionals who lived through the trauma and those who did not, this research is important.

Materials and Methods

A questionnaire tool was especially formulated for this research, by two emergency medicine doctors, and a medicine ethics specialist who has lived through earthquakes and aftershocks, and have provided after earthquakes health services.

The survey was distributed to both the health emergency service professionals who lived through main earthquakes with 7.2 mw and 5.6 mw intensity and their aftershocks, and to professionals from other provinces who did not experience earthquakes. Out of 150 participants, 17 did not answer most of the questions, and have been excluded from the research. The frequencies of the 133 surveys have been determined and a chi square test that has been applied.

42 Medicine and Law

The study was approved by the local ethical committee.

ResultsDemographic findingsOur survey group consisted of 133 health professionals who work in the emergency medicine department; 57.07% males and, 42.3 % females aged between 19-56 years (mean age 29.88±6.8 years).

The length of medical specialty education in Turkey is six years. After the medical faculty, emergency medicine education takes three years. Those who continue branch education are called “assistant doctor” and those who finish emergency branch education, “emergency specialist”. Nurse education is twofold: one, the health vocational high school and the other, university education takes four years after gymnasium. An emergency medical technician (EMT) studies at a kind of health vocational high school. Of the 133 participants, 2.9% were assistant professors, 14.6% specialist doctors, 8%, assistant doctors, 25% doctors, 43.1% nurses and 5.8 % EMTs.

Among the participants 16.8’i% were from a university hospital, 77.4’ü % from the Ministry of Health Hospital and 5.8’1% from special hospitals.

4% of the participants’ working period was 0-3 years, 25.5% worked 4-6 years, and 27.1% worked 8 years and over. The working period of emergency service was: 0-3 years > 65.5%, 4-7 years >19.1 %, 8 years and over >15.4%.

51.8 % of the participants have provided medical treatment in the emergency service during and after the earthquake. 9.4% of the earthquake victims received medical treatment; 2.6% psychiatric treatment; 8.5 % received both medical, and psychiatric treatment. 48.2 % of the second group of participants did not experience the same.

27% of the participants stated that the approaches they considered in the emergency service during the treatment process were triage; 37 % triage and law- patients’ rights, 31.4 % triage, laws and ethics and 4.4 % triage and ethics (Table 1). The acknowledged triage period for the emergency service professionals is about 60 sec. (mean period 2.84 ± 1.17).

Emergency Service: Triage, Legal Rules and Ethics Principles

43Medicine and Law

In Turkey, practitioner physicians take first an exam for being a specialist, and only then begin specialized training according to their exam scores. Nurses are appointed by the executive management. Survey data show that the participants’ answers given to that question is the desire to work in the emergency service, 42.7% very good, 6.8% good, 29.9% moderately good, 19.7% not good and 0.9% I don’t know.

To the question about the approaches they acknowledged during the medical services they provided, 13.7% of them specified triage, 12% law, 21.4% triage and law, 46.9% triage and 3.4% specified law and ethics.

It is essential for emergency service professionals, while providing health services, to consider triage, which has an essential role in signifying the priorities of the patients, a legal approach which jointly includes the patient rights regulation and ethical principles. To the question about the approaches they acknowledged during the medical services they provided, 27% of the participants specified triage, 37,2% triage and law, 31,4% triage, law and ethical principles, while 4,4% stated that they only took ethical principles into consideration. There is a significant difference between the approaches of the participants who have experienced earthquakes and those who have not (p<0.001).

35% of the participants stated that they did triage in 60 seconds, while 26,3% of them 45 seconds, 17,5% > 75 seconds and 13,1% stated that they did triage in 20 seconds. There was a significant difference between the approaches of the participants who have experienced earthquakes and those who have not (p<0.001).

When asked which principles were mostly recognized among the ethical principles, 36.5% of the participants signified ‘not to harm’, 38% ‘being beneficial’, 12.4% ‘being just’, 10.2% autonomy; only 2.9% of them point to ‘privacy’. EM professionals prioritized the principles of ‘being beneficial’ and ‘not to harm’ over the belief that the emergency service should immediately reach out to the patient. However, there is a significant difference among the participants who have experienced earthquakes and those who have not, in terms of the principles (p<0.001).

When asked if there was a priority in terms of considering ethical principles, 8.1% of the participants remarked that it depends on the situation; 9% stated that all of them are important, 50.4% said that they partially take them into consideration, 21.2% sometimes and 6.6% stated that they rarely consider ethical principles. There is a significant difference between the two groups (p<0.001) (Table 2.)

With respect to ethical dilemmas, 34.3% of the participants replied every

44 Medicine and Law

time, 27.7% said usually, 27.7% sometimes and 4.4% rarely. These answers show that they feel an obligation to evaluate the issue of ethics. It has been observed that there is a significant difference between two groups (p<0.000). As to potential ethical dilemmas, in terms of the acceptance of the patients to the treatment and the treatment process, 46% of the participants stated time management in the decision-making process, 9.5% of them addressed the bed-operation room and 7.3% stated that they have experienced ethical dilemmas in terms of transportation. It has been observed that there is a significant difference between the two groups (p<0.000).

In Cardio Vascular Resuscitation (CPR) application, 20.4% of the participants have experienced ethical dilemmas in terms of informed consent, 28.5% in terms of time management, 14.6% in connection to the intervention of the families to the application, 30.7% in decision-making process and 5.8% of them stated that they have experienced ethical dilemmas in terms of emotional reasons. It has been observed that there is a significant difference between two groups (p<0.001). Another important ethical dilemma has appeared in terms of the efficiency and usage of resources. 33.6% of the participants expressed that they have experienced ethical dilemmas in terms of medical pharmaceuticals and tools, 38.7% related to beds, 18.2% to ventilators and 9.5% stated that they have experienced ethical dilemmas with the usage of haemodialysis units. It has been observed that there is a significant difference in terms of the emergency service professionals post-traumatic approaches between the health professionals who have experienced earthquakes and those who have not (p<0.001) (Table 3).

It was asked in ED whether participants need ethical consultation or not; 39.4% of them answered they need this kind of consultation every time, 16.1% usually, 37.2% sometimes and 7.3% stated that they rarely needed ethical consultation. It has been observed that there is a significant difference between the two groups p<0.000. To the question about prevention of ethical problems, 38.7% of the participants proposed an ethical course, 21.2% an ethical consultation, 21.2% disaster ethics education and 27% proposed that more personnel and medical equipment might prevent ethical problems. It has been observed that there is a significant difference between the two groups p<0.001. When asked whether disaster medicine education is necessary or not, 44.6% of the participants estimated that a long education is necessary, 10.2% that an intensive course would suffice, 22.6% that it necessitates a short-term course, 13.9% conferences and 3.6% stated that they have no idea. It has been observed that there is a significant difference between the two groups p<0.001 (Table 4).

45Medicine and Law

Discussion

This research aims to provide some of the necessary data acquisition for triage, disaster ethics and legal issues of medical care in future disasters and to develop solutions to problem solving in ethical dilemmas.

Van earthquakes revealed that by the imbalance between needs and supplies required national and international foreign aid; thereby it was accepted as a disaster. After that quake the situation clearly presented numerous ethical and legal challenges, at various levels. Moreover, the contemporary issues of ethical concern and ethics dilemmas of disaster medicine are not only the patients and their relatives, but they also involve a doctor-patient dyad; doctor-patient relatives, fair distribution of limited medical resources, accurate triage, informed consent, autonomy and ethical decision making etc., that is, a disaster situation includes ethical, legal and triage problems inherent in disaster preparedness and response (Larkin, 2010). Under the disaster conditions, health workers already had a number of problems, as individuals working in the trenches.

The result of our survey has provided compelling data showing that there is a significant difference in health service applications, such as patient rights, in terms of triage, ethics and legal regulations. Furthermore, survey data have changed according to the health professionals who have experienced an earthquake and others who did not.

The research data showed that Simple Triage and Rapid Treatment (START) has been adopted by health professionals with a ratio of 64.2%, and ethical principles have been regarded less frequently. It is important to apply triage in a correct way. This situation has been declared by the WMA Declaration of Helsinki (1964,1996), Red Cross and Red Crescent Movement and Non-Governmental Organizations in Disaster Relief (1995), World Medical Association (WMA), Medical ethics in the Event of Disaster (1994 and 2006) as they stated that the medical motives of triage should be considered, sufficient medical resources, personnel with medical intervention capacity and a system which could meet the basic medical needs. Two different studies conducted in Turkey have shown that short-term education reformed the tendency towards insufficient triage decision-making (Ersoy, Çınar et. al. 2010). Further detailed studies about triage application are necessary.

74.4% of the participant stated that they completed triage in less than 60 seconds. 52.2% of the health professionals who did not experience earthquakes stated that they made triage in less than 60 seconds, while in the earthquake area it

46 Medicine and Law

was 18.6%, 25.7% for 45 seconds and 24.3% for 30 seconds. This situation shows that after earthquakes health professionals considered time management more frequently.

Another important finding concerns ethical principles. 74.5% of the participants stated that they apply the principles of ‘not to harm’ and ‘being beneficial’. This finding shows that health professionals primarily apply ethical principles in parallel to triage application. However, the Geneva Convention of 1864 and the Universal Declaration of Human Rights of 1948, the Helsinki Declaration of 1960, the Code of Conduct for the International Red Cross, the Red Crescent Movement and non-Governmental Organizations in Disaster Relief (Geneva 1995) and the WMA, clearly declared that disaster relief studies should respect human rights, culture, beliefs, structures and customs of the communities. In other words, ethical principles should be considered; the necessity for the match of ethical principles and procedures and the occupational ethics doctrine (tenets) of the health professional (WMA - Red Crescent). Unfortunately, the research findings showed that justice, autonomy, and privacy principles were not considered efficiently. Although, 67.8% of the participants stated that they have permanently experienced ethical dilemmas, 67.8% almost every time, 27.7% sometimes and 4.4%, it has been observed that they are sensitive in terms of ethical principles. However, as priority has been given to survival, the principles of justice, autonomy and privacy were not regarded efficiently. It has been observed that the most important ethical dilemmas are the treatment of injured patients, CPR application, and fair allocation of medical resources. Legal applications or justice does not mention that being fair is considered beyond legal regulations. Hence, considerations of ethical principles, which provide depth to legal regulations, prevent the emergence of various problems during the medical treatment process.

The most essential ethical dilemmas of the post-earthquake health professionals are the treatment of injured patients, the limits of treatment opportunities and the expectations of the patients’ relatives with a ratio of 52.9% and anxiety in the second rank. In the ED, the issue with professionals who did not experience earthquakes is quite opposite; 55.2% state that the most essential ethical dilemma is about time management while 20.4% expressed decision-making process of treatment. In research about the Haiti earthquakes, it has been stated that the treatment process of the injured patients, ethical decision-making and clinical urgency are among the most essential issues (Merin et. al., 2010).

47Medicine and Law

Another essential ethical dilemma emerged in the issue of deciding the application of CPR and time management. The most important ethical dilemma after earthquakes has been pointed to by 51.4% as decision-making and by 17.1% as families’ intervention in the decision-making process. In the comparison group, 46.3% stated time management and 32.8% remarked informed consent. These data suggest that there is a particular need for applied training in informed consent. Informed consent is important in developing autonomy enhancing strategies (Heggland at al. 2012) .

Concerning more productivity in treatment service, 43.8% of the participants stated that medical equipment should be enhanced and 22.6 % that the communication techniques and skills should be enhanced. The resolution of ethical problems has been stated by both groups but while 31.3% of the participants who did not experience earthquakes remarked its importance, in the participants who experienced earthquakes this ratio is 15.7 %.

Conclusion

Emergency services are the facade of the hospitals that introduce and tell the quality of medical service to society. Societies generally evaluate hospitals and other medical institutions with the approaches they encounter in emergency services. The findings of our study contributed to collecting information about the approaches that the emergency service professionals have adopted in the service presentation and the practices of these approaches.

When we evaluate the findings of our research, we have primarily seen that emergency service professionals generally decide and prefer the application of triage in terms of medical motives. However, they do not recognize ethical principles efficiently and they are aware of their deficiencies on that issue. It has been observed that emergency service professionals have agreed on the benefits of ethical principles and practices, ethical consultation and ethical education at the same time as emergency services. The fulfilment of the necessity in this issue will increase the efficiency of the emergency service practices.

Another essential finding of the research shows that in parallel to the present chaotic environment and conditions, emergency service professionals have various tendencies in terms of applying triage decision-making, ethical principles and legal regulations after natural disasters like earthquakes. For this reason, education, practices and evaluations in disaster medicine are necessary.

48 Medicine and Law

While in developed countries, disaster medicine exists as a separate branch of medicine, the education on disaster medicine in Turkey, like other developing countries, has been practiced through training performed by public health or emergency medicine branches. Besides prioritizing the disadvantaged groups like children, old and/or disabled individuals, the emergence of disaster medicine and media organizations on this issue could be considered as essential ethical issues in terms of providing maximum health services to all disaster victims, to injured patients and pregnant women. Therefore, disaster medicine - foreseeing the possible consequences of the disasters - should provide the necessary emergency action plans and programs, and an intense education of health professionals on the practices when facing disasters. The preparation of the applicable educational programs - triage decision making, ethics applications, and legal rules - in line with the research findings will improve the efficiency of the medical service and the patients’ satisfaction before or after natural disasters.

Ethical Consideration

Ethical issues (including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been strictly observed by the authors.

References

Cınar O. Cevik E. Salman N. Cömert B. Emergency Severity Index triage system and implementation experience in a university hospital Türkiye Acil Tıp Dergisi - Turk J Emerg Med 2010;10(3):126-131

Ersoy N, Akpinar A. 2010 Triage decisions of emergency physicians in Kocaeli and the principle of justice. Ulus Travma Acil Cerrahi Derg. May; 16(3):203–9.

Heggland L-H, Øgaard T. Mikkelsen A. Hausken K. 2012. Patient Participation in Surgical Treatment Decision Making from the Patients’ Perspective: Validation of an Instrument Hindawi Publishing Corporation Nursing Research and Practice Volume 2012, Article ID 939675, 8 pages doi:10.1155/2012/939675

49Medicine and Law

Karadag C.O ., Hakan A.K Ethical dilemmas in disaster medicine. Iran Red Crescent Med J. 2012 October; 14(10): 602–612. Published online 2012 October 30.

Larkin L.G. 2010. Ethical Issues in Disaster Medicine. In Kristi L. Koenig Carl H. Schultz H, Disaster Medicine: Comprehensive Principles and Practices (2nd ed., pp. 62-73), UK Cambridge University Press.

International Federation of Red Cross and Red Crescent Societies and the ICRC. Code of Conduct for the International Red Cross and Red Crescent Movement and Non-Governmental Organizations in Disaster Relief. Annex VI to the resolutions of the 26th International Conference of the Red Cross and Red Crescent. Geneva, Switzerland: 1995. [2011 May 12]. http://www.ifrc.org/Docs/idrl/I259EN.pdf.

Republic of Turkey Prime Ministry Disaster and Emergency Management Presidency, Earthquake Department Report on Van Earthquake December 2011, (AFAD) Ankara –Turkey. Retrieved 19 December, 2012. http://www.afad.gov.tr/Ingilizce_Site/index.

Merin O. Ash N. Levy G. Schwaber JM. Kreiss Y. 2010. The Israel Field Hospital in Haiti-Ethical Dilemmas as in Early Disaster DOI:10.1056/NEJMp1001693

Turkish Red Crescent Society (TRCS), Turkish Red Crescent Report, 2012. Retrieved 12. February 2013. http://www.kizilay.org.tr/english/index.php

World Medical Association. 3rd General Assembly of the World Medical Association. London, England: Oct, 1949. WMA International Code of Medical Ethics. (amended in 1968, 1983 and 2006). Retrieved 2013 February 19.http://www.wma.net/en/30publications/10policies/c8.

World Medical Association. Helsinki, Finland: Sep, 2003. [cited 2011 May 10]. WMA Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment. 54th WMA General Assembly. (amended in 2007). Available from: http://www.wma.net/en/30publications/10policies/t1.

50 Medicine and Law

Table 1. Characteristics of emergency professionals N=137

gender % N Male 57.7 79 Female 42.2 58 Age

Below 29 years 54.0 74 Over 30 years 46.0 63 Institutions University Hospital 16.8 23 Ministry of Health Hospital 77.4 106 Special Hospitals 5.8 8 Professional experience ≤ 3 years 47.4 65 4-7 years 25.5 35 < 8 years 27.1 57 Emergency experience ≤ 3 years 65.5 904.7 years 19.1 26 < 8 years 15.4 21 Disaster experience Earthquake experience 51.8 71 Non-earthquake experience 48.2 66

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Table 2. Health professionals: Triage, Law (patient rights) and Ethical Principles

Approaches n (%) %* %** p-valueTriage Time- approximate

n ( %) %* %** p-value

Triage 37 (27.0) 15.7 38.8 <0.001 30 second 18 (13.1) 24.3 1.5

Triage-Legal 51 (37.2) 15.7 47.8 45 second 36 (26.3) 25.7 26.9

Triage-Legal-Ethics 43 (31.4) 50.0 11.9 60 second 48(35.0) 18.6 52.2 <0.001

Ethics princip. 6 (4.4) 7.1 1.5 75 second 24 (17.5) 15.7 19.4

Ethics Principles n (%) %* %**

Considered Ethics Princip.

n (%) %*

%**

Nonmaleficence 50 (36.5) 22.9 50.7 Changes 11 (8.1) 15.7 0.8

Beneficial 52 (38.0) 44.3 31.3 <0.001 All of princip. 30(21.9) 27.4 16.4 <0.001

Justice 17 (12.4) 15.7 9.0 Partially 69(50.4) 24.3 50.4

Autonomy 14 (10.2) 11.4 9.0 Sometimes 29 (21.2) 35.7 21.2

Privacy 4 (2.9) 5.7 0.0 Rarely 9 (6.6) 19.6 6.6

%* experienced earthquake- Emergency Medicine Professional%** not experienced earthquake- Emergency Medicine Professional

52 Medicine and Law

Table 3. Ethical dilemma in emergency service

Ethical Dilemma n (%) %* %** p-valueInjury-Ethical

Dilemman (%) %*

%** p-value

Every time 47(34.3) 17.1 52.2

<0.001

Time 63(46.0) 37.1 55.2

<0.001Usually 46(33.6) 48.4 25.4Decision-making

51(37.2) 52.9 20.4

Sometimes 38(27.7) 34.3 20.9 Bed-

operation room

13(9.5) 5.7 13.4

Rarely 6 (4.4) 7.5 1.5 Transport 10(7.3) 4.3 10.4

Ethical Dilemma & CPR n (%) %* %** p-value

Ethical dilemma

with Recourses

n (%) %* %**

p-value

Informed consent 28(20.4) 8.6 32.8

<0.001

Med.Equipment

46(33.6)14.9 33.6

<0.001

Time 39(28.5) 11.4 46.3 bed 53(38.7) 47.8 38.7

Intervention of family 20(14.6) 17.1 11.9Mechanic ventilator

25(18.2) 29.2 18.2

Decision-making 42(30.7) 51.4 9.0 Hemodialysis 13(9.5) 7.5 9.5

Emotional 8 (5.8) 11.4 0.0

%* Experiencing earthquake- Emergency Medicine Professional%** Not experiencing earthquake- Emergency Medicine Professional

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Table 4. Ethical necessity and enhancement of health service’s efficiency.

Ethical Consultation n (%) %* %** p-value

Prevent ethical

problemsn (%)

%* %**

p-value

Every time

54(39.4) 15.7 64.2 Ethics courses 53 (38.7)

24.3 53.7 <0.001

Usually

22(16.1) 12.9 19.4 <0.001

Eth.Consultation

18 (13.1) 10.0 16.4

Sometimes

51(37.2) 62.9 10.4

Disaster ethics edu

29(21.2) 22.9 19.4

Rarely 10 (7.3) 4.4 2.9

More personnel-

med. equipment

37(27.0) 42.9 10.4

Disaster Medicine n(%) %* %**

More effectiveHealth service n(%)

%* %**

1 year education

68(44.6) 68.6 29.9 Resources 60(43.8)44.3 43.3 <0.001

Intensive course

14(10.2) 5.7 14.9 <0.001 Communication 31(22.6)20.0 25.4

Short-term course

31(22.6) 4.3 41.8 Solve ethics issue 32(23.4)15.7 31.3

Conferences 19(13.9) 21.4 6.0 Take place crisis

– table 14(10.2)

20.0 0.0

No idea 5 (3.6) 0.0 7.4 No idea 0 (0.0) 0.0 0.0

%* Experiencing earthquake- Emergency Medicine Professional%** Not experiencing earthquake- Emergency Medicine Professional

54 Medicine and Law

Table 5. The multiple categories coordinates clearly show the difference between health professionals who experienced an earthquake and those who didn’t.

55


Medicine and Law

ADOPTION LAW, DILEMMAS, ATTITUDES AND BARRIERS TO ADOPTION AMONg INFERTILITY PATIENTS IN ISRAEL

Amira Daher *,** ,*** , Yaakov Rosenfeld *, **, Lital Keinan-Boker *, ****

Abstract: Introduction: Israel Adoption Law requires absolute confidentiality. This type of adoption is basically prohibited by Islamic laws and thus creates a conflict between the State’s Law and the Qur’an’s directives.

Objective: (1) to study the attitudes and barriers with respect to adoption among Jewish and Muslim couples undergoing fertility treatments. (2) To describe adoption rates of children in Israel’s sectors.

Method: A cross-sectional survey was conducted in fertility clinics among 204 Muslims and Jews treated for infertility. The participants were asked about their attitudes & knowledge concerning adoption. Additionally, national adoption rates, by sector, were retrieved from the Ministry of Welfare.

Results: Adoption rates among Jews were higher than among Muslims’. A prolonged period of fertility treatment was more common among Muslims than among Jews. A quarter of the Muslim couples pointed at the conflict between Quran Law and State law as a potential specific barrier.

Conclusions: It is important to deepen the understanding of the barriers against adoption among Muslims who failed fertility treatments, as well as to examine whether the change in State Law will encourage adoption of children among Muslims in Israel.

Keywords: Closed Adoption; Open Adoption; Fertility Treatment; Adoption Law; Kafala; Jews; Muslims; Israel.

* School of Public Health, Haifa University. Email: amiradaher99@gmail,com** District of Haifa & Western Galilee, General Health Services*** Zfat College Academy**** National Center for Disease Control, Ministry of Health

Med Law (2015) 34:55-68

56 Medicine and Law

INTRODUCTION

The desire for parenthood is a global human trait. Unfortunately, about 16% to 20% of all couples who wish to conceive have difficulties having a biological child.1 Fertility treatments in Israel are covered by the National Health Insurance Law and are given, for a first and/or second child, free of charge to all women up to the age of 45. Israel is ranked first in the world with respect to the number of fertility treatments per capita and third with respect to the number of in vitro fertilization (IVF) units per million people.2 According to the Ministry of Health, the rate of IVF treatments has doubled3 between the mid-nineties and 2006. The use of IVF treatments is so widespread today, that 1% of infants in the United States were born through IVF.4 However, the application of Advanced Reproductive Technology (ART) for infertility treatment is not always successful. In these cases an alternative solution is to adopt a child.5 Adoption of an abandoned child or an orphan is also important for society as a whole. Providing permanent, loving homes to all children in foster care is essential. All children deserve to have a family that loves them, cares for them, and can provide support throughout their entire life. Whereas Islam forbids certain ART’s (such as sperm donation, egg donation and surrogacy), adoption has become a particularly relevant option for Muslim couples.

Adoption Law in Islam

Adoption legislation (Adoption Law - 1981) in Israel allows only “closed adoption”, i.e. it prohibits any connection between the adoptees and their biological parents (until the age of 18).

1. Israel Ministry of Health: The Public Professional committee for examination the egg donation issue; 2000. www.health.gov.il/units/egg_cont/found.htm (accessed 19 Apr 2014) (Hebrew)

2. Hellman U, Bentove j. Risk of birth defects in children born after IVF treatment - fertilization. Harefua 2005; 144: 852-858.(Hebrew)

3. Shalev C, Gooldin S. The Uses and Misuses of In Vitro Fertilization in Israel: Some Sociological and Ethical Considerations. Jewish Women’s Studies & Gender Issues 2006; 12: 151-176.

4. Van Voorhis B J. Outcomes from assisted reproductive technology. Obstructive & Gynecology 2006; 107: 183-193.

5. Landau R. Fertilization innovative technologies: the right to instruct the biological parents or identified right? Social & Welfare 1995; (4): 367-378. (Hebrew)

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The adoptee does not know who the biological parents are and the biological parents do not know the identity of the adopting family. Such “closed adoption” is called in Arabic “At - tabany” and in fact is forbidden by the Qur’an.6,7

The Islamic term for what is commonly called adoption is “kafala”, which means “to feed.” In essence, it describes more of a foster-parent relationship, which is similar to the model defined as “open adoption”. The Qur’an gives specific rules about the legal relationship between a child and his/her adopting family. The child’s biological family is never hidden and their ties to the child are never severed.6,7 The Qur’an specifically reminds adopting parents that they are not the child’s biological parents: “Call them by (the names of) their fathers; that is more right in the sight of Allah. But if you know not their father’s (names, call them) your brothers in faith, or your trustees. But there is no blame on you if you make a mistake therein. (What counts is) the intention of your hearts. And Allah is Oft-Returning, Most Merciful.” (Qur’an 33:4-5)

Under Islamic law, the guardian/child’s relationship is subject to specific rules, which render the relationship a bit different from what is common adoption practice today: (1) an adopted child retains his or her own biological family name (surname) and does not change it, to match the adopting family’s name. (2) An adopted child inherits first from his or her biological parents, and not automatically from the adopting parents (3) when the child is a grown-up, members of the adopting family are not considered blood relatives, and therefore are not muhrim (forbidden) to him or her. Essentially, members of the adopting family would be permissible as possible marriage partners, and the rules of modesty are observed between the grown-up child and the adopting family members of the other gender.6,7

In Israel, there is a special ruling, “Fatwa”, by Muslim Scholars, which attempts to bridge the gap between the Qur’an laws and the State Law regarding child adoption:8,9

6. Landau R. Fertilization innovative technologies: the right to instruct the biological parents or identified right? Social & Welfare 1995; (4): 367-378. (Hebrew)

7. Alkadi A. Adoption by Islam. Islam University; 1957. (Arabic)8. Fatwa. Accessed 19 Apr 2014. From http://betsafafa.com/vb /showthread.php?t=240

(2008)9. Fatwa, Accessed 19 Apr 2014. From http://www.fatawah.com/fatawa/267.aspx (2009)

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The “Fatwa” allows adoption under certain conditions:

1. The infant is younger than two years.2. The adopting mother (or one of her relatives) should breastfeed the baby.

In addition, when an adoptee wishes to marry, he/she is required to open the “adoption file” in order to be acquainted with his/her biological affiliation and find out if there is any association to the future marital partner’s family. Since that Fatwa is not accepted by all Muslim Scholars, this problem is only partially solved (Personal communication).

Adoption Law in Judaism

Jewish sources do not explicitly address the issue of adoption of children. There are, however, some ruling streams of Judaism in this regard.10,11 The Halacha (Jewish law) is resistant to the social reality of adoption of children. The only question that characterizes the religious system is whether it is possible to commune with adopted children12. Namely, whether the laws that prohibit a man from staying alone with a stranger in a closed area are also applicable in case of a father with his adopted daughter or a mother with her adopted son. A number of contemporary religious rulings allow communion with adopted children. On the other hand there are rulings that regard and treat adopted children as non-family individuals who must not commune with their adopting parent of the other gender.12

Rationale

To the best of our knowledge, the ethnical aspects of the adoption issue has never been fully studied in Israel. It is not clear today whether the applications and actual adoption rates between Jews and Muslims are similar. Understanding the different social and cultural forces that affect the two main national sectors may enable the authorities to improve their responses to humanitarian needs.

10. Eisenberg, Ronald L. The JPS Guide to Jewish Traditions. PA: Jewish Publication Society, 2004.

11. Kolatch, Alfred J. The Jewish Book of Why/The Second Jewish Book of Why. NY: Jonathan David Publishers; 1989.

12. Paluch, M. The law of communion with adopted children – Controversy in Jewish law. Following the reply of Tchich Eliezer. Yeshivat hahesder, Orot Shaul, Petah Tikva from http://www.ypt.co.il/show.asp?id=21838 (accessed 19 Apr 2014) (Hebrew)

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Objective: The purpose of this study was to compare the rates of applications for adoption and the rates of actual adoption of children by Jewish and Muslim citizens in Israel.

A second goal was to investigate factors that may differently affect Jews and Muslims’ attitudes toward adoption, and act as potential obstacles to couples who consider such an option.

Hypothesis:The corresponding rates of adopted children and applications for adoption in Israel is lower among Muslims than among Jews.

Muslims’ motivation for “closed adoption” is relatively lower than the Jews’

Muslim couples that consider adoption have to deal with more potential obstacles than Jews do.

Most Muslim participants are aware of the conflict between Islamic adoption law and the State Law.

The conflict between State Law and Qur’an directives is a potential barrier among Muslim couples who consider adoption.

Methods

Stage 1:Adoption application rates and actual adoption rates among Jews and MuslimsAggregate computerized data regarding adoption of children by sectors are documented in the Child Welfare Service only since 2007. Data about the number of applications for adoption and the number of actual adoptions for the years 2007-2011 were retrieved from the Welfare Service. Rates were calculated for adoption applications and for actual adoption rates (in Israel and abroad), normalized to the relevant population size.

Despite Israel’s Adoption law’s (1981) requirement that a child be adopted by a family of the same religion, the Child Welfare system does not distinguish between Muslim and Christian Arabs. Thus, a direct comparison between Jews and Muslims cannot be relied on. Yet, most of the Arabs in Israel are Muslims (Around 84% of the Arab population in Israel is Muslim, and 9% Christian).13

13. Selected Statistics on Jerusalem Day 2007 (Hebrew)”. Israel Central Bureau of Statistics. (2007)

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Stage 2:

A cross section study among couples undergoing fertility treatments was conducted in the fertility clinics in “Ha’emek” hospital in Afulla, and in “Rambam” and “Ben-Zion” hospitals in Haifa. The study’s criteria included heterosexual couples and individuals who attended the clinics for infertility treatments.

Self-administered (Hebrew and Arabic) questionnaires were handed to 204 people (37 men and 167 women), 101 of whom were Muslims (79 women, 22 men) and 103, Jews (88 women, 15 men). The purpose of the questionnaire was to examine intentions to adopt, encouraging factors, barriers, and knowledge about the various types of adoption. Some questions were intended only for Muslim participants. This section included questions about the conflict between the laws of Islam and the State’s adoption Laws. They were also asked about the “Fatwa” regarding adoption in Israel. The results were analyzed for each group separately (Jews and Muslims) and (when applicable) compared between the groups.

Statistical analysis

Stage 1:

Adoption rates were calculated according to: (1) the number of children adopted relative to the size of each sector (Jews and Muslims) in the general population, and under 18 years old in the relevant year, normalized to 100,000. (2) Adoption application rates were calculated according to the number of applications for adoption relative to the size of each sector (Jews and Muslims) in the general population and over the age of 20 during the relevant year, normalized to 100,000.

(3) The rate of adoption of children from abroad was calculated separately, using the same method. Calculation of the significance of the periodic change in any of the groups studied (Jews and Muslim) separately based on linear regression, where the rate was used as the outcome and the calendar year as the independent variable. The P value of the regression coefficient served to describe the statistical significance. Calculation of the significance of the periodic change between the study groups (Jews and Muslims) was similarly based on linear regression where the difference in the rates between Jews and Arabs was used as the outcome and the calendar year was the independent variable.

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Stage 2:

The data has been inputted in SPSS software; it was tested for errors and exceptions, using test frequencies and distributions, and checked for out-layers.

The distribution of population socio demographic variables was standard, and was described by standard descriptive statistics: mean and standard deviation.

The distribution of responses to most questions such as: adoption intentions, position of family and friends to adoption, attitudes toward the types of adoption (open vs closed) were non-standard in most cases. Therefore, a-parametric tests were used to evaluate statistical significance. All tests were two-tails and significance was set as a p value smaller than 0.05.

Results

Child welfare data about adoption for the years 2007-2011.

According to Child Welfare data, the adoption application rates among Jews from 2007 to 2011 had an average rate of 9.22 per 100,000 people over the age of 20, compared to 3.25 on average among Arabs (2.8 times higher) (Figure 1).

The actual rate of adoptions of Jewish children (in Israel) during these years was 4.3 per 100, 000 children under the age of 19, on average, compared to1.6 among Arabs (2.7 times higher).

The actual adoption rate of all children (including adoption of children from abroad) was on average 6.8 per - 100,000 children under the age of 18 among Jews compared to 1.7 corresponding rates among Arabs (4 times higher) (Data 2007-2009) (Figure 2).

Cross Sectional survey results

Characterization of the study population – The participating Jews and Muslims differed significantly with respect to their average age (34 years among Jews, 31 years among Muslims), (p = 0.006). Jewish participants had a higher education and higher incomes compared to the Muslim participants (p= 0.001). Prolonged periods of fertility treatment (6 years or more) were more common in Muslims (35%) than in Jews (10%) (Table 1).

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Attitudes toward adoption- Attitudes toward adoption were measured on a four categories scale:

1 (not at all interested) to 4 (very interested), and were summed up to create a score, which linearly described the acceptance of the given attitude (4 denoting highest acceptance). Both Jewish and Muslim participants had relatively low motivation for adoption. However, Jewish participants were more willing and open to the adoption option than Muslims. Average attitude ranks (and standard deviation) towards adoption were 1.97 (0.87) by Jews participants and 1.71 (0.64) by Muslims (P = 0.051). There was no difference between men and women on this issue.

Attitudes toward types of adoption - Jewish participants more clearly preferred a “closed adoption” than Muslims who strongly preferred the “open adoption - kafalla”. Jews strongly favored closed adoption at a 3.75 (0.70) rank, compared to Muslims who preferred a closed adoption at a 2.87(0.78) rank (p <0.001). As for an open adoption, Muslims strongly favored this option, at a 3.02(0.78) rank, compared to Jews who ranked lower, at 2.20(0.74) (P <0.001).

Encouraging factors and barriers for “adoption of a child” According to the participants’ perception, Jews felt more encouraged by their society to adopt a child than Muslims (z=-4.938, p<0.001, Mann-Whitney test). The factor which had the most deterrent effect on attitudes in both sectors against adoption was the lack of a genetic link with the adopted child. Two factors mainly were linked to attitudes towards adoption among Jews: the presence or absence of biological children (χ2 (2) = 9.68, p <0.01) (Kruskal-Wallis test) and the number of persons in the family (χ2 (2) = 6.90, p<0.05) (Kruskal-Wallis test). Participants who had biological children and a higher number of family members had more negative attitudes toward adoption.

Two factors that were linked to attitudes towards adoption among Muslims were: Years of fertility treatments (χ2 (2) = 8.39, p <0.05) (Kruskal-Wallis test) and income level (χ2 (2) = 7.29, p <0.05) (Kruskal-Wallis test). As the number of years of treatment increased, the attitudes toward adopting turned more positive. However, among those with low income, aversion to adoption was greater.

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Knowledge about the conflict between the State’s Adoption Law and Islamic laws towards “closed adoption” among Muslim participants:

Interestingly, only 31% of the Muslim participants were aware of the Islamic adoption law (which allows only “open” adoption) and its conflict with the State Law (which allows only “closed” adoption). Remarkably, no differences were found in attitudes towards adoption between those who knew about the conflict, and those who did not, except that those who were aware of the Islamic law and the conflict had usually undergone more years of fertility treatment (p<0.01, z= -2.62) (Mann- Whitney test).

Twenty four percent of Muslim participants expressed their willingness to change their attitude towards adoption to a more positive one, were they able to adopt in accord with Islamic law. This group of participants was also undergoing more years (more than seven years) of fertility treatment than those who said they would not change their attitude towards adoption even if they were able to adopt in accord with Islamic law (P < 0.001). 90% of Muslim participants were unaware of the existence of the “Fatwa” that compromises between State Law and Islamic Law on the adoption type issue. After receiving the information on this ruling, 50% of the participants assessed that the Muslim “Fatwa” solved the problem partially, and 14% considered it fully solved.

Discussion

There is no better way to convey the message of the importance of adoption of orphans than the fact that the Prophet Moses was adopted by Pharaoh’s daughter and the Prophet Muhammad himself adopted a former slave and raised him with the same care as if he were his own son.6,7 Muhammad also said that a person who cares for an orphan will be in Paradise with him. However, according to the results of the present study, the message either was not passed on, or has been forgotten. The results of our study indicate that the rates of requests for adoption and actual adoption among Muslims are significantly lower than those among Jews. The Jewish participants’ attitudes toward adoption were more positive than the Muslims’. In both sectors, there was no enthusiasm for adoption as an alternative option for a biological child. However, the surveyed population was based on fertility patients, and apparently, people who choose to undergo these treatments wish to conceive a biological child. Those who had already chosen adoption were probably not represented in this study, which is one of the study’s limitations. Our findings, concerning the negative attitudes toward adoption of Muslims, support the results of qualitative research from

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Lebanon.14 The Lebanese study examined attitudes toward adoption “At - tabany” among Muslim men who were undergoing fertility treatment and found that out of 44 Muslim men who were interviewed about adoption, the vast majority (34 participants -77%) did not agree in any way to the idea. Study subjects were cited as “guardian of an orphan “kafala” - yes, “closed adoption” - no.

Another study by Aisicoglo et al15 from Turkey partially reinforces our results about the negative attitude of Muslims towards adoption. Their study included 400 Muslims participants, men and women, who were undergoing fertility treatment.

More than half of the respondents believed that egg donation is a better option than adoption, despite the fact that donor eggs are prohibited by law in Turkey. In our study, both Jewish and Muslim participants were mainly discouraged from adopting a child by the lack of genetic connection to the child. This finding is supported by previous studies. Van Den Akker16 found that fertility patients give the utmost importance to the existence of a genetic link with the child. It should be noted that 11% of the Muslim participants attended fertility treatments for more than seven years, while the corresponding rate among Jews was only 5%.

The reason for this gap may be explained by the fact that some ART’s (such as sperm donation, egg donation and surrogacy) are forbidden by Islamic laws but practiced by Jewish subjects. The adoption option should be a real and practical alternative for these couples, especially Muslims.

One of our research hypotheses concerned the possibility of a religious barrier among Muslims. Our study found that the Muslim participants’ knowledge about the conflict between State Law and Islamic Law concerning the adoption type was low and only 30% of Muslim couples in the study were aware of the issue, mostly those who had longer periods of fertility treatments. On the other hand, 24% of Muslim participants expressed their willingness to react more positively to the option of adoption, if they were able to adopt by Islamic Law. These data are consistent with the information provided by the Child Welfare

14. Inhorn M C. “He won’t be my son”: Middle Eastern Muslim men’s discourses of adoption and gamete donation. Medical Anthropology Quarterly 2006; 20(1), 27-94

15. Isikoglu M, Senol Y, Berkkanoglu M, Ozgur K, Donmez, L Stones-Abbasi A. Public opinion regarding oocyte donation in Turkey: first data from a secular population among the Islamic world. Human Reproduction 2006; 21(1): 318-323.

16. Van Den Akker O.B.A. Adoption in the age of reproductive technology. Journal of Reproductive and Infant Psychology 2001; 19(2): 147-159.

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Service that Muslim couples who realize that the only adoption type accepted in Israel is in contradiction to Islamic law, often withdraw from the process (personal communication).

As mentioned above, the adoption of children in Israel is regulated by law and is a “closed adoption.” The Israeli “closed adoption” regime is based on psychoanalytic theories, based on the concept that such an adoption style best serves the interests of the child. However, in recent years there are publications of relevant professional literature in Israel and abroad in favor of the “open adoption” approach. It seems that each approach has its merits, making it the best choice only according to case specifics.17-20 In New Zealand, for example, open adoption is the accepted method, and is consistent with the best interests of the child. The same is true in several US states.20

Conclusions

It seems that both Jewish and Muslim participants have no enthusiasm for adoption. While Jewish society, when compared to Muslim society, is more open to closed adoption, it is still ambivalent concerning adoption.

Muslim society in Israel does not embrace “closed adoption – Eltabany” even though large parts of it do not know the Islamic roots of this attitude. It is possible that the conflict between the type of adoption permitted by Islam and that practiced by Israeli State Law adversely affects the adoption decision among “ Muslim fertility patients” who do not achieve the desired result after many years of treatment, and probably begin to consider the option of adoption. It is possible that many couples who suffer physically and emotionally from years of fertility treatments21, 22 would be redeemed from this suffering if an opportunity to adopt according to their religion was open to them.

17 Triseliotis J. Adoption - The evidence examined. In. Adcock M. Kaniuk J. &. White R. (eds.). Exploring Openness in Adoption. London: Significant Publication; 1993.

18. Demick J, Warner S. Open and Closed Adoption: A Developmental Conceptualization. Family Process 1998; 27: 229–249.

19. Gross H E. Open adoption: A research-based literature review and new data. Child Welfare 1993; 77: 269-284.

20. Gottliev D. Open adoption: Formation Israeli access. Medicine and Law 1989; 19. (Hebrew)21. Menning BE. The emotional needs of infertile couples. Fertility and Sterility 1980; 34:

313-319.22. Wright J. Duchesne CS. Sabourin S. Psychosocial distress and infertility: men and women

respond differently. Fertility and Sterility 1991; 55: 100-107.

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Summary and Recommendations

1. The correlation found between years of fertility treatment (which was particularly high among Muslim patients) and more positive attitudes towards adoption, indicates the importance of providing clear and reliable information about the option of adoption by the medical staff ( doctors and nurses) in fertility clinics. It can be done by raising awareness and giving information about adoption opportunities to medical staff in fertility clinics that can then encourage and refer patients who failed fertility treatments over long years to turn to the option of adoption.

2. In view of our findings regarding negative attitudes towards adoption among both Jews and Muslims, it is necessary to increase awareness of the importance of the adoption of children in fertility patients’ population. Better understanding of cultural / social / religious factors affecting these positions may allow targeted interventions for change. This can increase the level of freedom, and allow greater opportunity for adoption especially among Muslims.

3. In light of the missing data on the relevant Muslim population who failed fertility treatments and began considering adoption, further qualitative research, investigating barriers against adoption, should be done among this specific population. It is important to deepen the knowledge about the existing ruling (Fatwa) while also considering a change in the relevant State Law. That is, to examine the possibility of granting Muslims in Israel the freedom to choose their adoption procedures according to the laws of their religion. Same should apply to other family laws, such as marriage and divorce which, today, already are under the authority of their respective religious courts.

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Figure 1

Figure 2

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Table 1: Characterization of the study population by sector

Variable Jews N (%) Muslim N (%) P-value1

Status:

MarriedsingleDivorced

87 (84.5)12 (11.7)4 (3.9)

101 (100.0)0 (0)0 (0)

<0.001

Primary infertility (no children) 61 (59.2) 65 (64.4) 0.453

Education:

Primary school High school and professional Academic

0 (0)52 (50.5)51 (49.5)

5 (4.9)72 (71.3)24 (23.8)

<0.001

Income2:

Below averageEqual to the averageAbove average

33 (32.0)15 (14.6)55 (53.4)

42 (42.0)31 (31.0)27 (27.0)

<0.001

Years fertility treatment:

1 - 56-10Over 10

92 (90.2)9 (8.8)1 (1.0)

66 (65.3)26 (25.7)9 (8.9)

<0.001

Level of religiosity:

SecularTraditionalReligiousGodly

55(53.4)34 (33.3)9 (8.8)4 (3.9)

2 (2.0)49 (48.5)44 (43.6)6 (5.9)

<0.001

1 Chi-square test2 Average family monthly income: 8,000 NIS

69


Medicine and Law

THE PUBLIC’S PERCEPTION OF THE STATUS AND IMAgE OF THE NURSINg PROFESSION

Salam Hadid, Ph.D.* and Mohammad Khatib, Ph.D.**

Abstract: The International Council of Nurses (ICN) defined nursing as a sphere integrating autonomous and collaborative care provided to the individual, family, and community within and outside of the care setting. Furthermore, the ICN noted that the profession comprises four major spheres of action: promoting health, preventing illness and treating patients, treating people with disabilities, and providing end-of-life care. The ICN’s directives and recommendations for assimilating its Code of Ethics emphasized that the nursing staff and nursing students must understand its clauses, act according to them, discuss them with colleagues and others, and integrate its details in all spheres of action, teaching, administration, and research. Over the past half century since publishing the Code of Ethics, nursing as a care profession has developed broadly in terms of its essentials, expertise, and primarily academically. Despite the impressive growth of the profession, there is still extreme diversity in the public’s perceptions and opinions of the profession and its professionals and in the knowledge of the fundamentals of its true function and spheres of engagement. The current study examines the existing knowledge among the general population regarding the nursing profession.

Keywords: Nursing Ethics; Nursing Profession; Autonomous Care; Collaborative Care, Nurse’s Image, Nurse’s Status.

The ICN first published its Code of Ethics for the profession in 1953. In its 2012 latest update, the nursing profession was defined as rendering “health services to the individual, the family, and community and coordinating their services with those related groups” (http://www.icn.ch/images/stories/documents/about/icncode_english.pdf). Thus, the profession is a sphere which integrates autonomous and collaborative care directed at the individual, family,

* Department of Nursing, Zefat Academic College, Zefat, Israel. e-mail: [email protected]** Department of Nursing, Zefat Academic College, Zefat, Israel. e-mail: khatib.health@

gmail.com

Med Law (2015) 34:69-90

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and community within and outside of the care settings.” Similarly, it defined the nursing profession as comprising four principal elements that outline the standards of ethical conduct: “to promote health, to prevent illness, to restore health, and to alleviate suffering,” i.e., care for the terminally ill. Additionally, nurses must be involved in advocacy, environmental change, research, change in policymaking, and education, as an integral part of the modern nursing professionals’ function.

The Israel Nurses Association Code of Ethics (2004), based on the ICN Code of Ethics, demonstrates the link between selected values and patient’s rights and the caregiver’s obligations. It sets down a pathway of care directed towards three spheres: the nursing staff and patients, the nursing staff and society, and the nursing staff and its professional colleagues — nurses and others. According to the Israeli Code, the nursing staff must work to promote the health of society as a whole and of interest groups with a common interest in health, as well as to initiate and act to empower the individual and the community and represent its positions and needs. In addition, nurses must maintain and improve the quality of the environment with the assistance of various agencies, and take part in various professional committees and agencies.

The nursing profession, which according to the World Health Organization (WHO) (2007) comprised approximately 14 million male and female nurses worldwide, provided various educational programs in nursing studies as well as continuing education modules for academic studies, such as Masters and doctoral degrees.

However, despite the impressive development and growth of the nursing profession, there is a great diversity between the public’s perceptions and opinions of the profession and its practitioners and between the essence of the true function represented in the Code of Ethics and definition of the profession. On one hand, the nursing profession succeeded in developing independently and producing an evidence-based body of knowledge, which includes care protocols and directives, the significant development leading to a more professionalized field; on the other hand, many studies have shown that nursing still receives insufficient recognition for its actions from the majority of the public (Hoever, Jansen & Roodbol, 2013; Goban & Kasikci, 2011).

The image of nursing among the general public is incompatible with the intense development the profession has undergone over recent decades and the re-definition of its roles (Coban & Kasikci, 2011), its spheres of engagement, the monetary remuneration, degree of independence in decision-making, and

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the opportunities for development and advancement (Morris-Thompson, Shepherd, Palat, & Marks-Maran, 2011). This gap continues to constitute one of the challenges the profession is attempting to overcome (Buerhaus, Donelan, Ulrich, DesRoches & Dittus, 2007). As early as the 19th century, the image of the nurse was a major issue, and challenged all those who worked in the field (Rezali-Adryani, Salsali, &Mohammadi, 2012). The image of the nursing profession was of a voluntary profession suited to “low class” people, akin to maternal caregiving, and merely assisting physicians (Kunene, Nzimande&Ntuli, 2001).

Although as early as 1869, nursing pioneer Florence Nightingale defined nursing as a profession which was independent and parallel to the function of the physician, for years, nursing was perceived as a profession inseparable from medicine and not autonomous (Hoever, Jansen, & Roodbol, 2013). Florence Nightingale fought to promote the image of the nurse as a care professional in the face of the public image that the nurse was morally inferior, and little better than a prostitute.

The Oxford Dictionary defines “image” as “the general impression that a person, organization, or product presents to the public.” The image of the nursing profession has been defined as the perception of the profession as seen by the multidisciplinary nursing staff, patients, and their families (Morris-Thompson, Shepherd, Palat & Marks-Maran, 2011).

The image of the nursing profession since the 20th century is not a static concept, and is dynamically changing over the years, as impacted by its times and environment. Political, socioeconomic, cultural, technological, and educational factors, as well as contemporary times, stances, and public opinion, all impact the nurse’s image (Lesolang, 2011; Rezali-Adryani, Salsali, & Mohammadi, 2012). Most importantly, the profession’s image is likely to impact the nurse-patient relationship, their cooperation, and provide a positive response to the proposed care protocol provided by the nursing staff (Takase, Maude, & Manias, 2006). In the same vein, the literature pointed out that the image of the nursing staff is significant for the profession, since it impacts decision making on whether to study nursing, work as a nurse, and remain in the profession (Emeghebo, 2006; Price, Hall, Angus & Peter, 2013 ; Whitehead, Mason & Ellis, 2007).

Rezali-Adryani, Salsali, and Mohammadi (2012) studied the concept of the “image of the nursing profession” and described it as multifaceted, comprehensive, and inclusive of several elements: how the general public

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perceives the profession; how nursing students and graduates perceive the profession; and the nursing staff’s own view of their image among the general public and the nursing staff as reflected in the media.

Other factors impacting the image of the nursing profession are the media, flawed communication, dress and type of uniforms, behavior of the nursing staff, and gendered views. For the most part, nursing has been represented as a feminine profession in which the males are managers and hold positions of authority (ibid.).

The profession’s image can impact other aspects of nursing, such as functioning, recruitment of new staff, nursing shortages, the relationship with other healthcare professionals and paraprofessionals, violence against the hospital staff, trust among the public in nurses, low salary levels, burnout, job satisfaction levels, job performance, and leaving the profession (Takase, Maude & Manias, 2006; ). Many governmental health authorities, such as the Strategic Health Authority for London (SHA) and the National Health Services (NHS) of London and West Midlands, have established research teams to examine the relationship between the image of the nursing profession and recruitment of nurses and holding on to staff as forming the basis for serious strategies to improve the image. An improved image of the profession increases awareness to the skills and the importance of the profession, leading to attracting more people to study the profession (Morris-Thompson, Shepherd, Palat, & Marks-Maran, 2011). The more positive the image, the more students decide to study nursing and enter the profession (Bar Natan & Becker, 2010).

The image of the nursing profession among the general public is fed by various stereotypes. It is usually considered a feminine profession, valued, courageous, insufficiently compensated for their work, overworked, passive, involved in unhappy mental processes and situations, requires empathy but does not require expertise or education (Morris-Thompson, Shepherd, Palat & Marks-Maran, 2011).

The literature shows that the image of the nursing profession among the general public is impacted by information coming from the media (Hoever, Jansen &Roodbol, 2013 ; Donelan, Buerhause, DesRoches, Dittus & Dutwin, 2008). Additional characteristics attributed to the profession, such as prestige and respect, as well as the nurses’ degree of independence and the perception of nursing as a profession based on humanistic values and leadership, are impacted by the dominant culture of the general public. Despite the literature pertaining to the image of nursing and the public perception of its functions

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and spheres of action, these components have been insufficiently studied in Israeli society with its cultural diversity, specifically in the Galilee, which is characterized by a broad spectrum of subcultures and religious and ethnic communities. Consequently, the current study is doubly important since it examines the public’s knowledge about nursing, and the commonly held perceptions of the main characteristics and values on which the profession is based. It can thus become the basis for the development of the existing knowledge about the image and status of nurses towards interventions aimed at promoting the nurses’ status and improve their image.

MethodThe descriptive quantitative methodology used in this current study is based on direct data, gathered from respondents among the public. The goal of this research was to examine the public’s perception of the status and image of the nursing profession and nurses, the general level of knowledge about nurses’ responsibilities, their spheres of action and the nature of the profession. We further aimed at examining whether there is a correlation between several selected traits of the public (demographic and social data) and exposure to medical or nursing care with the public’s opinions and perceptions of the profession.

Measures The study used a semi-structured questionnaire in Hebrew, developed by the authors for this specific study. The questionnaire comprised 15 questions; seven of which were on demographic details and personal background, such as education, profession, and exposure to healthcare. Two open-ended questions elicited knowledge of the nurse’s spheres of action and workplaces as perceived by the respondents; two questions examined the level of prestige of the nursing profession among professions in general and among healthcare professions in particular. Responses were ranked on a Likert scale from 1-5 in which 5 represented the highest prestige and 1 the lowest. Seven statements examined the public’s perception of the nursing profession; respondents were asked to rank their agreement or disagreement with the statement on a 4-point Likert scale (4=completely agree, 1=completely disagree). Such statements were: “The nurse is an assistant to the physician,” “Nursing is a woman’s profession,” “Nursing is a difficult profession,” “There is no need for academic studies in order to be a nurse,” “The nurse is a leader,” “The nurse is ‘an angel in white,’” and “Nursing is not a suitable profession for men.”

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The questionnaire responses were filled out in Hebrew by nursing students from an academic college in northern Israel, who conducted face-to-face interviews with respondents in their home communities, in whichever language they felt most comfortable with (Arabic, Hebrew, English, Russian). The research population consisted of 498 respondents.

Data analysisThe data were coded and input for statistical processing, which comprised a description of the research population (distribution by selected demographic characteristics) and the extent to which respondents were exposed to care in the past, averages, and standard deviation. Linear regression, t-test and x2 were applied to the data in accordance with the questions and the research goals.

ResultsA total of 498 people participated in the current study while 52.6% were females and 47.4 males (Table 1); 48.2% were Muslims; 31.7%Jews; 12.4% Christians and 7.6% Druze. The age of the participants ranged from 18-81 years. About 61% of them had higher education. Most of the participants (86.5%) had been exposed to some kind of health care while 80.5% of them were cared for by a physician, and 70.9% by a nurse. 20.7% signed that they were cared for by a physiotherapist and 4.4% by other healthcare professionals.

The majority of the respondents noted that nursing focuses on the technical aspects, while the emotional aspects and promotion of health for the patient are not the nurse’s responsibility. Most of the respondents saw nurses working mainly in hospital and community-based clinic settings. They considered nursing to be a high prestige profession when compared to professions in general, but less prestigious among respondents exposed to healthcare. Most of the respondents considered nursing to be a humane profession but lacking independence and with no need for academic studies.

The public’s knowledge about the nursing professionThe public’s knowledge of nursing was examined through several questions referring to spheres of care by nursing personnel: general care, provision of basic needs, emotional support, performing skilled techniques, education and advancement of health, technical assistance to the physician, and questions on nurses’ possible work settings. A total of 91.2% of the respondents noted that providing emotional support to patients was not part of the nurse’s job, while 69% stated that the nurse’s job is to perform technical skills. About one third noted that providing basic needs, general care, and assistance to the physician

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are part of the nurse’s role. Only 8% noted that health education and promotion of health are part of the nursing role.

As for possible work settings for nursing personnel, 90-97% of the respondents noted the care settings (hospitalization and community-based settings; community-based clinics, and well-baby clinics), while 63-72% of the respondents mentioned geriatric nursing institutions and schools as additional workplaces.

The findings show a difference between male and female respondents’ knowledge of the nurse’s functions (see Table 3). The women knew more about nurses’ work, but the differences were not statistically significant. In contrast, it was found that respondents who had been exposed to care knew more about nurses’ work than those who did not experience or witness nursing care. These data showed a significant relationship between exposure to care (in general or by a nurse) and level of knowledge of nurses’ functions, as compared to those who were not exposed to care, with a significant correlation between exposure to care and level of knowledge about nurses’ skilled techniques as part of the nurse’s job (p=0.001). It was also found that people who were cared for by a nurse noted promotion of health as one of a nurse’s functions (p=0.03) more than those who were not exposed to nursing care. Furthermore, a significant positive correlation was found between exposure to care and public awareness of care settings – both hospitalization and community-based – as workplaces for nursing personnel.

In order to predict the general level of prestige attributed by the public to the nursing profession and based on existing knowledge of the spheres in which nursing engages, we applied multiple regression analysis to the data. We could therefore explain the low level of prestige attributed to nurses resulting from the perception that nursing is the physical care and provision of basic needs for the patient (p=0.01). In contrast, we could explain the high level of prestige attributed to nurses by the public perception of the nurse as performing skilled techniques. Table 4 presents the results of the multiple regression analysis. As for the specific level of prestige attributed to nursing as compared to other healthcare professions, none of the associations were found to be statistically significant.

Perceptions and opinions of the nursing profession among the general publicPerceptions of nursing as a profession were examined by studying the level of prestige and respect the public attributes to the profession as compared

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to other professions and as compared to healthcare professions, the need for academic studies, the perception of the profession as a “female profession” or as suitable for males, as well as level of difficulty and of independence of the profession and of those who engage in it. Furthermore, we examined whether there was a correlation between these perceptions and selected demographic characteristics and exposure to medical care provided by various types of practitioners in the healthcare delivery system.

Overall prestige of nursing as compared to other professionsFindings showed that the public attributes a high level of prestige to the nursing profession in relation to other professions. The average score on the prestige scale given to nursing overall was 3.75. Though the difference was not significant, it was found that respondents who had been exposed to medical care provided by a physician or by a nurse attributed a higher degree of prestige to nursing than respondents who had not been exposed to medical care. In addition, we found no significant difference between male and female respondents in terms of the general prestige attributed to nursing in relation to all other professions. However, we did find significant differences in the level of general prestige of nursing among respondents of different religions. The Druze attributed higher prestige to nursing (4.0) as compared to Muslims (3.9), Christians (3.8) and Jews (3.0).

Univariate analysis did not produce differences in the general prestige of the profession among respondents grouped according to level of education. In contrast, we found significant differences according to age groups, with young people (18–30) attributing less prestige to the nursing profession as compared to other groups. We found a positive correlation between age and level of general prestige attributed to nursing.

Prestige of nursing as compared to other healthcare professionsIn general, respondents awarded a higher score to the profession of nursing as compared to other healthcare professions (x=3.70; SD=.93). We found that people exposed to medical care attributed less prestige to the profession as compared to other healthcare professions than respondents who were not exposed to medical care (3.72 and 3.97 respectively) significant p=0.04. In addition, we found that respondents exposed to care by a nurse also attributed less prestige to the nursing profession in terms of other healthcare professions than the prestige attributed by respondents who had not been exposed to medical care (3.89 and 3.71 respectively), significant p=0.03.

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Female respondents attributed more prestige to nursing as compared with other healthcare professions than male respondents, with the women awarding a 3.84 score and men 3.6 significant (p=0.04(. It was found that Druze respondents attributed more prestige to nursing than other healthcare professions (x=4.12) as compared to Muslims (3.85), Christians (3.86) and Jews (3.45) (p=0.001).

Furthermore, although we found no significant differences due to respondents’ education, we did find a positive correlation between age and degree of prestige attributed to the nursing profession. Referring to other healthcare professions, young people (18–30) attributed less prestige to the profession (3.67) as compared to adults (51+) (4.13) where p=0.003.

Respect, humanism, independence, leadership and professionalization

The current study examined the general public’s perceptions referring to several characteristics of the nursing profession: respect towards the profession in society in general, to what extent the profession is considered humanistic, the extent of the nurse’s independence and the dependence on the physician, leadership, and the need for greater academic studies in the profession. The respondents’ opinions were examined by giving a score between 1–4 to each component (in which 1=“completely disagree” and 4=“completely agree”).

The findings show that there is a broad consensus in considering nursing as a respected profession (x=3.72); however, the public’s perception of the nurses still considers them as assistants to physicians (x=3.23), with less professional independence (x=1.77). Furthermore, there is medium-level agreement on the need for more academic studies in the profession (x=3.18), perceiving nursing as a humanistic profession (the nurse as “an angel in white”) (x=3.40), and as a leader (x=3.19).

The above characteristics of the profession were also examined according to selected variables applied to the respondents: gender and exposure to care by a nurse and other healthcare providers. Research results showed that there are no significant differences between men and women referring to the nurse’s independence (1.78 as compared to 1.75, respectively), the nurse’s dependence on the physician (3.22 as compared to 3.24), referring to nursing as a respected profession (3.68 and 3.76), the need for academic studies for nurses, and the nurse as a leader. It is important to note that the statistically significant difference found between men and women referred to the statement that nursing is a humanistic profession and that the nurse is an “angel in white” (3.47 as compared to 3.32, respectively, with p=0.003).

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The findings showed that exposure to nursing or medical care had no impact on the public’s perception of the nurse’s dependence on the physician, degree of professional independence, respect for the profession in general society, need for academic studies, nursing being a humanistic profession, and the nurse as a leader.

Nursing as a “woman’s profession” and a “difficult profession”The findings showed in general that the public does not consider nursing as a “women’s profession,” perceiving it as a profession suited for men, as well. The average score of agreement that nursing is a “woman’s profession” was 2.9, while a 3.14 score was obtained on agreeing with the statement that the profession was also suited to men. There was no difference found in this perception among men and women (2.77 as compared to 2.99 respectively). Furthermore, no differences were found in these perceptions among those exposed to medical or nursing care and those who were not exposed to such care.

We found that the public perceived nursing as a “difficult profession” (x=3.62, SD=0.59), with a significant difference between women’s and men’s perception. Women considered nursing more difficult than men did (3.69 as compared to 3.57). Exposure to medical care did not impact the perception of the difficulty of the profession. Similarly, people who were exposed to healthcare by nurses showed greater agreement (x=3.66) with the statement that nursing is a difficult profession than those who were not exposed to nursing care (x=3.57), but the difference was not statistically significant.

DiscussionThe current study examined the general public’s knowledge and attitudes to the image of the nursing profession as well as perceptions held by the public on the definition of the nurse’s role, spheres of activity and value-based characteristics and their impact on background variables of these areas.

The findings showed a lack of knowledge among the general public as to the essential function of the nursing profession and its spheres of action. Most considered it a care profession based mainly on performance of skilled techniques. About one third (33.5%) perceived the nurse as assisting the physician, as dependent on the doctor, and not as an autonomous professional. Very few noted the role of promoting health and providing emotional support as part of the nurse’s job. These findings are similar to those of Morris-Thompson, Shepherd, Palat and Marks-Maran (2011), who found that the knowledge

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existing among the general public in England referring to the definition of the function of nursing is flawed and lacking. Respondents in England noted the nurses’ functions, such as dispensing medicines and providing care and assistance, as the major components of their job. Despite precise definitions of nursing, as defined by the ICN and its Code of Ethics, the image of nursing among the general public is incompatible with the great progress achieved in the field of nursing and the definition of its functions; promoting health, preventing illness, restoring health and alleviating suffering (Hoever, Jansen, &Roodbol, 2013).

In the current study, these functions were noted as marginal. It was found that awareness of the nurse’s spheres of engagement was impacted by exposure (or non-exposure) to nursing care. The variables of exposure to medical care in general as well as exposure to care specifically by a nurse (and not by another professional) were examined, and it was found that respondents exposed to care noted that the nursing profession is engaged mainly in skilled techniques. Those who were exposed to care provided specifically by a nurse, noted that the issue of promoting health constitutes a significant part of the function of the nursing staff. These findings emphasize the importance of using the care encounter to the fullest, in terms of using the interaction between the nursing staff and the patient and family as a springboard for raising the level of the image of the profession. Health authorities in countries such as England have established teams of scholars to examine the association between the image of nursing and recruitment of nurses for policymaking to prevent serious nursing shortages in their countries (Morris-Thompson, Shepherd, Palat, & Marks-Maran, 2011; Morris, 2010).

The current study found that the level of knowledge among the respondents referring to the nursing profession impacted the degree of perceived prestige attributed to nurses. The more the respondents attributed only functions of physical care and provision of basic needs, the lower the level of prestige attributed to the nurse. In contrast, respondents who considered nurses as having the capacity to perform skilled techniques rated the profession as more prestigious. This finding can be explained by modern nursing techniques involving a high level of technological expertise, which leads to the public perceiving nursing as a more prestigious profession than merely taking care of patients’ basic physical needs. Other studies have found that in recent years, nursing has been described as a profession engaged in state-of-the-art technologies more than a profession that provides physical care for patients (ibid.). Merling and Van Wyk (2013), who studied the image of nurses as

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perceived by the public in South Africa, found that respondents perceived nursing as a care profession engaged in skills requiring manual work, which led to a positive perception of the profession.

The ICN defined nursing also as a field that integrates autonomous and collaborative care of the individual, family, and community, within and outside of the care setting. Autonomy and collaboration were not perceived as part of the nursing profession in the current study; on the contrary, respondents in northern Israel perceived nursing as a profession of assisting physicians and subject to physicians, whose major sphere of action is focused on technical skills. Although as early as 1869, nursing pioneer Florence Nightingale defined nursing as a profession which was independent and parallel to the function of the physician, for years nursing was perceived as a profession inseparable from medicine and not autonomous (Hoever, Jansen, & Roodbol, 2013)

As shown in the current study, the level of prestige of the nursing profession attributed by the respondents rose under the impact of exposure to healthcare. The image of the nursing profession was greatly impacted, though not exclusively influenced, by the experience of care in which a nurse was involved.

The media also had a great impact on the nurse’s image (Donelan, Buerhaus, DesRoches, Dittus & Dutwin, 2008; Hosken, 2009). In their study on the image of the nursing staff as seen by nurses and as perceived by the general public, Morris-Thompson, Shepherd, Palat & Marks-Maran (2011) noted that the public respected nurses but would not choose it as a lifetime profession that they would recommend studying themselves or advise their children or students to take up.

Furthermore, the degree of prestige attributed to the profession was impacted by the age of the respondents. Younger people (18–30) attributed less value to nursing than did respondents aged 50 and over. This finding can be explained by the fact that as people age, they are exposed more frequently to nursing care, thus having more opportunities to be aware of additional aspects of the profession.

Nursing receives a different rank when compared to other healthcare professions and to professions in general, as shown by Seago et al. (2006). Approximately 3,000 students of sciences and mathematics were asked to rank nursing as a profession, with the result that nursing was described in positive terms regarding salary, job opportunities, and interest on the job. However, it was ranked after other healthcare professions such as physiotherapy and

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education in terms of perceived independence and as a “woman’s profession.” A similar trend was found in the present study: respondents exposed to medical care in general or by a nurse attributed less prestige to the nursing profession as compared to other healthcare professions. This finding shows that, when compared to other healthcare professions, the current type of care encounter does not contribute positively to the nurse’s professional image.

In addition to examining the knowledge of nursing held by the public and the prestige attributed to the nurse, the current study also examined attitudes towards nursing as a profession. Findings showed that although the general level of perceived prestige of nursing was high, the respondents considered nursing as a profession that was dependent and not autonomous, and perceived nurses as assistants to physicians and subject to them. Nursing was perceived as a profession for women, without the necessity for academic studies. The literature showed similar findings, with the general public perceiving nursing as a difficult profession, underpaid, requiring “obedience” and following instructions, passive, vilified, feminine, and providing care (Morris-Thompson, Shepherd, Palat& Marks-Maran, 2011). Furthermore, nursing was perceived as engaged in unhappy mental processes, requiring empathy, yet with no need for expertise or higher education. Additional perceptions were that nursing was still considered a “feminine profession,” a care profession with a low status, subject to physicians (Lui, 2010). Other studies found that despite the process of nurses’ training, respondents still considered nursing to have relatively low prestige, subject to physicians, non-autonomous and not requiring academic licensing (Hoever, Jansen, & Roodbool, 2013).

The knowledge and perceptions of nursing as described above can make it difficult to recruit nursing students. The current study did not examine this aspect, but the literature discusses the problem. Factors encouraging young people to choose nursing as their field of study are associated with the essential nature of the job in terms of healthcare provision, independence, leadership and other factors. The prevalent image of the profession and erroneous perceptions of nursing blur the fundamental nature of the role of the nurse, and make it more difficult to attract young people to study the profession (Price, Hall, Angus & Peter, 2013).

Conclusions and recommendationsThe general public seems to have flawed knowledge regarding the nursing profession. Despite efforts by the various nursing associations and nursing schools to promote the profession in terms of academic studies, role definition, and improving its image, they have less impact on the general public

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The research findings show that the general public still holds various negative perceptions of the nursing profession. This is despite the changes and developments in defining the professional roles of the nurse as reflected in the ICN Code of Ethics and the Code of Ethics of the Israel Nurses Association and the training processes of the numerous tracks for nursing studies. It seems that notwithstanding the many actions by the various schools of nursing and nursing associations to promote the profession academically and improve its image, the change in the public’s knowledge and perception has yet to be internalized. Much effort is still needed to achieve this goal.

In addition, the existing knowledge among the general public regarding the nursing profession is flawed and lacking. It seems that due to the lack of knowledge, perceptions of nursing as “a woman’s profession,” and the nurse as dependent, still exist. Nevertheless, nursing is considered a valued profession among the public, even though there is erroneous thinking as to the need for expert skills, level of knowledge required, degree of autonomy, and status of the profession. These perceptions and level of knowledge can explain the difficulty in recruiting new, high-quality personnel to the profession. Consequently, serious steps must be taken to improve the image of the nursing profession on several levels and on various fronts (Auker, 2004).

We suggest that nursing schools address the student nurses, who can be the best ambassadors for the profession (Hanson, 2013). The students can do so by addressing their home communities (family, friends, and community) and/or through their patients and patients’ families. In addition, staff training can improve communication skills among the nursing staff, explaining how the nurses can use the healthcare encounter with the public to improve the image of nurses. The care encounters can place greater emphasis on the role of nursing and the responsibilities of the nurse to leverage assimilation of the ICN Code and its image. Such efforts in implementing the recommendations of the Ethical Code would lead to emphasis on the necessity for the nursing staff and nursing students to understand its provisions and act accordingly. It would encourage a collegial discourse on ways to integrate the recommendations of the Code throughout all areas of nursing in practice, training, administration, and research.

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Ben Natan, M. (2009).Effect of nursing education on the image of nursing as a profession in Israel.International Journal of Nursing Education Scholarship 6 (1), DOI: 2202/1348923X, Article 38.

Bar Natan, M., & Becker, F. (2010). Israelis’ perceived motivation for choosing a nursing career. Nurse Education Today 30(4), 308-313.

Buerhaus, P. I., Donelan, K., Ulrich, B. T., DesRoches, C. & Dittus, R.( 2007). Trends in the experiences of hospital employed registered nurses: Results from three national surveys. Nursing Economics, 25(2), 69-80.

Emeghebo, L.E. (2006). Nurses’ perceptions of the image of the profession of nursing. (Dissertation submitted for the degree of Doctor of Education, Columbia University of New York, USA).

Donelan, K., Buerhaus, P., DesRoches, C., Dittus, R., &Dutwin, D. (2008). Public perception of nursing career: The influence of the media and nursing shortage. Nursing Economics 26(3), 143-165.

Goban, G. & Kasikci, M. (2011). Development of the attitude scale for nursing profession. International Journal of Nursing Practice. 17: 518-524.

Hanson, J., (2013). From me to we: transforming values and building professional community through narratives. Nurse Education in Practice 13 (2), 142-146.

Hoever, Y., Jansen, G., & Roodbol, P. (2013). The nursing profession: Public image, self-concept and professional identity. A discussion paper. Journal of Advanced Nursing.Doi: 10.1111/jan.12177.

Hosken, G. (2009). Nurses drink tea while mom gives birth. Pretoria News, 1 June: 1.

International Council of Nurses-ICN. (2006).The ICN Code of Ethics for Nurses. Revised and updated 2012 version. Retrieved from:

http://www.icn.ch/images/stories/documents/about/icncode_english.pdf

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Israel Nurses Association Bureau of Ethics.(2004).Code of Ethics of the Israel Nurses Association, revised version of 1994 Code.

Kunene, P.A., Nzimande, P.N., & Ntuli, P.A.(2001).The image of nursing profession as perceived by the community members of three adjacent residential areas of Empangeni in Kwazulu-Natal.Curation. 24(2): 35-41.

Lesolang, E. (2011). Help clean up the image of nursing. Nursing Update.December.40-41.

Lui, Y. (2010). Nurses’ work role in the context of gender and Chinese culture: An online forum study. Journal of Nursing Research 18(2), 117-124.

Merling, A.,& Van Wyk, N.C. (2013).The image of nurses as perceived by the South African public.African Journal of Nursing and Midwifery, 15 (2), 3-15.

Morris-Thompson, T., Shepherd, J., Palat, R., & Marks-Maran, D. (2011). Diversity, fulfillment and privilege: the image of nursing. Journal of Nursing Management, 19, 683-692.

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17(1), 16-19.

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Takase, M., Maude, P., & Manias, E. (2006) Impact of the perceived public image of nursing on nurses’ work behaviour , Journal of Advanced Nursing 33(3), 333-343.

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Table 1. Distribution of the research population by demographic characteristics and exposure to healthcare.

N %general 498 100gender Male 236 47.4

Female 262 52.6Religion Jewish 158 31.7

Muslim 240 48.2Christian 38 7.6Druze 62 12.4

Age 18-18 273 54.8031-40 90 18.1041-50 69 13.9050+ 66 13.30

Education None 3 0.6Elementary 29 5.8Secondary 163 32.7Higher education 303 60.8

Past healthcare recipients Yes 431 86.5No 67 13.5

Cared for by physician Yes 401 80.5No 97 1.5

Cared for by nurse Yes 353 70.9No 145 29.1

Cared for by physiotherapist Yes 103 20.7No 395 79.3

Received care from other healthcare professional

Yes 22 4.4

No 476 95.6

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Table 2: The public’s knowledge of nurses’ spheres of action and work setting

N %

Sphere of work of nurses

General patient care Yes 170 34.10

No 328 65.90Physical care and provision of basic needs

Yes 170 16.30

No 417 83.70Emotional support Yes 170 8.80

No 454 91.20Performing skilled tech-niques

Yes 170 69.10

No 154 30.90Promoting health Yes 170 8

No 458 92Assisting physician Yes 170 33.50

No 329 66.10Work settings of nursing personnel

Residential hospitalization institutions

Yes 170 97

No 15 3Community-based care settings

Yes 170 90

No 51 10Geriatric institutions and daycare centers

Yes 185 37

No 313 63Elementary schools – Stu-dent health

Yes 140 72

No 358 28

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Table 3: Correlation between the public’s level of knowledge and gender and exposure to healthcare

Gender Exposure to healthcare

Exposure to healthcare by a nurse

Male Female X2 Yes No X2 Yes No X2

Nurse’s jobGeneral patient care

80 90 0.61 148 0.22 0.06 116 54 0.88

Physical care and provision of basic needs

36 45 0.33 67 14 1.12 51 30 2.94

Emotional support

19 25 0.34 39 5 0.18 30 14 0.17

Performs skilled tech-niques

160 184 0.34 309 35**

10.27264 80

** 18.50

Promotes health

16 24 0.90 39 1 4.48 34 6**

4.19

Assists physician

80 83 0.70 148 19 0.81 115 52 0.54

Nurse’s work setting

Residential institutions

231 251 1. 24 420 62*

5.22343 139 0.87

Commu-nity 207 240 2.05 392 55*

4.95324 123

* 5.41

Geriatric institutions and daycare centers

100 85 *5.22 166 19 2.56 135 50 0.23

Elementary schools-stu-dent health

60 80 1.60 120 20 0.11 98 42 0.07

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Table 4: Multiple regression applied to predicting the general level of attributed prestige

Variable B SE β t R2

General patient care 0.06 0.11 0.03 0.65 0.04Physical care and concern for basic needs 0.33- 0.01 0.13 2.71 **

Emotional support 0.05 0.12 0.02 0.32Performing technical tasks 0.27 0.16 0.13 **2.70

Promoting health 0.01 0.10 0.00 0.03Assisting the physician 1.14 0.09 0.07 1.15

P**<0.001

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Table No. 5: General and specific levels of prestige according to selected background variables

Average level of general prestige(in relation to all other professions) (S.D.)

Specific prestige(in relation to

other healthcare professions)

(S.D.)

Sig.

general (0.96) 3.75 (0.93) 3.76Exposure to medical care by physician

Yes (0.96) 3.73 *(0.96) 3.73 *

No (0.95) 3.82 (0.96) 3.97Exposure to nursing care by nurse

Yes (0.95) 3.72 (0.93) 3.71

No (0.98) 3.81 (0.93) 3.8

genderMale 3.67 (0.99) 3.6 (0.96)Female (0.90) 3.79 *(0.90) 3.84 *

Religion

Jewish (0.94) 3.49 3.45 (0.99) **Christian (0.89) 3.81 (0.93) 3.86Muslim (0.49) 3.87 (0.87) 3.85Druze (0.49) 4.0 (0.79) 4.12

Age

18-30 (0.94) 3.60 (0.93) 3.67 **31-40 (0.81) 3.81 (1.02) 3.6741-50 (1.01) 3.86 (0.84) 3.8551+ (0.82) 4.15 (0.78) 4.13

*P<0.05 **P<0.001

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Table 6: The correlation between the public’s perception of the nursing profession and gender and exposure to care

general genderExposure to medical care by physician

Exposure to nursing care

by nurseMale Female Yes No Yes No

Respect 3.72 3.68 3.76 3.72 3.70 3.70 3.76Humanism 3.4 3.32 3.47 * 3.40 3.40 3.43 3.33Independence 1.77 1.78 1.75 1.75 1.83 1.77 1.75Dependence on physician 3.23 3.22 3.24 3.24 3.16 3.23 3.24

Academization 3.18 3.14 3.21 3.03 3.14 1.84 1.78Leadership 3.19 3.17 3.22 3.18 3.72 3.15 3.30

*P<0.05 , **P<0.001

Table 7: The correlation between the public’s “stereotypical” perceptions of nursing with gender and exposure to care

general genderExposure to medical care by physician

Exposure to nursing care

by nurseMale Female Yes No Yes No

Feminine profession 2.90 2.77 2.99 2.85 3.15 2.92 2.82

Profession suitable for men

3.14 3.14 3.15 3.15 3.07 3.23 3.25

Difficult profession 3.62 3.57 3.69 * 3.63 3.63 3.66 3.57

*P<0.05 , **P<0.001

91


Medicine and Law

ACADEMIC DISHONESTY AMONg NURSINg COLLEgE STUDENTS: ATTITUDES, PERCEPTIONS AND DISHONEST ACTIVITIES

Rabia Khalaila RN, PhD.*

Abstract:

Objective: The aim of this study is to investigate the relationship between attitudes, perceptions and behaviours associated with nursing students’ academic dishonesty. A cross-sectional study was carried out on a convenience sample of 158 students at an academic college in one of the regular nursing programs taught in Israel. The research instrument was a self-report. Regression analysis was applied to the data. Results showed that about 44% of the students engaged in one or more dishonest activities. Students with a greater fear of dropping out and those with a higher perception of justification of academic dishonesty were more likely to engage in dishonest activities. Respondents with more condemnatory attitudes and those with higher perceived risk of being caught were less engaged in such activities. Nursing educators should enhance ethics education and focus on the values embodied in each country’s nurses association’s ethical code, as well as develop an appropriate integrity policy for each academic institution.

Keywords: Academic Dishonesty; Attitudes; Behaviour; Nursing Students; Perceptions.

IntroductionThe nursing profession is reputed to be among the most honest, trustworthy, and highly ethical professions worldwide (Langone, 2007; McCrink, 2010; Woith et al., 2012). The Israeli Patient’s Rights Law (1996), which serves as a guide for nursing practice in Israel, includes ethics as an integral part of the profession. In addition, the Israeli Nurses Association Code of Ethics (Bureau

* Zefat Academic College, Israel. Director, nursing department, Zefat Academic College. 11 Jerusalem St., P.O.B 169, Zefat 13206, Israel, Tel: (972) 4 692 7778.Fax: (972) 4 692 7776. E-mail: [email protected]

Health Law (2015) 33:91-108

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of Ethics, 2004), which is very similar to the International Council of Nurses Code (2006), expresses the fundamental values and boundaries of duty and loyalty for the nursing profession with respect to individual clients and society as a whole. Therefore, reflecting these social and professional aims, the nursing profession requires and expects nurses and nursing students to demonstrate ethical behaviour (Kececi et al., 2011; McCrink, 2010).

Unfortunately, academic dishonesty among nursing students, with rates ranging from 58% to 94%, has been on the rise in the past few decades (Kececi et al., 2011; Krueger, 2014; McCabe, 2009; Woith et al., 2012) and is reaching epidemic proportions (McCabe, 2009; Roberson, 2009). It’s being linked to present and future unethical behaviour in clinical settings (Laduke, 2013 ) has become a source of legitimate concern to nursing faculties (Balik et al., 2010; Gaberson, 1997; Harper, 2006; Langone, 2007; Kenny, 2007; Krueger, 2014) and has a negative effect on the integrity and prestige of the nursing profession (Arhin, 2009; Azulay et al., 2014; Lesley & Leigh, 2013; McCabe et al., 2001; Theart & Smit, 2012).

There are many factors underlying the increased academic dishonesty among nursing students (Klocko, 2014). The current article attempts to provide additional empirical data on the attitudes towards and perceptions of such activities and the forms of academic behaviour among the current generation of nursing students, focusing specifically on a students in a nursing program in an academic college in Israel.

Background

Academic dishonesty in institutions of higher education is a widespread problem (McCabe et al., 2008). Dishonest academic activities, such as plagiarism or omission of data, have been occurring among researchers (Koocher & Keirth-Spiegel, 2010) as well as among undergraduate students around the world and in all academic disciplines, including healthcare and other professions (Al-Qaisy, 2008; Harper, 2006; Henning et al., 2014; Rabi et al., 2006). Academic dishonesty among students is a significant issue for any profession, particularly the nursing profession, in which preliminary evidence indicates that nursing students who cheat in the classroom are more likely to cheat in the clinical setting (Harper, 2006; Laduke, 2013). Academic dishonesty in nursing is defined as unethical behaviour in the classroom and/or clinical practice (Arhin, 2009; McCrink, 2010).

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The literature revealed that nursing students engage in a wide range of high- and low-tech forms of academic dishonesty. Low-tech activities including the traditional activities of cheating and plagiarism, such as flouting examination rules and arrangements, copying from another’s test, helping someone on a test, using a crib note, exchanging examination papers, modifying results, and stealing answer keys (Arhin, 2009; Langone, 2007; Woith et al., 2012).

However, the new media and high-tech methods have given rise to more sophisticated methods of dishonest behaviour. The advent of internet and wireless internet technology has made plagiarism easier than ever, and provides further opportunities for accessing the internet to engage in cyber-plagiarism, such as the search for ready answers, “copy/paste,” i.e., copying a vast amount of information into a few keystrokes, and use of information obtained from the World Wide Web without proper citation (Harper, 2006). Further high-tech means include the “KeyKatcher”, a small technological device that records keystrokes on a personal computer in order to obtain an instructor’s computer password, and camera-phones and smart cell phones used to photograph tests and to access the Internet to send or obtain answers to test questions (Harper, 2006).

Academic dishonesty at all stages of the education of nursing students (i.e., clinical, classroom and online learning) is growing (Harper, 2006; McCabe, 2009). The increased incidence of academic dishonesty is commonly attributed to high-tech, which made the dishonest academic activities easier than ever (Arhin, 2009; Azulay et al., 2014; Faucher & Caves, 2009; Harper, 2006; Tayaben, 2014).

The motivation behind the decision to engage in academic dishonesty has been the subject of significant research (McCabe, 2001; Rabi, 2006; Sohrabi et al., 2011). Typically, motivating factors are categorized as contextual and individual (Harper, 2006; McCabe, 2001). Contextual reasons include pressure from educators, parents, and peers; competition to succeed; lack of adequate time to prepare for exams or to complete assignments; and unduly difficult curricular material and examinations (Park et al., 2013; Schmidt, 2006; Roberson, 2009; Woith et al., 2012). Further reasons are related to the professor’s academic behaviours. For example, where students perceived their professors having copied data from the internet, as was found among Iranian students, there is a higher incidence of the same type of copying (Sohrabi et al., 2011).

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Individual reasons for academic dishonesty include students’ background characteristics, and personal attitudes and perceptions. Engagement in academic dishonesty varies with background characteristics, including gender, age, religiosity, and years of study. Dishonest behaviour was more prevalent among males, younger, and first and second year students (Kececi et al., 2011; Krueger et al., 2014; McCabe & Trevino, 1997). Balik et al. (2010) found more inclination to academic dishonesty among secular than among to religious students.

Other individual factors that may also be related to academic dishonesty are the student’s attitude and perception regarding academic dishonesty (Krueger, 2014). Studies determine that individual factors, such as attitudes and perceptions, are more significant than contextual factors in the decision to engage in academic dishonesty (McCrink, 2010; Sohrabi et al., 2011). For example, nursing students who are ‘tolerant‘ of academic dishonesty were more likely to engage dishonest behaviours, whereas those with more condemnatory attitudes were less likely to engage in such activities (Arhin & Jones, 2009; Balik et al., 2010; Jordan, 2001; McCrink, 2010; Park et al., 2013). In addition, nursing students have been shown to be willing to cheat in order to ‘survive’ in their academic studies, even if this misconduct conflicts with their social and professional ethical codes (Balik et al., 2010). Students who felt that such activities were strongly justified are more likely to be academically dishonest (Eastman et al., 2008; Lambert et al., 2003).

Factors restraining individuals from engaging in dishonest activities include institutional use of an honour code, fear of being reported or caught, and penalties, such as ending their career (McCabe et al., 2001). For example, students who fear detection or serious academic penalties tend to cheat less (McCabe et al., 2001). Further study demonstrated a negative correlation between the personality characteristic of conscientiousness and using technology to commit plagiarism (Sohrabi et al., 2011).

Although academic dishonesty among nursing students has been well studied, it still remains a complex and unsolved phenomenon. The present study is one of the few efforts to examine personal attitudes and perceptions of academic dishonesty in order to understand the individual reasons behind such activities among nursing students. Therefore, the current study aims to determine: (1) The frequency of self-reported academic dishonesty; (2) The attitudes and perceptions of nursing students towards dishonest behaviour during their academic studies and; (3) The association between students’ perception of risk, harm, justification, benefits barriers to academic dishonesty and fear of

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dropping out if they fail in studying, and between the probability of engaging in dishonest behaviour, after controlling for social desirability and background variables.

Methods

Design and participantsA cross-sectional, descriptive-correlational study of a convenience sample of 158 undergraduate nursing students (66% enrollment rate) at an academic college in Israel was conducted following approval by its Research Committee.

Procedure

A research assistant distributed a voluntary questionnaire throughout all the nursing studies students who were present. English instruments\items were translated into Hebrew by two bilingual translators via the translation\back-translation process (Brislin, 1970). Prior to conducting this study with students, two scholars perused the instruments. Experts were recruited to provide information for face and content validity of the attitudes and perceptions instruments. Following their comments, several of the statements and words on the questionnaire were slightly changed.

The complete questionnaire underwent a pilot test on 20 different students from another program in the college. The questionnaire took approximately 15 minutes to complete, the written and verbal instructions were comprehensible, and there was no need for further changes prior to administering the questionnaire.

A group of second-year nursing students collected data by distributing a self-administered questionnaire among students who signed voluntary informed consent forms. No data were missing on variables of interest to the present analysis, and all 158 respondents were included in the current analysis.

Measures

Dependent VariablesEngagement in academic dishonesty: The list of 22 dishonest activities (see Table 1) was based on previously developed instruments (Arhin 2009; McCabe, 2009) and aimed to assess the engagement of the undergraduate nursing students in dishonest activities. The students were asked to rate their frequency

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of carrying out various specific activities during their academic careers, with no need to indicate what specific activities they engaged in. The answer was ranked on a 4-point scale, ranging from ‘never’ (1), 1-to-5 (2), 6-to-10 (3), and ‘more than 10’ (4), dichotomized to a binary outcome variable reflecting never (0) or engagement in one or more form of dishonest behaviour (1).

Independent VariablesAttitude toward academic dishonesty: The list of 22 dishonest activities used to assess attitudes toward dishonest academic activities, was adopted from previous studies (Arhin, 2009; McCabe, 2008; McCrink, 2010). Students were asked which of them constituted cheating, offering three possible responses: (1) Not unethical, (2) slightly unethical, and (3) extremely unethical. The higher the score, the more negative was their attitude to dishonest behaviour (α = 0.78).

Perceived academic dishonesty: The 39 items used to assess the perception of academic dishonesty were developed by the researcher in the Hebrew language, and express the different perceptions of students that are identified in the literature, such as perceived risk, justification, barriers, and more (Eastman et al., 2008; Jordan, 2001; Park et al., 2013; Theart & Smit, 2012). Students were asked to state the extent of their agreement with various statements on a 5-point scale, ranging from ‘completely disagree’ (1) to ‘completely agree’ (5). The instrument included perceived justification for engaging in dishonest behaviour (10 items, α = 0.95); the perceived benefits (6 items, α = 0.82); risk of being caught (4 items, α = 0.73); harm to the student, professional integrity and the institution’s prestige (8 items, α = 0.85); and barriers to involvement in unethical activities (9 items, α = 0.86).

Respondents also rated their fear of dropping out due to failing their examinations by one item on a 5-point scale, ranging from ‘no fear‘ (0) to ‘extreme fear’(5).

Background data were obtained on the students’ age, gender, religiosity level, and years of study, dichotomized as up to and including the second year (0), and the third and subsequent years (1). ‘Self-definition of religiosity’ was scored on a 4-point scale, dichotomized to being not religious (0), or religious (1).

The Marlowe-Crowne Social Desirability scale (MCSDS) measures inclination to respond in culturally approved ways (Reynolds, 1982). The shortened 11-item version was used to control such biased responses. The higher the score, the more socially desirable the response (α = 0.66).

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Data Analysis

Independent t- and Pearson chi-square tests were used to determine the differences between those who engaged in dishonest behaviour and those who did not (p<0.05). Pearson product moment correlations were also computed to clarify the associations among the continuous independent variables. In addition, binary logistic regression analysis for the frequency of dishonest activities (‘never’ vs. ‘one or more’) was carried out. After controlling for social desirability and background variables, attitudes, fear of dropping out, and perceived barriers, risk, harm, justification and benefits, as predictors of engagement in dishonest behaviour, were analysed.

Results

More students in the sample were female (58.9%) than male, aged between 19 and 38 (mean = 22.0, SD = 2.9). About 74% of the respondents were first, or second year students. Only about a quarter (26%) defined themselves as ‘religious’ or ‘very religious.’

The majority of students (87.3%) were aware of the institution’s honour code on academic dishonesty, and most of them (92.4%) believed that a strict deterrence policy with severe penalties for engaging in dishonest academic behaviour might prevent students from engaging in such practices. However, only 55.2% of the students felt that the academic dishonesty rules were enforced by the institution; and about 58% that the penalties imposed by the college on students caught for dishonest activities were light.

Table 1 shows the respondents’ attitudes to various forms of academic dishonesty, which they perceived as ‘slightly’ to ‘extremely unethical’. However, some students did not view certain forms of academic dishonesty as unethical: only about 29% of the respondents perceived the collaboration on assignments that were supposed to be completed alone as unethical; turning in work or assignments completed by someone else (19.1%) and; using a false or forged excuse to delay a test, submit an assignment (39.9%), or justify absence from lectures (34.2%).

Also, about 44.3% reported having been engaged in one or more of the 22 forms of behaviour listed in Table 1: in one to five of the activities (32.9%); six to 10 (7.6% ); and 11 or more (3.8%) dishonest types of activity. The activities included low-tech and hi-tech practices, but did not report the specific activity employed. Over half the respondents (55.7%) claimed not to have been involved in any such activities.

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Table 2 shows descriptive statistics and bivariate comparisons of students’ attitudes and perceptions regarding the various forms of dishonest behaviour. The mean scores of perceived justification, benefits, and fear of dropping out were significantly higher among students involved in one or more forms of dishonest behaviour, as compared to those who reported never having been involved in any such activities. Students who had committed one or more forms of dishonest behaviour were more likely to report lower scores on perceived risk and harm. In addition, most students who had engaged in one or more forms of academic dishonesty held more positive attitudes to such behaviour than those who had never been involved in such activities. However, no difference was found in perceived barriers between those who engaged in dishonest behaviour and those who did not.

Table 3 presents the logistic regression analysis for frequency of dishonest behaviour as the outcome. The final model was significant [χ² (11, 158) = 114.98, p < 0.001], explaining 0.69 of the variance (pseudo R2). Seven significant predictors were identified, including perceived justification, risk of being caught, fear of dropping out, and attitude to dishonest behaviour. The control variable of social desirability was entered first and made a significant contribution to the dependent variable (22%). The greatest changes occurred when the perceptions of the attitude measures were entered (ΔR2 = .35, p < 0.001), followed by the effects of the background variables (ΔR2 = .12, p < 0.001). The probability of engaging in dishonest forms of behaviour decreases with increasing social desirability. In addition, two background variables, age and gender, were found to be related to the outcome variable. Mature or female students were less likely to engage in dishonest behaviour. However, years of study and religiosity were not found to be related to academic dishonesty.

The probability of engaging in one or more dishonest activities decreases when the students’ perceived risk of being caught increases. However, the greater the perceived justification for dishonest behaviour and the fear of dropping out, the higher the probability of engaging in one or more dishonest forms of behaviour. In addition, students with negative attitudes toward such activities were less likely to engage in them. However, there was no significant relationship between engaging in dishonest behaviour and the perceived benefits or harm.

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Discussion

The results indicated that about 44.3% of the undergraduate nursing students self-reported engaging in one or more of the 22 dishonest activities, using either hi-tech or low-tech means, or both. These results confirm the moderate-to-high prevalence of academic dishonesty among nursing students reported in previous studies (Balik et al., 2010; McCabe, 2009; Roberson, 2009). It is reasonable to assume that the actual incidence of dishonest behaviour is likely to be higher than revealed by self-reporting.

An interesting finding was the degree to which the students were able to categorize their attitudes toward the identified behaviours of academic dishonesty. The finding of most concern, however, was the percentages of students who did not consider behaviours such as copying as dishonest. For example, when respondents reported their attitudes toward copying and pasting information from a source paper or internet site without proper citation, 39.2% perceived the behaviour to be ‘unethical’, 51.3% perceived the behaviour to be ‘slightly unethical’, and only 9.5% perceived the behaviour to be ‘not unethical’. Moreover, none of the identified activities were perceived as entirely unethical. These results suggest that nurse educators should be more concerned by students’ ability to stratify their attitudes toward the various activities of academic dishonesty. Although representing a minority of the respondents, these students may become nurses who will be able to rationalize their unethical behaviours in any health care setting. Special attention should be paid by nurse educators to the tolerant attitudes toward using high-tech dishonest activities (such as, using hacker software or small devices to gain access to a lecturer’s computer password, examinations or other material), a new phenomenon arising great concern in the nursing arena (Azulay et al., 2014; Lesley & Leigh, 2013).

The students’ fear of dropping out from nursing studies made the strongest unique contribution to predicting engagement in dishonest academic behaviour. Wong et al. (1999) found similar results among medical students, many of whom claimed they would act against their conscience and cheat if they feared they would not obtain a passing grade in a particular assignment or examination. Other researchers found that the fear of failure among pharmacy and medical students due to their family pressure to succeed made them engage in dishonest behaviours to avoid shame and embarrassment for their family (Henning et al., 2014). In addition, these results reinforce the finding that Israeli nursing students are willing to engage in dishonest behaviour in order to ‘survive’ in their studies and avoid failing (Balik et al., 2010). Thus, some

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students involved in such activities do not aim to acquire higher academic grades, but rather to avoid failing in examinations and assignments, which, in turn, would result in their possible expulsion, their family’s disappointment, and self-destruction of their own professional life plan.

Students’ perceived justification made the next highest contribution to predicting dishonest academic behaviour. The results also suggest that students who felt they had strong justification for such behaviour (i.e., unfair or confusing examinations or insufficient time to prepare for them or other important assignments), were more likely to engage in it, reinforcing other studies on the tendency to view academic dishonesty as justified and acceptable, thereby avoiding self-blame (Arhin, 2009; Balik et al., 2010; McCrink, 2010). Academic dishonesty, increasingly justified by the view that ‘‘everyone’ does it’, possibly leads to a vicious circle, further promoting such unwarranted behaviour. This finding should concern nursing educators since it might allow these students to compromise their internal values while maintaining the expected external professional image of honesty and integrity.

The perceived risk of being caught was also inversely proportional to the students’ engagement in dishonest behaviour. This is in keeping with McCabe’s findings, who emphasises that college administrators must be willing to employ sanctions that have both significant educational and deterrence value to reduce the incidence of academic dishonesty (McCabe et al., 2001). The significance of perceived risk in preventing dishonesty suggests that nursing educators should staunchly enforce existing policies on cheating. Through clear public announcements, they should ensure that students are aware of the penalties that such possibly criminal behaviour violating the honour code might incur.

As reported elsewhere (Arhin & Jones, 2009; Balik et al., 2010; Jordan, 200; Krueger et al., 2014; McCrink, 2010; Park et al., 2013), negative attitudes toward academic dishonesty, such as obtaining and plagiarizing assignments and examination papers, were found to be also related to students engaging in dishonest behaviour. This might possibly relate to other common variables involved in attitudes to and engagement in academic dishonesty, such as perceived risk and justification. Indeed, as shown by previous studies (Balik et al., 2010; McCabe et al., 2001) and analysis, students with negative attitudes to academic dishonesty perceived the risk of being caught as higher, and justification as lower, and therefore engaged less in dishonest behaviour.

The background variables of gender and age, less among females than males, were found to be significantly related to academic dishonesty among nursing

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students, hence supporting previous studies (Kececi et al., 2011; Krueger, 2014; McCabe, & Trevino, 1997). This can possibly be explained by superior study skills, ability to work harder, or a more adaptive approach and motivation to learning tasks among Israeli female students, who, in turn, feel less need for involvement in dishonest behaviour than males. Other explanation is that men typically possess lower levels of self-control making them more likely to cheat, while women have higher levels of anticipated shame, making them less likely to engage in dishonest academic activities. Further research on the reasons underlying the gender differences in this area is highly recommended.

In keeping with previous research (Kececi et al., 2011; McCabe & Trevino, 1997), mature students were less likely to engage in dishonest behaviour than younger ones. This might be explained through an additional factor uniquely addressed in the present study, namely, perceived justification. Both the present findings and previous research (Balik et al., 2010; Kececi et al., 2011) show a negative correlation between age and perceived justification.

Certain limitations of the current study should be noted. First, the cross-sectional design does not allow confirmation of causal inferences about the association between the independent variables and academic dishonesty. Secondly, due to the single site and non-random selection of the convenience sample, it may be difficult to generalize the results beyond this particular population. However, the present study still provides initial insights into attitudes and perceptions involving academic dishonesty among nursing students, which has not been widely studied to date.

Conclusions and Recommendations

Academic dishonesty is prevalent among undergraduate nursing students in this Israeli sample. Although identified activities of academic dishonesty were seen as ‘not unethical’ by a small percentage of respondents, this should be of very high concern for nursing educators. The thought that students do not consider copying, cheating, or plagiarism as unethical behaviour is a source of deep worry.

Individual factors, including personal factors, (i.e., attitudes and perceptions) and background variables (i.e., gender and age) contributed significantly to students deciding to engage in academic dishonesty. However, the personal factors were more significant than background variables in the decision to engage in dishonest activities. Thus, these results suggest that any intervention to diminish the incidence of academic dishonesty should include activities to


change the personal attitudes and perceptions toward academic dishonesty. Therefore, it is important to instil a sense of ethics in all nursing students. Honour codes would facilitate communication about behavioural expectations between faculty and students and emphasize the importance of ethical behaviour in the classroom and in the clinical setting.

The educators should stress the integrative nature of the code, emphasizing the implications of dishonest behaviour in the academic environment on dishonesty in the clinical environment. Early socialization into the profession of nursing, such as values of nursing practice, ethics of caring, integrity, respect, and responsibility, are critical components of nursing education and a responsibility of all nurse educators. This may, in turn change the students’ attitudes and perceptions towards academic dishonesty.

To reduce the fear of dropping out, we suggested various recommendations that aim to diminish the pressure to engage in dishonest behaviours, such as allowing a student more than two test opportunities to pass an examination, averaging the results, or considering the higher grade. The institution may also allow the students more time to prepare for each exam, with limited material for the exams.

Finally, research should be carried out at colleges and universities to clarify the relationship between academic dishonesty in the classroom and the professional settings. Future studies should also explore where the academic dishonesty occurs: is it in the science-based courses; or in the nursing-based courses; or in assignments and homework. Future researches, aimed at reducing dishonest behavior in practice in the clinical setting with actual patients, should also examine the impact of the online learning environment on the academic integrity among nursing students.

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Table 1. Attitudes to Dishonest Academic Behaviour (N=158)

Behaviour Not unethical

Slightly unethical

Extremely unethical

1. Copying another student's homework or assignments without his or her knowledge 7.6 53.2 39.2

2. Allowing another student to copy your homework or assignments 13.3 61.4 25.3

3. Collaborating on assignments that are supposed to be completed alone 28.5 51.9 19.6

4. Using an unauthorized ‘cheat sheet’ in examinations 3.2 18.4 78.5

5. Looking at or copying from someone else in examinations 4.5 19.1 76.4

6. Allowing someone else to copy from you during examinations 5.1 37.3 57.6

7. Finding out the examination questions beforehand 7.0 33.8 59.2

8. Telling another student about the examination questions beforehand 8.2 30.4 61.4

9. Copying and pasting information from a source paper or internet site without proper citation 9.5 51.3 39.2

10. Changing test answers by ‘opening the test form’ after the release of grades 4.4 17.1 78.5

11. Turning in as yours work or an assignment completed by someone else 19.1 35.7 45.2

12. Changing answers made with an erasable pen during tests after ‘opening the test form’ 5.1 16.5 78.5

13. Using hacker software or small devices to gain access to a lecturer's computer password, examinations or other material 1.3 11.4 87.3

14. Signing the attendance sheet in class for another student who is absent 5.7 40.5 53.8

15. Looking at hidden notes to find answers on visits to the bathroom during examinations. 12.7 44.3 34.0

16. Using cell-phones to send messages or photograph tests and send them to other student during or after examinations 2.5 15.8 81.6

17.Writing notes on the table, hands or arms to use during examinations 1.3 15.8 82.9

18. Using a false or forged excuses to delay tests or submission of assignments 39.9 42.4 17.7

19. Using a ‘professional super pen’ to scan and store information and transfer it to PCs. 15.4 55.1 29.5

20. Contacting professors before and immediately after the examinations to influence them 8.2 49.4 42.4

21. Falsifying or fabricating data 3.8 33.5 62.7

22. Using a false or forged excuse to justify absence from lectures 34.2 52.5 13.3

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Table 2. Descriptive Statistics and Bivariate Comparison of Students’ Attitudes and Perceptions of Academic Dishonesty as Assessed by Engagement in Dishonest Behaviour (N = 158)

Frequency of dishonest behaviour

Variables

Range

All students (N = 158)

Mean (SD)

Never (N = 88)

Mean (SD)

One or more

(N = 70) Mean (SD)

t-test

Perceived justification 1 – 5 2.1 (0.8) 1.7 (0.7) 2.5 (0.8) -6.5***

Perceived benefits 1 – 5 1.9 (0.7) 1.7 (0.7) 2.0 (0.7) -3.4**

Perceived risk 1 – 5 3.8 (0.8) 4.1 (0.7) 3.6 (0.9) 4.4***

Perceived harm 1 – 5 3.8 (0.7) 4.0 (0.7) 3.7 (0.7) 3.0**

Perceived barriers 1 – 5 3.6 (0.6) 3.6 (0.6) 3.5 (0.6) 0.6

Fear of dropping out 1 – 5 2.5 (0.9) 2.1 (0.6) 3.0 (1.1) -6.0***

Negative attitudes 1 – 3 2.4 (0.3) 2.5 (0.2) 2.2 (0.4) 6***

*p < 0.05. **p < 0.01. ***p < 0.001.


Table 3. Multiple Logistic Regression Analysis of Independent Predictors of Students’ Engagement in Dishonest Behaviour (N = 158)

Variables B Adjusted OR

95 % CI B Adjusted

OR 95 % CI B Adjusted OR 95 % CI

Social desirability -0.42 0.7***0.5 – 0.8

-0.42 0.6*** 0.5 – 0.8 -0.48 0.6*** 0.5 – 0.8

Age -0.28 0.8** 0.6 – 0.9 -0.29 0.7* 0.6 – 0.99

Gender (RC = female)

Male 0.82 2.3* 1.05 – 4.9 1.19 3.3* 1.08 – 9.9

Year of study (RC = 2nd year or less)

3rd and subsequent years

0.59 1.8 0.7 – 4.4 1.17 3.2 0.9 – 11.7

Self-rated religiosity (RC= Religious)

Not religious -0.08 0.9 0.4 – 2.0 -0.76 0.5 0.1 – 1.6

Perceived justification 0.97 2.6* 1.1 – 6.1

Perceived benefits -0.82 0.4 0.2 – 1.09

Perceived risk of being caught

-0.96 0.4* 0.2 – 0.8

Perceived harm -0.07 0.9 0.4 – 2.3

Fear of dropping out 1.6 5.0*** 2.1 – 11.5

Negative attitudes -2.3 0.1* 0.02 – 0.6

Model summary

Chi square 28.45*** 45.36*** 114.36***

Log likelihood 186.88 169.98 100.36

Nagelkerke (R2) 0.22 0.34 0.69

*p < 0.05. **p < 0.01. ***p < 0.001.

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Medicine and Law

RESEARCH ETHICS COMMITTEES’ ANALYSIS OF NURSINg PROJECTS IN BRAZIL

Isabel Amélia Costa Mendes, RN, PhD*, Maria Auxiliadora Trevizan**, Carla A. Arena Ventura, LLM, PhD***, Ann gallagher RN, PhD****, Robert Jago, BA(Hons), Mphil.(Cantab)***** and Juliana gazzotti******

Abstract: The objective in this exploratory study is to consider the demand for nursing related projects in the Ethics Committees registered on the website of the National Information System Commission about Ethics in Research Involving Human Beings (SISNEP) between 2003 and 2010. The data were collected in two phases: research projects approved in specific Ethics Committees of Nursing Schools/

* Full Professor. University of São Paulo at Ribeirão Preto College of Nursing. WHO Collaborating Centre for Nursing Research Development, Brazil. Correspondence Address: Av. Bandeirantes, 3900 – Campus Universitário. 14040-902 Ribeirão Preto, São Paulo, Brazil. Email:[email protected]

** Full Professor, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil. Correspondence Address: Av. Bandeirantes, 3900 – Campus Universitário, 14040-902 Ribeirão Preto, São Paulo, Brazil. Email: [email protected]

*** Associate Professor, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil. Correspondence Address: Av. Bandeirantes, 3900 – Campus Universitário, 14040-902 Ribeirão Preto, São Paulo, Brazil Email: [email protected]

**** Reader in Nursing Ethics, Chair, University Ethics Committee, Director, International Centre for Nursing Ethics. Editor, Nursing Ethics, School of Health and Social Care, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey GU2 7TE. Email: [email protected]

***** Senior Lecturer, Deputy Head of School, Director of Undergraduate Studies, School of Law

University of Surrey, Guildford, Surrey GU2 7TE. Email: [email protected]

****** Administrative Analyst, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil. Correspondence Address: Av. Bandeirantes, 3900 – Campus Universitário, 14040-902 Ribeirão Preto, São Paulo, Brazil Email:[email protected]

Health Law (2015) 34:109-120


Faculties registered for at least four years, and projects whose title contained the keywords Nurse and/or Nursing, approved in general Ethics Committees. In total, 2576 projects were approved in the six Committees analyzed.

Keywords: Research Ethics; Nursing Research. INTRODUCTIONAfter the enactment of the Brazilian Federal Constitution in 1988 which, in line with the international movement for the protection of human rights, is considered a landmark in the consolidation of the fundamental rights in that country, the Brazilian government, through the implementation of Resolution 196/1996 on October 10th 1996, started a public policy for the regulation of scientific research involving human beings. This pioneering initiative in Latin America was based on the Constitution, and particularly on the concept of community participation, which is one of the guidelines of the Unified Health System (SUS).

Resolution 196/1996 and its revision Resolution 466, from December 12th 2012, were elaborated and developed based on a multi/inter-disciplinary approach. Incorporating suggestions from different sectors in society, the rule was established that all research involving human beings should be submitted to a Research Ethics Committee (REC) The implementation stage of this policy has been concluded. Today, the country possesses 414 RECs that use the National Information System Commission about Ethics in Research Involving Human Beings (SISNEP), a website managed by the National Research Ethics Committee (CONEP), to register all information about research involving human participants and generate a protocol number for projects the institutional REC has to analyze. The SISNEP website is managed by CONEP in order to ensure reliability, protect personal data, integrate the evaluation system for research with human beings in Brazil, and develop a national database.

As nursing is a profession committed to ethical principles and research-based practice, the objective of this study is to consider the range of nursing related research projects reviewed by the Ethics Committees and registered on the website of the National Information System Commission about Ethics in Research Involving Human Beings (SISNEP).

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THE RESEARCH ETHICS COMMITTEES AND BRAZILIAN NURSINgThe Brazilian government, through the National Health Council (CNS), assumed the responsibility for examining the ethical aspects of research involving human beings and setting standards and rules to preserve the subjects in the development of this kind of research, in line with global trends in the area.

The objective of the CNS is to contribute to the safe development of research that can benefit Brazilian society, as well as trying to avoid abuse and protecting the research participants. Since 1996, the country exercises CNS Resolution 196/96, revised in 2012 through Resolution 466, to regulate the functioning of the sector, According to these resolutions, any ongoing research in Brazil which involves human beings should be submitted to Research Ethics Committees accredited under the ultimate coordination of the National Research Ethics Committee. In addition to controlling the Brazilian research assessment system, this committee analyzes specific cases and carefully monitors all changes to protocols, which are further updated in accordance with international agendas in this area.1 CONEP is a consultative and education committee that formulates guidelines and strategies in its action sphere, whose mission is to elaborate and update the guidelines and standards for the protection of research subjects and coordinate the network of institutional Research Ethics Committees.2

The Comitê de Ética em Pesquisa (CEP) is an interdisciplinary and independent Research Ethics Committees that should be in place at the institutions that engage in research involving human beings in Brazil. They are created to defend the research subjects’ interest in their integrity and dignity, and to contribute to the research development according to ethical standards.3 The CEP is responsible for assessing and monitoring the ethical aspects of all research involving human beings. This role has been well established in the different international ethical guidelines4, which underline the need for ethical

1 Brasil. Ministério da Saúde/Conselho Nacional de Saúde. Manual operacional para comitês de ética em pesquisa [online]. Brasília: Ministério da Saúde; 2006 [acess 22 Ago 2011]. Available in: http://www.conselho.saude.gov.br

2 Disponível em http://conselho.saude.gov.br/web_comissoes/conep/index.html [acesso 22 Agosto 2011].

3 Brasil. Ministério da Saúde. Diretrizes e Normas Regulamentadoras da Pesquisa Envolvendo Seres Humanos - Resolução 196/1996 do Conselho Nacional de Saúde, 1996, II.4.

4 Helsinki Declaration, International (CIOMS) and Brazilian Guidelines for Biomedical Research involving Human Beings (CNS Resolution 196/96, CNS Resolution 466/12 and complementary documents.


and scientific review of research involving human beings, with a view to safeguarding the dignity, rights, safety and wellbeing of the research subjects.

CONEP and the CEPs have a multidisciplinary composition that involves researchers, bioethics experts, lawyers, health professionals; social, human and exact science professionals, and user representatives. It is important to highlight the latter with a view to “independence and equity in the consideration of the scientific and external communities’ viewpoints”5.

On that basis, the Ethics Committees represent an important forum for the consolidation and inculcation of a culture of respect for the human rights of all people, particularly the subjects of scientific research. They should also put in practice social control over scientific practices, qualifying them based on ethical principles and aiming to avoid the exploitation of the most vulnerable and the exposure of subjects to predictable risks and damage.

In line with ethical principles guiding its practice, Brazilian nursing is starting to comply with the regulation established for the development of research involving human beings with a view to guaranteeing qualified humane care that considers the research participants’ free consent and wellbeing.

According to COFEN Resolution – 161, which approves the Code of Ethics of Nursing Professionals: “Nursing comprises a component of scientific and technical knowledge, constructed and reproduced by a set of social, ethical and political practices that is processed through teaching, research and care. It is accomplished through the delivery of services to individuals, families and groups, in their context and life circumstances. The improvement of the professionals’ ethical behavior involves the construction process of individual and collective awareness, through social and professional commitment, configured through responsibility, at the level of the work relations in the scientific and political sphere.”6

With regard to the ethical delivery of services and care for human beings, this is part of the nurses’ daily life. In the development of scientific studies, this situation is no different. “In the nurse’s professional life, knowledge is acknowledged as a fundamental value. To identify and distinguish their clients’

5 Freitas, C. B. D. e Novaes, H. M. D. Lideranças de Comitês de ética em pesquisa no Brasil: perfil e atuação. Revista Bioética, 18(1): 185-200, 2010, p. 197.

6 Ramos, F.R.S. et al. A eticidade na pesquisa qualitativa em saúde: o dito e não dito nas produções científicas. Ciência e Saúde Coletiva, 15 (Supl. I): 1673-1684, 2010.

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needs, get to know the aspirations of their collaborators, consider this staff’s capacity, deliver individual care, make an appropriate decision, make a cautious judgment, in short, to present a coherent attitude, the nurses need to depart from the truth, through knowledge.”7 Thus, nurses are increasingly concerned with the acquisition of knowledge through research development, starting to take part in established CEPs and creating CEPs at academic and nursing service institutions. Among the factors that contributed to the establishment of CEPs at nursing schools and health services, the following can be mentioned: the need to increase access at RECs to submit projects for ethical analysis; the increase of health research projects to be analyzed by CEPs; the requirement of documentation proving the approval of the project by CEP and/or CONEP by funding agencies and the editorial board of scientific journals; and researchers’ increasing awareness of the need to submit projects to CEPs.8

Whereas the regulations are unable to be exhaustive to the extent of detailing and covering all subtleties and situations, whether forecasted or not, of the research process and the relations among the subjects, to the extent that we could do without good sense in conducting the research processes and the effects of their outcomes, the researcher’s ethical position is essential in avoiding abuse or disrespect for the research subjects. Therefore, above all regulations, professionals still need to act with responsibility and solidarity.8 Thus, regulations alone are not sufficient. In sum, in a culture of support for ethical decision-making, the guidelines and principles demand interpretation, which requires experienced and competent people. Thus, the moral and scientific progress depends on the critical skills in relation to the existing knowledge; availability to raise questions; the search to get to know the specific cultural context in which the project is inserted; sensitivity to recognize the other person’s limitations; and particularly the availability to discuss the differences with an academic focus.9

In view of these nuances in research with human participants, and in order to guarantee integrity and respect for these participants, nursing training should emphasize the importance of closely watching the promotion of ethics, human

7 Trevizan, M. A., Mendes, I. A. C., Cury, S. R. R., Mazon, L. A. A dimensão moral e a ação é tica no trabalho gerencial da Enfermeira. Escola Anna Nery Revista de Enfermagem, v.4, n.2, p. 181-186, 2000.

8 Ramos, F.R.S. et al. Op.cit.9 Benatar, S. R. Reflections and recommendations on research ethics in developing countries.

Social Science & Medicine, 54: 1131-1141, 2002.


rights and the preservation of life in the assessment of the ethical characteristics of research.10 Therefore, the accomplishment of these premises in practice should be guaranteed, turning the researcher’s ethical commitment into a sine qua non condition.

METHODAn exploratory study was undertaken. The data were collected through the SISNEP website (www.sisnep.saude.gov); managed by CONEP, which registered all information about research and generated the protocol number for the project the institutional CEPs are to analyze. The analyzed data concerned the projects listed on the website between 2003 and 2010. This snapshot of time is justified by the change in the registering of research projects involving human beings in the National Information System about Ethics in Research Involving Human Beings (SISNEP) in 2011. This change started an adaptation period for the CEPs all over the country.

The data were collected in two stages. First, the CEPs registered in SISNEP, and which were specific to nursing schools/faculties and possessed at least four years of records, were selected, so as to permit a comparison of data on both the evolution and consolidation of the CEPs. The number of projects was tracked per year and per Committee. Second, in view of the possibility of nursing research projects being submitted to other Committees external to the nursing schools/faculties, a search was undertaken per project title, on the SISNEP website, using the keywords nurse and/or nursing, in the same period considered for the study. The number of projects was tracked and linked per year and by region of the country.

The data were organized in Excel worksheets, submitted for descriptive statistical analyses, presented in the form of tables and figures with absolute and relative frequencies.

RESULTS AND DISCUSSIONSix specific committees of Nursing Schools/Faculties registered in SISNEP were selected, which complied with the inclusion criteria for this research. Among these CEPs, four are located in the Brazilian Southeast, two in the State of São Paulo, one in Rio de Janeiro and one in Minas Gerais; and two in the Northeast, both in the State of Paraíba.

10 International Council of Nurses. Code of Ethics for Nurses. Geneva: ICN; 2000.

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Based on the initial analysis of the specific ethics committees of nursing schools/faculties between 2003 and 2010, Table 1 displays the number of projects these committees approved. The first observation to make is that the specific ethics committees at nursing schools/faculties with the longest tradition and the largest volume of projects analyzed are concentrated in the Southeast, the richest and most developed Brazilian region, which houses nursing schools with the longest tradition in research and the development of scientific studies, such as the two nursing schools of the University of São Paulo, located on the campuses in São Paulo and Ribeirão Preto, and Anna Nery School of Nursing, affiliated with the Universidade Federal do Rio de Janeiro. It should be emphasized that, in general, the number of research ethics committees established in nursing schools/faculties increased, as well as their recognition by the academic community over the years. The analysis flow increased, with periods of decline and stability. In addition, it is corroborated that the nursing area, in line with the global trend towards the protection of the citizens’ fundamental rights and with the requirement of funding entities and scientific journals, is increasingly concerned with having its scientific studies with human participants certified through the preliminary analysis of an ethics committee.

The data in Table 2 relates to the projects whose titles contained the keywords Nurse and/or Nursing and were approved by the committees in the different regions of the country:

In addition to the data in Table 2, Figure 1 displays the percentage of CEP approved projects whose titles contained the words Nurse and/or Nursing in relation to the total number of projects approved per region of the country between 2003 and 2010. This data reveals the increase in the number of projects whose titles contained the words Nurse/Nursing and which were analyzed in CEPs in Brazil’s different regions. The highlighted upward trend in the number of projects approved in the Northeast reached 11% of all projects in 2010.

The role of institutions from the Southeast is noteworthy, as a pioneering region in research development and in the supply of graduate programs, serving as a true cradle for researchers from all other regions in the country. The graduates from these programs led the creation of new graduate programs in the Central-West, South, North and Northeast. Since the most developed region houses more researchers and therefore succeed to collect more resources from funding agencies, because it, who are more renowned due to the research tradition, the government has started, as from 2003, to encourage and induce scientific


development in the North and Northeast, using strategies like specific calls for researchers from these regions. The present research results show the larger growth of projects in CEPs in those regions, reflecting this policy, which not only aims to enhance the ability to collect more resources, but also contributes to attract and permanently set up Ph.D. graduates at the universities in that region.

In general, the results demonstrate that nurse researchers are increasingly submitting their projects to CEPs’ evaluation. Another factor that explains the CEPs’ increased project demand is the growth of graduate nursing programs in the country in the same period: in 2003, 31 programs existed, including 21 Masters’ and 10 Ph.D.s. Until the year 2010, the end period in this research, ended with 72 programs, including 42 Masters’ and 23 Ph.D.s. In the course of the study period, a 100% increase is observed in the Masters programs and a 130% increase in the Ph.D.s in nursing. This strong expansion entails a corresponding increase in the number of projects the CEPs evaluate, considering that nursing research generally involves data collection from human beings and that each student should submit at least one thesis or dissertation project to a CEP, depending on the level of the respective program. The CEP approval of the project is a prerequisite of graduate programs to obtain the degree.11

Similarly, these rules apply to the scientific initiation programs developed in undergraduate nursing programs; the students who take part in this research training modality start their learning of the research process as early as that educational level and, hence, in addition to their compliance with the resolution, they submit their projects to the CEPs, together with their advisors.

Therefore, the CEPs’ demand can be interpreted as a consequence of the college policy’s requisites; of the guidelines of the graduate programs, research funding agencies, scientific journal standards and of the agency that regulates the profession in the country that prescribes, in its Code of Ethics’ chapters on the nurse’s duties and rights, the necessary caution to develop research.

A considerable evolution in the number of nursing projects submitted to general ethics committees, as well as an increase in the project demand for ethics committees established at nursing schools/faculties has been observed across all the regions.

11 Ministério da Educação (BR). Secretaria de Educação Superior. Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Homepage na Internet). Acesso em 01/09/2011. Disponível em http//www.capes.gov.

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According to the International Council of Nurses, nurses are responsible for health promotion, disease prevention, re-establishment of health and relief of suffering.12 All of these issues and responsibilities should be considered within a global perspective of health and wellbeing. That is due to the fact that patients, besides calling upon nurses to protect their individuals’ rights and defense, can always address them in search of explanations, teachings and decisions on care matters. With that perspective, and since they often have contact with the people involved in the research, nurses are professionals that are qualified to serve as advisors and participate in ethics committees. Serving as advocates for the benefit of health and work on behalf of an entire society,13

their work has political aspects as well.

Working with human beings in health care and in the enhancement of care techniques through scientific research implies the preservation of the subjects’ rights and the researchers’ duties.

CONCLUSION Nursing is a research-based profession committed to ethical principles and engaged in compliance with the rules for research involving human beings, focusing on human dignity. This research presented a general view of nurses and the nursing area’s demand for research ethics committees at nursing institutions and other institutions in each region of Brazil.

The results demonstrate a considerable evolution in the projects presented to the nursing committees and in the projects whose title contains the words Nurse/Nursing and were submitted to other Brazilian ethics committees, revealing the importance nursing attributes to the ethical analysis of projects involving human beings, in compliance with the principles of respect for human dignity that support this science and its practice.

LIMITATIONS The inclusion criteria for the data analyzed in this research considered the search by title of the projects approved in CEPs and the words Nurse and/or Nursing. Nevertheless, the projects from the nursing area do not necessarily contain these words in their title. Hence, this study does not present the entirety of all nursing projects approved during the period the Brazilian CEPs analyzed.

12 International Council of Nurses. Op.cit.13 Tschudin, Verena. The future Nursing Voice. Revista Latino-americana de Enfermagem; 11

(4):413-9, julho-agosto 2003.


Table 1 – Number of projects approved by ethics committees established at Brazilian Nursing Schools/Faculties between 2003 and 2010

Research Ethics Committees 2003 2004 2005 2006 2007 2008 2009 2010 Total

EERP/USP 98 73 103 116 112 115 66 99 782

EE/USP 99 90 104 93 102 71 83 80 722

EEAN/ UFRJ - 27 95 102 117 116 107 119 683

EEWB 02 06 05 14 25 70 63 64 249

RODAT - - 09 07 04 02 08 04 34

CEM/FACENE/FAMENE - - - - 20 25 23 38 106

Total 199 196 307 341 380 399 350 404 2576

Data obtained on the website of the National Information System about Ethics in Research involving Human Beings – SISNEP: http://portal2.saude.gov.br/sisnep/menuusuario.cfm Abbreviations: University of São Paulo at Ribeirão Preto College of Nursing – EERP/USP; University of São Paulo School of Nursing – EE/USP; Anna Nery School of Nursing - EEAN/UFRJ; Wenceslau Braz School of Nursing (EEWB) – Itajubá – MG; Santa Emília de RODAT School of Nursing – PB; Nova Esperança School of Nursing – CEP-CEM/FACENE/FAMENE – PB

Table 2 – Number of projects whose titles contained the words Nurse and/or Nursing and were approved by the research ethics committees distributed among the regions of the country between 2003 and 2010

SoutheastYear Total Projects Nursing Projects Total %2003 911 30 3.32004 915 22 2.42005 3986 264 6.62006 6376 463 7.22007 9613 800 8.32008 11435 1073 9.42009 12332 1008 8.12010 12670 928 7.3

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Northeast2003 - - -2004 27 02 7.42005 1193 82 6.92006 2614 228 8.72007 3723 326 8.72008 3897 481 12.32009 4787 452 9.42010 6953 764 11.0

North2003 - - -2004 - - -2005 26 - -2006 85 03 3.52007 495 12 2.42008 1022 52 5.12009 980 54 5.52010 1201 56 4.7

Central-West2003 52 01 1.92004 65 02 3.12005 779 70 9.02006 338 33 9.82007 438 26 5.92008 579 29 5.02009 603 36 5.92010 679 41 6.1


South2003 719 66 9.12004 720 49 6.82005 2072 142 6.92006 3406 252 7.42007 3892 307 7.92008 6327 439 6.92009 6394 390 6.12010 6960 542 7.8

Data obtained on the website of the National Information System about Ethics in Research involving Human Beings – SISNEP: http://portal2.saude.gov.br/sisnep/menuusuario.cfm

Figure 1 - Percentage of projects with CEP approval whose titles contained the words Nurse and/or Nursing in relation to the total number of projects approved per region of the country between 2003 and 2010their patients.

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Medicine and Law

DIFFERENCES IN THE INTERPRETATION OF “DNR” AMONg PHYSICIANS AND NURSES ON INTERNAL MEDICINE WARDS

Tal Ilsar, RN, MPH*

Abstract: In 2005, in an attempt to regulate care for patients expected to live no longer than six months, Israel enacted the Dying Patient Law. The law sets forth in detail actions that should be performed to respect the patient’s wishes, and also defines treatment to be given to patients who have directed that there be no heroic measures taken to prolong life. In some terminal cases, such as a patient who stops breathing or has a cardiac arrest, health care providers are instructed not to perform cardiopulmonary resuscitation (CPR). However, most healthcare providers are unsure of exactly what the definition of the Do-Not-Resuscitate order (DNR) means. The research goal was to identify opinions held by nurses and physicians as to the meaning of the DNR directive. The study was of a descriptive correlational design, based on a convenience sample of 61 physicians and nurses. The research instrument comprised a structured self administrative questionnaire. The results showed differences in the opinions of the health care staff as to which actions should be performed on patients who signed DNR directives, and which should not. While a majority of the respondents agreed that heart massage and ventilation were considered actions that should not be performed on DNR patients, other actions were found to be the subject of differences of opinion. For example, about half the respondents considered imaging tests and other tests as actions that should not be performed if a DNR order is in place. The study emphasizes the need to set multiple parameters and not only a single-dimension definition of DNR. Nurses and physicians should have regularly scheduled meetings to discuss the DNR order of specific patients.

Keywords: DNR, Physicians and Nurses; Opinion; End-Of-Life Directives.

* Hadassah Hebrew University Medical Center, Head Nurse, Internal Medicine C Department, Ein Kerem, Jerusalem, Israel. Email: [email protected]

Health Law (2015) 34:121-134


IntroductionPatients are hospitalized on internal medicine wards in various states of health. Some are experiencing unstable breathing, or are hemodynamically unstable and in need of nursing interventions to prolong their life. At present, if a patient requests that no extraordinary measures be taken to prolong life, such as cardio – pulmonary resuscitation (CPR) if needed, the physician records a DNR directive. Often, the staff initiates the contact with the patient or family and asks if the patient wishes resuscitation if needed (Perron, Morabia, & De Torrente, 2002).

If there is no clear instruction in place, if the patient has a crisis, the medical staff asks a close family member what the patient’s desire would be, would he be able to speak. In many places around the world, staff members are unsure of exactly what the definition of DNR (Santonocito, Ristagno, Gullo, & Weil, 2013) is.

In 2005, in an attempt to regulate care for patients expected to live no longer than six months (also called the Terminally-Ill Patient Act, as there is no official translation yet), Israel enacted the Dying Patient Law.

The law sets out in detail which acts may be performed to respect the patient’s wishes, and defines the care to be given to the patient who has expressed his wish not to extend his life. Among others are: symptomatic care (palliative care, shortness of breath, anxiety, nausea and vomiting) and avoiding strenuous care (ventilation, resuscitation, chemotherapy, dialysis). Not only is there no uniform understanding of DNR among staff, but it is often unclear among patient families, as well.

A study, using an online questionnaire, which examined the opinions of 107 physicians and 159 pediatric nurses (PICU and Pediatric Oncology) on the meaning and timing of the DNR decision, found that 66% respondents thought that it meant using fewer means if the patient arrested; 33% thought it meant overall less effort in providing care; while 6% thought that DNR meant providing palliative care only (Sanderson, Zurakowski, & Wolfe, 2013).

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The above results emphasize the lack of uniformity of understanding of the directive by the medical care staff. The question arises as to whether to administer procedures considered “aggressive”, such as dialysis, transfusions or ICU care for a patient who has signed a DNR directive (Hewitt & Marco, 2004). The latter stated in their case study that the decision on DNR means that a different type of treatment should be provided without CPR, and that the staff should focus on lessening distress as compared to other patients who have not signed a DNR.

Santonocito, Ristagno, Gullo, & Weil (2013), who surveyed the meaning of DNR directives around the world, found no uniformity or consensus on its implications for care. They found that there was often confusion between the directive, its meaning, and the implementation of instructions for the transition to palliative care.

In view of the possible various interpretations of the DNR directives among nurses, physicians, patients and their families, rules should be set for the DNR with complete transparency, among the hospital staff and between staff and patient.

Methods The current study has a descriptive correlational design aimed at gathering data from nurses and physicians in internal medicine wards. The research population comprised nurses, specialist physicians and residents on three internal medicine wards of Hadassah Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel.

This convenience sample comprised the doctors and nurses who participated in the staff meetings and agreed to fill out the questionnaire. Response was about 80%. The study was accomplished during 2014, over three months as of the questionnaires’ distribution.

The research instrument, aimed at identifying opinions held by doctors and nurses on the concept “DNR”, was a questionnaire, developed by the staff of the internal medicine department. The questionnaire


statements were formulated to be answered Yes or No, with the main question being, “When you are treating a patient with a DNR order, do you think that you should perform the following?” This was followed by a list of various actions associated with patient care. In addition, there was room to comment freely. The study also received from the institution’s Ethics Committee authorization.

Results Table 1 presents the characteristics of the research sample. The results show differences in the caregiving staff’s opinions on several activities associated with the DNR directive. While cardiac massages and ventilation are definitely considered to be included in the DNR directives, i.e., more than 90% of the respondents thought that if the patient has signed a DNR, the caregiving staff should not carry out these procedures. Other activities, such as imaging tests (i.e., Magnetic Resonance Imaging-MRI/Computed Tomography CT), are under disagreement and have been considered, by about half the respondents, as part of DNR, while the other half stated that they are not. Such answers can lead to a lack of uniformity in the care provided by various staff and create confusion among the caregiving staff.

While there is a comprehensive consensus on issues of palliative care, procedures which should be carried out under all circumstances such as washing the patient, changing position, and caring for pressure ulcers, other types of interventions, such as pleural and peritoneal fluid aspiration, remain the subjects of differences of opinion: approximately 60% of the respondents thought that they should be carried out on patients classified as “DNR.” This is an interesting finding, since this is an invasive procedure which lessens patient suffering and is usually not especially painful. Thus, we may have expected that more staff members would not use these invasive procedures of pleural and peritoneal fluid aspiration on a DNR patient.

Table 2 presents statements with over 80% agreement on whether

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to perform specific actions or not. Some actions have a clear status, with over 80% of respondents of the opinion that they must be carried out: treating pressure ulcers, suction, changing position, washing the patient, supplying oxygen, supplying intravenous fluids, and supplying subcutaneous fluids. Results also showed a consensus not to carry out the following on a DNR patient: cardiac massages, pulmonary resuscitation with an Ambu bag, administering inotropic agents (dopamine/noradrenaline), and intubation.

Table 3 presents the controversial activities, i.e., those with less than 80% agreement that they should be performed or not. The table demonstrates the disagreement among staff members as to whether certain treatments should or should not be performed on a patient who has signed a DNR directive.

It is interesting to note the distribution of the disagreement between physicians and nurses, as shown in Table 4. Due to the small sample size, we cannot call it significant, but the differences between the nurses’ and the physicians’ approach are obvious with respect to performing dialysis, connection to non-invasive ventilation devices, inserting a central line, carrying out blood tests, and especially invasive fluid aspiration procedures.

When compared to physicians’ opinions, nurses tend less to agree that invasive fluid aspiration procedures should be offered, however, when referring to connecting the patient to the non-invasive ventilation machine, nurses tend, more than physicians, to think that this action should be performed.

DiscussionThe current paper examined the definition of “DNR” by the medical and nursing staff in the internal medicine departments of a leading Israeli medical center. Results show differences between caregiving staff members’ understanding of the concept, without any uniform definition. The simplest, literal meaning of “DNR” is Do Not Resuscitate – do not carry out cardiac massage, and do not carry out


mechanical ventilation – yet different staff members use this definition to define palliative care.

According to Veller (1994), among the principles of palliative care are alleviation of symptoms and sharing decisions with the patient and their family. The research results show that actions likely to alleviate painful symptoms, such as invasive fluid aspiration procedures, are perceived by most staff members as actions which should be performed, while 40% of the respondents thought that such actions should not be carried out because they are invasive and may cause pain as well as extend the patient’s life under painful conditions.

The current study found several interventions, such as performing a cardiac massage or giving inotropic agents, on which staff members agree that they should not be performed on patients who have signed a DNR directive. However, they agree to supportive actions such as washing the patient, changing position, and treating pressure ulcers. With reference to the latter interventions, there is no disagreement in our sample, and it is clear to all staff members that they are all included in the DNR definition.

Since some of the decisions are value-based and ethics-based decisions, which are not purely medical decisions and assuming that consensus is needed when working as a team, there is a lack of consensus on the care protocol. Lack of consensus is likely to lead to moral distress, burnout, and leaving one’s job in the internal medicine department, as well as more suffering for the patient and their family, and lack of trust in the care team. A study which examined conflicts among ICU staff found that there is a significant correlation between conflicts at work and care for patients who have made end-of-life decisions (Azoulay, et al., 2009).

There is a vagueness about which actions should be performed, and what is exactly comprised by the definition of DNR; there is a wide range, from carrying out resuscitation to alleviating symptoms by connecting the patient to non-invasive mechanical ventilation.

127Medicine and Law

Israel’s Dying Patient Law, 2005, states that patient’s consent must be obtained, and that staff actions should not be based only on their opinions. We must note that the law prohibits withholding of any feeding and fluids, or palliative and supportive care, from a dying patient – even if the patient has explicitly requested their not be administered. Such a situation compels the staff to daily face dilemmas when caring for the terminally ill. The “gold standard” is to ask the patient individually what his wishes are, but there are many hospitalized on internal medicine wards with cognitive difficulties or who are unconscious, due to various reasons, such as high level of blood CO2 gas or high ammonium content, which makes it unrealistic. Decisions on the care protocol is a value-based and ethics-based decision which takes into account the possible suffering to be felt by the patient (Santonocito, Ristagno, Gullo, & Weil, 2013).

Recommendations and nursing implications To avoid lack of communication between staff on issues associated with DNR, we recommend several steps: 1) to assess what the patient and his family know about the patient’s condition; 2) to hold a discussion on the status of the DNR in a broader sense than just the care goals; 3) to obtain as specific instructions as possible from the patient, and 4) to make a professional assessment of the specific patient’s chances of resuscitation: if the chances are zero, the staff is not obligated to resuscitate him (Murphy & Price, 2013).

A living will is likely to help the staff and family understand the patient’s wishes. In 2013, Israel’s Ministry of Health national database registered only 2,662 living wills, i.e., 0.3% of Israel’s 65 and older population. There is a need to increase public awareness of the importance of living wills among the elderly through advertising and publicity, as well as family doctors and community-based healthcare workers asking their clients individually (Shvartzman, Reuven, Halperin, & Menahem, 2015).

Guidelines should be set for the medical and nursing staff, explained in staff meetings with both physicians and nurses’ presence, in which the staff can discuss the department’s patients’ status, from the medical and


ethical aspects. The discussion on end-of-life decisions are very often held under pressure, in a very sad atmosphere, which does not facilitate clear thinking by the patient or the family, and often takes place right before the patient requires resuscitation. End of life decisions should be made in a calm atmosphere, with people who are familiar with the patient’s desires and values. The literal definition, Do Not Resuscitate, is problematic in terms of the caregiving staff/patient communication. Perhaps it should be changed to a new terminology – Allow Natural Death (AND) (Santonocito, Ristagno, Gullo, & Weil, 2013).

The current study did not examine the perceptions of patients and their families about the meaning of DNR. Additional research should be carried out to examine whether the patient understood the decision, and whether the family understood what the patient wished for. It is important to examine the congruence between how the medical and nursing staff understand what is DNR and how the patients and their families perceive it.

The current study emphasizes also the need to set several parameters for DNR, and not only a single definition, as well as regulate the need to have periodic meetings and discussions on specific patients.

ReferencesAzoulay, E., Timsit, J. F., Sprung, C. L., Soares, M., Rusinová, K., Lafabrie, A., & Schlemmer, B. (2009). Prevalence and factors of intensive care unit conflicts: the conflicts study. American journal of respiratory and critical care medicine, 180(9), 853-860.

Hewitt, W.J., & Marco, C.A. (2004). DNR: Does it mean “Do Not Treat?” ACEP News, 3.

Israel. Dying Patient Law, 5766-2005. Published in the Government Gazette.

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Jesus, J. E., Allen, M. B., Michael, G. E., Donnino, M. W., Grossman, S. A., Hale, C. P. & Fisher, J. (2013, July). Preferences for resuscitation and intubation among patients with do-not-resuscitate/do-not-intubate orders. In Mayo Clinic Proceedings (Vol. 88, No. 7, pp. 658-665). Elsevier.

Murphy, P. & Price. P. (2013). retrieved 7.2.2015: www.nursingmanagement.com

Perron, N.J., Morabia, A., & De Torrente, A. (2002). Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital. Journal of Medical Ethics, 28 (6), 364-367.

Sanderson, A., Zurakowski, D., & Wolfe, J. (2013). Clinician perspectives regarding the do-not-resuscitate order. JAMA Pediatr, 167 (10), 954-958. doi: 10.1001/jamapediatris.2013.2204.

Santonocito, C., Ristagno, G., Gullo, A., & Weil, M.H. (2013). Do-not-resuscitate order: a view throughout the world. J Crit Care, 28 (1), doi: 10.1016/j.j rc.2012.07.005

Schwarzkopf, D. (2014) A novel questionnaire to measure staff perception of end-of-life decision making in the intensive care unit—Development and psychometric testing. J Crit Care, 30,187-195.

Shvartzman, P., Reuven, Y., Halperin, M., & Menahem, S. (2015). Advance Directives–The Israeli Experience. Journal of pain and symptom management.

Veller, A. (1994). Philosophy and principles of the hospice. Gerontologia. 14-22. (Hebrew).


Table 1. Distribution of the study variables (N=61):

Variables % (N)

ProfessionPhysicians 21.3% (13)

Nurses 70.5% (43)

gender Men 26.2% (16)

Women 65.6% (40)

Age

20-30 24.6% (15)

31-40 27.9% (17)

41-50 19.7% (12)

51-60 9.8% (6)

>61 4.9% (3)

Years of work experience

0-5 39.3% (24)

6-10 13.1% (8)

11-20 16.4% (10)

21 < 19.7% (12)

Position:

Senior Physician 13.1% (8)

Specialist Physician 8.2% (5)

Registered Nurse 57.4% (35)

Graduate nurse with advanced clinical

course13.1% (8)

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Table 2. Actions with a high percentage of agreement to perform them.

Description Perform Do not perform p

Perform cardiac massage 8.2% (5) 91.8% (56) 0.93

Resuscitation with ambu bag 14.8% (9) 82% (50) 0.95

Administer inotropic agents (dopamine/noradrenaline)

13.1% (8) 83.6% (51) 0.67

Intubation 3.3% (2) 95.1% (58) 0.42

Care for pressure ulcers 98.4% (60) 1.6% (1) 0.56

Change position 98.4% (60) 1.6% (1) 0.58

Suction 90.2% (55) 6.6% (4) 0.89

Wash the patient 100% (61)

Supplying oxygen 98.4% (60) 1.6% (1)

Feed through nasogastric tube 85.2% (52) 11.5% (7) 0.49

Supplying intravenous fluids 95.1% (58) 4.6% (3) 0.43

Supplying subcutaneous fluids 85.2% (52) 11.5% (7) 0.52

Table 4. Distribution of the disagreement between physicians and


nurses.

Procedure Should be performed

Do not perform p

Nurses Physicians Nurses Physicians

Dialysis 33.3% (14) 25% (3) 66.7% (28) 75% (9) 0.58

Connection to CPAP 48.8% (20) 33.3% (3) 51.2% (21) 66.7% (6) 0.4

Administration of antibiotics 83.3% (35) 75% (9) 16.7% (7) 25% (3) 0.51

Administration of inotropic agents (dopamine/ noradrenaline)

14% (6) 9.1% (1) 86% (37) 90.9% (10) 0.67

Insert IV into central vein 26.8% (11) 16.7% (2) 73.2% (30) 83.3% (10) 0.47

Blood count and biochemistry 76.2% (32) 91.7% (11) 23.8% (10) 8.3% (1) 0.24

Blood cultures 71.4% (30) 75% (9) 28.6% (12) 25% (3) 0.8

Pleural fluid aspiration 57.1% (24) 76.9% (10) 42.9% (18) 23.1% (3) 0.2

Peritoneal fluid aspiration 57.1% (24) 76.9% (10) 42.9% (18) 23.1% (3) 0.2

Imaging test (i.e., CT/ MRI) 45.2% (19) 46.2% (6) 54.8% (23) 53.8% (7) 0.95

Table 3. Controversial procedures, i.e., with less than 80% agreement

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as to performance or failure to perform the following procedures

Procedure Perform Do not perform P

Dialysis 31.1% (19) 65.6% (40) 0.58

Connect to CPAP 42.2% (26) 47.5% (29) 0.4

Administration of antibiotics 78.7% (48) 18% (11) 0.51

Insert IV into central vein 23% (14) 72.1% (44) 0.47

Blood count and chemistry 75.4% (42) 27.9% (17) 0.24

Blood cultures 68.9% (42) 27.9% (17) 0.8

Pleural aspiration 62.3% (38) 36.1% (22) 0.2

Peritoneal aspiration 60.7% (27) 54.1% (33) 0.2

Imaging test (CT/MRI) 44.3% (27) 54.1% (33) 0.95

Bronchoscopy 26.2% (16) 72.1% (44) 0.8

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Medicine and Law

“END-OF-LIFE” DECISIONS: DNR VS. AND

Dorit Rubinstein, R.N., Ph.D.*

Abstract: According to the patient autonomy principle, competent patients should be given the opportunity to choose their treatments, or refuse unwanted ones. The implications of refusing or requesting treatments differ, in both legal and moral terms. Complying with this principle may exemplify challenging issues and some confusion relating to the decision-making processes associated with “End-of-Life” issues.

Over the past few decades, health professionals and ethicists have become aware of the confusion caused by the failure to distinguish between the obligation of health-care professionals to respond to the patients’ requests for treatment or their refusal to be treated, especially those relating to the “End of Life,” including Euthanasia DNR (Do Not Resuscitate), and AND (Allowing Natural Death).

This confusion is due to the misinterpretation of the terms. With regard to patients’ preference to end their lives without suffering, and the use of the terms, such as end-of-life decisions or choices, which may be refusals of, or requests for treatment. This can be understood as the patient’s right to choose or reject one or more end-of-life options presented by the physician. However, the issue of physician compliance with the patients’ requests to end their lives is not even considered.

This paper aims to clarify the meanings and differences between these “End-of- Life” options and the disputes around them. The patient’s part and the nursing professional’s important role in honoring these options are elucidated.

Keywords: End-of- Life; Allowing Natural Death; Nursing; Patient’s Rights

* Division of Geriatrics, Ministry of Health, Israel. Email: [email protected]

Health Law (2015) 34:135-146


INTRODUCTION

Over the last three decades, health professionals and ethicists have become aware of the need to deal with the end-of-life relating to the patients’ right to request to end their lives with dignity. In western societies, there is an ongoing emotionally charged debate around ethical issues, such as “Euthanasia – Mercy Killing” and related options.1 This article reviews the definitions of various terms related to Euthanasia, DNR and AND. It also focuses on which principles should be preserved and which may be violated; and the influence and the weight of all these components on the debate development. Furthermore, it highlights some of the claims and justifications in favor and against these options and the factors influencing medical professionals to act according to these principles.

Much of the debate around the euthanasia options and the alternatives related to ending human life arose in the wake of in court deliberations. Many of them were provoked and developed through slogans in the mass media, followed by arguments in favor, or against them. They differed in terms of legal, ethical and clinical justifications and the weights given to these factors by public opinion; and were affected to varying degrees by the emotional dead weight created by descriptions of various disturbing circumstances. The intensity of the reactions may be due to many reasons, including personal, cultural and religious influences, often not based on grounded knowledge. They may reflect both the health professionals’ attitudes and public opinion with regard to various end-of-life issues. Over the last 15 years, there has been increasing debate around whether to respect, or ignore, patients’ advance directives (AD’s) or requests to stop treatment. In Israel, section 13 of the “Patient Rights Act”2 refers to the patient’s alternative to refuse treatment. Such patient preferences should be respected by all health professionals, especially if patients are competent and understand the consequences of their requests. Medical professionals cannot force patients to receive recommended treatments, except for emergencies in which physicians believe that the patient’s decisions were not made with full awareness of their consequences.

In general, physicians may give the recommended treatments if they believe that patients would appreciate them later, when their condition improves. In

1 Emanuel, E. J., (1994). Euthanasia historical, ethical, and empiric perspectives. Arch to Internal Medicine, 134: 1890–1901.

2 Patient Rights Act (1996). Compendium of Laws.5756. 327.

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such cases, their decisions require the signatures of three physicians. However, the situation differs for incompetent patients. In such cases, the guardian has to be consulted about continuity of treatment. Furthermore, none of these options involve the issue of ending the patient’s life. The difficulties are even greater in dealing with the need to respect AD’s of incompetent patients, even if they were considered competent when they signed the AD’s not to prolong their life in an aggressive fashion. The issue of respecting the AD’s of terminal and dying patients and their wish to end their lives with dignity became the focus of the “Dying Patient Act.”3 Nevertheless, the options for allowing end-of- life procedures in this Act are difficult to understand and problematic to apply.

The obstacles to achieving them derive from a combination of factors, including religious, medical and legal limitations, and fear of the slippery slope. Moreover, the failure to distinguish between the obligations of medical professionals, physicians and nurses to act in response to patients’ refusal of treatments or request to “end life” has become more and more confusing and frustrating. In part, such confusion is caused by lack of clarity, difficulty in understanding the meanings and differences among the various end-of-life options, and the ways medical professionals can implement patients’ requests.

Clarifying this situation requires first, clear and distinguishable definitions of the three main terms. Euthanasia4 — is defined as a deliberate intervention undertaken with the express intention of ending a life; its goal is to relieve intractable suffering;5 the painless killing of a patient suffering from an incurable and painful disease or an irreversible coma.6 The second term is DNR (Do Not Resuscitate order) — which is defined as a legal order, written either in the hospital or on a legal form, to respect the patient’s wish to refrain from CPR (Cardio-Pulmonary Resuscitation). The DNR request, usually made by the patient or health-care power of attorney, allows the medical teams to respect

3 Dying Patient Act (2005). Compendium of Laws. 2039. 68-71. 4 Also connected to or interpreted as assisted suicide, physician-assisted suicide (dying),

doctor-assisted dying (suicide), voluntary, involuntary and non-voluntary active euthanasia, passive euthanasia, indirect euthanasia, and more loosely termed as mercy killing,

5 Harris, N. M., (2001).The euthanasia debate. Journal of the Royal Army Medical Corps, 147(3): 367–70.

6 Euthanasia (2010). Oxford Dictionaries, Oxford University Press, Retrieved August 28, 2012. From: http://www.oxforddictionaries.com/definition/euthanasia.


these wishes.7,8 The third term is AND (Allowing Natural Death request). This term, defined as an order to Allow Natural Death, comes to ensure that only comfort measures are provided to the terminally ill patient.9 This order allows the terminally patient to die quietly and peacefully by removing all the options that might interfere in the patient’s natural death. By focusing on what should be done, rather than on what should be avoided, this term quickly gains favor.

What the Differences in the Procedures Mean

Medical professionals, legal authorities, church leaders, philosophers, and commentators on ethics and morality usually make the distinction between passive10 and active euthanasia. Delineating these processes in terms of essential definitions should allow us to sharpen the differences between them. Moreover, it is helpful to distinguish between them, based on the attitudes of various medical professionals (such as physicians and nurses), nature of the action, extent of patient consent, and degree of family involvement in the decision-making procedures. In voluntary or positive-active euthanasia, such as cases of “physician-assisted suicide,” the procedure is carried out with patient consent. The physician’s and the patient’s intentions are similar, namely, to end the patient’s life. The end of life is deliberate, with an action taken to cause the patient’s death, such as administration of a lethal drug.11 Another option is involuntary active euthanasia. If the physician and the family member(s) intend to end the sufferer-patient’s life, the decision may sometimes be made without patient consent. In case the patient is incapable of doing so, the decision is made by a surrogate.1 Whereas it may emerge in different contexts or situations, involving different persons, and various intentions, the definition of negative, or passive, euthanasia is often not clear-cut, and the process may be interpreted in different ways. For example, a suffering, comatose, terminally ill

7 Gehlbach, T. G., Shinkunas,L. A., Forman-Hoffman,V. L., Thomas, K. W.M, Schmidt,G. A., Kaldjian,L. C., (2011). Code status orders and goals of care in the medical ICU. CHEST, 39(4): 802–809.

8 Do Not Resuscitate (DNR) Order (2008). Surgery Encyclopedia. Retrieved August 28, 2012. From: http://www.surgeryencyclopedia.com/Ce-Fi/Do-Not-Resuscitate-DNR-Order.html.

9 Hospice Patient Alliance (1998). New designation for allowing a natural death (“A.N.D.”) would eliminate confusion and suffering when patients are resuscitated against their wishes. Retrieved August 28, 2012. From: http://www.hospicepatients.org/faq.html

10 Euthanasia (2009). Mosby’s Medical Dictionary, 8th edition, Elsevier. 11 The practice of injecting a patient with a lethal dose of medication with the primary

intention of ending the patient’s life, at the patient’s request. See Active Euthanasia (2012). Segen’s Medical Dictionary. Joe Segen and Farlex, Inc.

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patient, may have, against the family’s wishes, previously asked the physician to end his or her life as quickly as possible without pain and suffering. If the physician prescribes increasing doses of narcotic, which may eventually be toxic, it is possible to claim that this is passive, rather than active euthanasia. In most cases, the physician’s measures are considered passive. Many claim that this is an incorrect use of the term, since this is not euthanasia, because there is no intention to take life.

Another example is the physician who intentionally withholds life-preserving procedures that would prolong the life of an incurably, terminally ill patient, who could not survive without them.12 Sometimes, such decisions do not include stopping hydration and nutrition. The meaning of withholding life-preserving procedures is different for the dying patient close to the end-point of a terminal condition, surrounded by family, than for the physician. Firstly, the patient and his family usually13 intend to forego life-sustaining treatments, while not withholding life-preserving procedures. Secondly, foregoing life-sustaining treatment includes stopping hydration, nutrition, as well as avoiding the patient’s transfer to hospital, especially from a long-term residence facility.14

This explanation may shed light on the differences in the end-of-life perceptions between medical professionals, and competent patients and their families. In my view, withholding some, but not all, life-preserving parameters and procedures misses the mark in helping the patient to die with dignity. By continuing hydration and nutrition, medical professionals may prolong patients’ lives, thereby also increase their suffering. To end this unfortunate situation, there is a need to clarify what “withholding life-preserving procedures” means and include. Then, the required action should involve the intention to end the suffering patient’s life by foregoing all life-sustaining treatments. As demonstrated by this extreme description, all such options can generally be interpreted as active euthanasia.

12 Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, (2003). 7th edition. Saunders, an imprint of Elsevier.

13 Dreyer, A., Forde, R., Nortvedt, P., (2009). Autonomy at the end of life: life – prolonging treatment in nursing homes – relatives’ role in the decision–making process. Journal of Medical Ethics. 35: 672-677. DOI:10/1136/jme.2009.0300668.

14 California Healthcare Foundation & HSM Group Ltd. (2008). Improving End of Life Care in California’s Nursing Homes. Retrieved August 28, 2012. From: http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/E/PDF%20EOLCareNursingHomes.pdf 1-9.


15 Watson, J., Hockley, J., Murray, S., (2010). Evaluating effectiveness of the GSFCH and LCP in care homes. End of Life Care, 4(3): 42 – 49.

Medical professionals may sometimes be torn by religious, moral, ethical and compassionate arguments that influence their intentions. Searching for justifications for their actions is not enough, and mostly does not give clear answers, reflecting the confusion between withholding life-preserving procedures and foregoing life-sustaining treatment. Furthermore, it emphasizes the differences in definition and context, and between active and passive euthanasia, underlining the notion of active euthanasia as much more controversial than passive euthanasia.12 Moreover, passive, and not active, euthanasia is the more accurate term to describe foregoing life-sustaining treatment.

DNR orders only affect a small group of patients and are designed to avoid suffering in medically irreversible terminal illnesses and other serious conditions. The order actually authorizes withholding medical treatment. Requesting DNR does not mean stopping the care, but rather changing the goal of the treatment. As specified in the chart of medical orders, DNR restricts the use of CPR techniques and other measures to revive the patient by hospital and pre-hospital personnel.5 Thus, the DNR order is not really suited to dying or terminal cases and, insofar as all kinds of active, aggressive, life-sustaining treatments are inappropriate, it does not answer the patient’s and/or the family’s needs.9,15 While a DNR patient hospitalized in Intensive Care might be put on a ventilator, given artificial hydration, or have a feeding tube inserted, such procedures, being painful and burdensome for the terminally ill, would not be initiated, or would be withdrawn or discontinued in a AND patient.

Subsequently, a DNR order, by a patient who was informed about this option and expressed his consent beforehand, may be considered voluntary active euthanasia; or involuntary active euthanasia, if the patient’s condition deteriorated rapidly, before the physician could ask for his consent. By allowing AND, physicians and other medical professionals would effectively acknowledge that the patient is dying and that everything done at that stage, including the withdrawal of nutrition and hydration, would allow the death process to occur as comfortably as possible. By permitting AND, unintentional pain could be prevented and natural death9 would simply be allowed to occur. In this way, AND may be defined as foregoing life-sustaining treatment or passive euthanasia, thus allowing the patient to die naturally, without or by avoiding intervention.

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Preserved or Violated Values and Principles

This paper only focuses on AND, a term recognized as passive euthanasia or foregoing life-sustaining treatment, and on the principles and values that may be preserved or violated by this option. This is done in several steps: (1) The known facts, and thoughts and feelings about this situation are described; (2) The principles involved are identified; (3) How the situation influences these components is determined, and; (4) Weights are assigned to the principles discussed. In passive euthanasia by AND, the principle of Quality of Life1 is, most frequently, weighed against the Sanctity of Life.16,17 Other possible relevant principles are: Autonomy,1,16,18 Patient Consent, Persons’ Incapacity to Consent,16,18 Mercy,16,17,19 Compassion,16,19 Relief of Suffering,16,19 and the Slippery Slope.16,17,20 These principles and values have become the basis of all credible arguments in the debate. Through them, claims may be made in favor or against all forms of euthanasia,16 particularly the AND option.

Claims and Justifications in Favor and Against Passive Euthanasia

Justifications for Passive Euthanasia (AND)

Quality of Life has been claimed as a justification for euthanasia. Neither the physician nor the family can understand the dying process. Only the patient is really aware of what it is like to experience intractable suffering, even with pain-relievers. Those who have not experienced it cannot fully appreciate the effects on quality of life. Apart from physical pain, only the patient can fully comprehend the emotional pain of losing independence in all life activities.21 Patients who strove for independence and meaningfulness all their lives would be expected to continue their search for them despite terminal sickness. Viewed in this light, the option of choosing how to die becomes

16 Pence, G.E., (2000). Physician – Assisted Dying. Classic Cases in Medical Ethics. Boston: McGraw Hill. 85-113.

17 Ryder, R., (2001). Political Philosophy and Painism Will Follow, Oxford: Opengate.18 United Nations Educational, Scientific and Cultural Organisation (UNESCO) Sector

for Social and Human Sciences (2008). Bioethics Core Curriculum. Retrieved August 28, 2012. From: http://www.unesco.org/new/fileadmin/MULTIMEDIA/HQ/SHS/pdf/BioethicsCore_Section2_18Jul08_EN.pdf

19 Cassell, E. J., (1995). Pain and Suffering. In: Reich, W. T. (ed.), Encyclopedia of Bioethics, New York: Simon & Schuster, Macmillan. 4: 1897–1905.

20 Cassell, E. J., (1995). Pain and Suffering. In: Reich, W. T. (ed.), Encyclopedia of Bioethics, New York: Simon & Schuster, Macmillan. 4. 1897–1905.

21 Van Hooft, S., (1998). The meanings of suffering. Hasting Center Report, 28 (5): 3-19.


more considerable. Quality of death and the quality of life may become equal priorities in the patients’ eyes. Society acknowledges the individual’s quality of life by granting him or her the right to continue to pursue independence - from advanced issues, through instrumental matters, to basic life activities. Thus, the life of an individual who for some reason or other becomes disabled or handicapped and has to depend on others for help in all activities may not be considered worth living. According to proponents of euthanasia, such as AND, the gap between the individual perception of the kind of life worth living and reality may considerably vary. Significant gaps seem to support the need for patient preferences and respect for such choices.

Autonomy, or the patient’s ability to participate in medical decisions, is an important component of patient rights.2 Thus, the patient has the autonomy to consent or refuse treatment. Society acknowledges individuals’ autonomy by granting them the right to pursue their view of what they consider as good life. Protecting patient autonomy encompasses the treatment choices available at the time and the manner of death. A proper death is as much a part of the vision of a good life as anything else.16 Medical intervention that seems to conflict with the patient’s personal meaning of good life, brings the patient’s right to refuse medical treatment to the forefront. According to proponents of euthanasia, such as AND, respect for individuals’ autonomy should involve self- determination22 with respect to the preference for natural death.

Mercy, when observing another human being in untreatable or unbearable pain, is aroused even in the most callous. Furthermore, the suffering of a terminally ill patient is confined not only to physical pains, but also to emotional and mental suffering, followed by hopelessness,16 depression,20 exhaustion,16,19

and other unpleasant experiences. The desire to bring it to an end is the first response to such pain. Being merciful to dying patients is to understand what they each mean by this term and what each of them really wants. One of the options they might request is to be allowed to die without interventions that would prolong their suffering. According to proponents of euthanasia, such as AND, showing mercy to dying patients is to support and encourage them to persist with their decisions to die naturally, without unwanted interventions. Promoting the scientific skills to allow patients to die naturally should be actively funded and such mercy should be valued by society.17

These arguments for allowing natural death can be summarized as respect for patients’ quality of life, autonomy, and the need for mercy from medical

22 Brock, D.W., (1992). Voluntary active euthanasia. Hastings Center Report, 22: 10-22.

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professionals to fulfill such requests, including stopping hydration and nutrition. These guidelines may also be useful for justifying other euthanasia alternatives.

Reasons for Opposing Passive Euthanasia (AND)

Sanctity of Human Life may be compromised by respecting individuals’ wishes to allow death to occur in natural way, since physicians opt not to give treatments, and to withhold resuscitation, hydration and nutrition. In certain cases, this might cause unbearable suffering, and should be avoided. If withholding anything causes pain or distress, then it ought not to be done. According to opponents of euthanasia, such as AND, it is preferable to keep patients well-fed , comfortable, and free from pain by administering sufficiently high doses of analgesic and psycho-active drugs so as to enhance their sense of well–being until they die. They do not consider that allowing patients to die naturally has any moral value, per se.17

Persons without the Capacity to Consent18 are those who become incompetent to make such decisions consciously. Requests to die naturally by passive euthanasia, such as AND, are voluntary only if patients are mentally competent, with lucid understanding of the available options and their consequences. Determining or defining competence is not straightforward. The only way to respect incompetent patients’ wishes is if they previously signed advance directives. However, it is misleading to think that passively allowing incompetent people to die slowly, by natural processes, is morally superior to actively ending their lives.16 According to the opponents of euthanasia, AND is just as bad (or good) for an incompetent patient as “killing” them. However, there is nothing inherently moral or immoral in the act of passive Euthanasia; rather its morality or immorality is determined by the motives and results of the act.

The Slippery Slope in this context is difficult to evaluate, since the capacity to predict bad events is often so far in the future. Thus, proponents of euthanasia, such as AND, only seek this option for competent adult patients, who can be defined as dying, and not for others. However, some cases call to violate this condition, e.g., the need to take care of end-stage demented patients, and defective neonatal newborns.23 However, allowing behavior that seems to be morally correct in certain situations leaves an opening, albeit small, for

23 Dombe, S., (2011). Neonatal intensive care nurses’ attitudes and behavioral intentions toward euthanasia in very ill preterm infants and newborns. Masters degree paper. Department of Nursing, University of Tel Aviv.


immoral behavior under other conditions. If a small change is made in a moral rule, other changes will inevitably follow in order to meet the rational demands for consistency in treating apparently similar cases.16

The arguments against AND conform to the idea of the Sanctity of Life while respecting the patient’s requests by applying the safeguard that the patient has to be competent to make such decisions. However, the need to cater for those without the capacity to consent (incompetent patients), as well as defective newborns, can lead to the Slippery- Slope problem.

Various studies reveal that Attitudes and Intention to Act are related to personal characteristics. Social and cultural backgrounds may influence physicians’ and nurses’ intentions to act with respect to Euthanasia.24,25,26,27,28 Most of the studies that focused on the relation between attitudes and the intention to act showed similar tendencies. However, those dealing with euthanasia have contradictory outcomes,29,16 with a gap between attitude and intention to act, depending on the procedure’s legality, 30 its society’s6 legitimization and personal characteristics7 of the health professionals involved. Sometimes, they are faced with unresolved situations concerning euthanasia. Health professionals may find themselves in confusing or frustrating situations, in which they reject or disregard various issues. The options of clarifying these situations and breaking them up into components may contribute toward coping with them meaningfully.

24 Kushe. H., Singer, P., (1993). Voluntary euthanasia and the nurse: An Australian survey. International Journal of Nursing Studies, 30(4): 311–322.

25 Asch, A. D., Dekay, M. L., (1997). Euthanasia among critical care nurses. Practices, attitudes and social and professional correlates. Medical Care, 35(9): 890–900.

26 Asch, A. D., Hansen, F. J., (1995). Decisions to limit or continue life sustaining treatment by critical care physicians in the U.S.: Conflicts between physician practices and patients’ wishes. American Journal of Respiratory Critical Care Medicine, 1(2): 282-288.

27 Lam, H. S., Wong, S.P.S., Liu, F.Y.B., Wong, H. I., Fok, T.F., Ng. P.C., (2009). Attitudes toward neonatal intensive care treatment of preterm infants with a high risk of development of long-term disabilities. Pediatrics, 123(6): 1501–1508.

28 Rebagliato, M., Cuttini, M., Broggin, L., Berbik, I., DE Vonderweid, U., Hansen, G., et al (2000). Neonatal end of life decision making, JAMA, 284(19): 2451–2459.

29 Pen, L., (2006). Examination of the relationship between nurses’ personality and professional variables, and their stances and behavior intentions toward mercy killing. Masters degree paper, Department of Nursing, University of Tel Aviv.

30 Tanida, N., Asai, A., Ohnishi, M., Nagata, S. K., Fukui, T., Yamazaki, Y., Kush, H., (2002). Voluntary active euthanasia and the nurse: a comparison of Japanese and Australian nurses, Nursing Ethics, 9(3): 313 – 322.

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Discussion and Conclusions

There are several stimulating and challenging motivations underlying the need to define and distinguish among the terms Euthanasia, DNR and AND. The efforts to explain them are expected to contribute toward answering of the following questions:

1. What are the predispositions of these terms?2. What are the differences between passive euthanasia and a euthanasia

directive? 3. What are the differences in their ethical and legal status? 4. Is the patient, caregiver, or both, the subject of such requests? 5. Who has the priority in euthanasia-related issues?

The awareness of physicians toward actively using various semantic options of DNR, such as for changing the treatment goal, and not only for stopping care, reflects the intervention in the dying process of terminally ill patient. Stopping the treatment, which might prolong the patient’s suffering rather than shortening it, may be misinterpreted as helping the patient to die with dignity. While the DNR order is active euthanasia; AND is passive euthanasia, since it does not involve intervention with the course of dying, rather the patient is allowed to die in a peaceful way.

Implications for nursing practice

One’s decision to withdraw life support can be distressful and painful for his family members and surrounding environment. Further to the patient’s fear of a painful dying process, nurses play a vital role in supporting the patient’s preference and family acceptance. They play an important role as the patient’s advocates in facilitating his end of life decisions. They can encourage the patient to reaffirm, by an advance directive, the way he wishes to be treated or his life to end. Moreover, they can, at the start point, support him in receiving palliative care when medical treatment may be futile. Throughout this process, nurses are demanded to help the patients to achieve or to preserve a sense of coherence and a sense of control of the remains of life. The consequences of these efforts create a lot of pressure on the nurses. At times, when the nurses’ preferences differ from the patient’s or his family’s, the pressure on the nurses is even greater. They have to decide if their obligations are to the patient or to themselves. On those occasions the nursing system has an important role. A


supervising framework should help the nurses to maintain their professional approach while allowing them to express their feelings. Caring for and supporting nurses to continue with their approaches are fundamental and vital in reducing the nurses’ burden.

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FAMILY PRESENCE DURINg RESUSCITATION: PROFESSIONAL CONSIDERATIONS AND ETHICAL ISSUES

Rabia Khalaila RN, Ph.D.* and Zipi Avraham RN, Ph.D.**

Abstract: A review of articles, carefully selected from several databases, was conducted for identifying research findings related to the professional considerations and ethical issues involved respecting the presence of the patient’s family during resuscitation in adult intensive care units (ICU), the perspectives of the patients; family members and health care staff. Studies on family presence during resuscitation indicated that the majority of patients desire family members’ presence during resuscitation. However, based on professional considerations, the healthcare staff held mixed, and sometimes opposite, opinions. Only a few hospitals had active family presence policies in place. While the majority of healthcare providers expressed their preference for a written policy allowing family presence during resuscitation as an option, the decision to establish a formal policy that offers this option is fraught with ethical issues. Consequently, nurses should promote a unit-specific policy on family presence in resuscitation, which takes into account the professional considerations, ethical issues, and the patients’ cultural, social background and preferences. To ensure effective implementation of family presence, such a policy should include staff training, and a family facilitator to support and accompany the family during the patient’s resuscitation.

Keywords: Ethics Issues; Professional Considerations; Family Presence; Intensive Care Unit; Resuscitation.

* Zefat Academic College, Zefat, Israel. e-mail: [email protected]** Zefat Academic College, and Ziv Hospital, Zefat, Israel. e-mail: [email protected]

Health Law (2015) 34:147-160


IntroductionThe practice of allowing family members’ presence at their relative’s resuscitation has been discussed over the past few decades (Doyle et al., 1987; Hanson & Strawser, 1992; Leung & Chow 2012; MacLean et al., 2003). Traditionally, when a patient suffers a cardiac arrest in a hospital, the family is guided away from their loved one into a waiting room, while lifesaving measures are initiated, for fear of immediate and long-term impact on the family, the patient, and the healthcare providers (Critchell & Marik, 2007). As soon as a nurse can safely break away from the resuscitation, the nurse updates the family on the patient’s status. But with the rise of family-centered care, there has been an increase in family input into healthcare decisions. Strict visitation policies have been relaxed, even including family at the bedside during invasive procedures and resuscitation (Davidson, 2009).

The concept was first presented in the early 1980s when, in response to relatives’ demands, Foote Hospital in Michigan began a program to facilitate the practice of patient family members’ presence during resuscitation in the emergency room (Doyle et al., 1987). Of the 18 surveyed family members, 13 (72%) responded that they wished they had been present during the resuscitation. A program of family presence during resuscitation (FPDR) was instituted at Foote, with a follow-up survey in 1985. This survey, which included 47 relatives who had been present during resuscitation, revealed that 94% believed that they would choose to be present again during cardiopulmonary resuscitation (CPR) if given the opportunity, and 64% felt that their presence was beneficial to the dying person (Hanson & Strawser, 1992). Since then, the research has centered on several different aspects of this issue.

Even though a great deal of evidence and professional guidelines support family presence during resuscitation among healthcare providers, as well as among respondents who were patient relatives (Fulbrook et al., 2005; Knott & Kee, 2005; Leung & Chow, 2012), many researchers revealed that family presence during resuscitation is one of the most unmet needs for critical patients’ families in the ICU setting (Lee & Lau 2003, Browning & Warren 2006, Khalaila, 2013; Wanger, 2004).

The studies reviewed here examined the attitudes of patients, family members, and healthcare providers toward ICU patient family presence during resuscitation and discussed the related clinical considerations and ethical issues.

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Literature review

Attitudes of healthcare providersFindings from the reviewed studies identify mixed opinions among healthcare providers regarding FPDR (Howlett et al., 2010). Overall, studies showed that nurses were more supportive than physicians (Leung & Chow, 2012). The studies also showed that cultural values and societal traditions impact healthcare providers’ views on the practice of FPDR (Al-Mutair et al. 2012; Demir, 2008). The majority of studies on FPDR concentrated on western countries such as the US and European countries (Fallis et al., 2008; Fulbrook et al., 2005; Knott & Kee, 2005). However, due to recent awareness by healthcare providers in non-western countries of the practice, studies have been conducted examining attitudes among healthcare personnel and families towards the practice (Al-Mutair et al. 2012; Leung & Chow, 2012).

Studies in western countries showed that nurses displayed positive attitudes to the presence of family members and thought that allowing relatives to be present would reassure families that everything possible has been done to save the patient; they also believed that it would have a positive impact on patient care outcomes (Fallis et al., 2008; Fulbrook et al., 2005; Knott & Kee, 2005). Additionally, these studies endorsed the need for policies to guide the practice. Moreover, nurses participating in those studies expressed their feelings that a member of the resuscitation team shoud act as the facilitator for the patient’s family, assisting them in comprehending what happens throughout the experience and providing emotional support, explanations, and interpretations of the procedure to the attending families (Fulbrook et al., 2005; Knott & Kee, 2005).

In contrast to studies conducted in western countries that reported strong agreement with family presence among critical care nurses, studies in non-western countries, including critical care nurses and physicians from Turkey, Iran, and Saudi Arabia (Al-Mutair et al. 2012; Badir & Sepit 2007; Gunes and Zaybak, 2009; Demir, 2008; Kianmehr et al. 2010) showed a high percentage of opposition among healthcare providers to the family presence. The most common reasons for the respondents’ objections were possible interference from relatives with the resuscitation team’s performance, and the ensuing trauma and stress on relatives from witnessing resuscitation.

Other studies undertaken in Muslim communities reported negative attitudes regarding this practice (Al-Mutair et al. 2012; Badir & Sepit 2007; Gunes and


Zaybak, 2009; Demir, 2008; Kianmehr et al. 2010). For example, Demir (2008) identified that about 82% of physicians and nurses in emergency medicine departments and intensive care units in Turkey felt it was inappropriate for the patient’s relatives to witness resuscitation. The author suggested that, compared to others, cultural differences may have accounted for the much lower level of approval of the practice in this study. The practice is relatively new to those countries, and the majority of the healthcare providers did not approve of the practice of FPDR (Al-Mutair et al. 2012; Badir & Sepit 2007; Gunes and Zaybak, 2009). Kianmehr et al. (2010) cited that Muslim family members are invariably closer to each other and more prone to display strong emotions than Europeans, and healthcare practitioners feared that an emotional storm might disrupt the medical procedures. Similar findings were found by Leung and Chow (2012) who studied traditional Chinese and predominantly Christian patients. They examined the attitudes of both healthcare staff and family members towards the practice in Hong Kong. In that study, it was found that the majority of healthcare providers did not accept the practice; in contrast, nearly 80% of the family members welcomed the practice.

Family members’ attitudes A large number of research studies were conducted from the family’s perspective. FPDR is an element of the proximity needs of family members of critically ill patients which has been, in studies of met and unmet patient family needs, identified as the families’ priorities (Al-Mutair et al 2013, Khalaila 2013; Wanger, 2004). A majority of family members asked about their opinion on FPDR, expressed their desire to be present during procedures, and supported the practice (Al-Mutair et al., 2013; Holzhauser et al., 2006; Hung & Pang, 2011; Leung and Chow, 2012; Mortelmans et al., 2010; Wanger, 2004).

Wanger (2004) believed that families who did not receive information during resuscitation were unable to understand what was going on. Participants maintained that during resuscitation of their loved one, the family was in crisis, needing reassurance and informational support to cope effectively. The results of Holzhauser et al. (2006) also demonstrated that 100% of the family members who were present during resuscitation were relieved and pleased that they were able to provide emotional and physical support to their ill relative. They were comforted by the thought that everything possible had been accomplished to ensure recovery, and that the resuscitation procedure, which seemed traumatic, was beneficial to their loved one, as well as having reduced the family’s anxiety and fear. They also agreed that their presence helped them to come to terms with the patient’s care outcome. In the survey by Mortelmans

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et al. (2010), 75% of patients’ family members expressed their wish to stay with their loved ones, of whom 49% had no fear that it would be too traumatic.

Patients’ preferences Although there is little evidence to indicate any effect of family presence on the patient, some surveys reveal that up to three-quarters of the respondents would, nonetheless, want their loved ones at their bedside during resuscitation efforts (Doyle, et al. 1987; Mortelmans, et al., 2010). Anecdotal reports from patients who have lived through the resuscitation experience indicate that patients overall did not feel that their privacy and confidentiality were violated by the presence of their family members (Grice et al., 2003). Benjamin and colleagues (2004) who conducted the largest study to date specifically examining this issue, found that 72% of 200 emergency room patients wanted family members present during resuscitation. However, 56% of these patients wanted only certain family members there. Those who did not want relatives present cited reasons such as embarrassment, mental anguish for the family, and fear of their inconveniencing or being disruptive to the staff.

In a survey of postoperative ICU patients, more than 70% indicated they would not want family members there during resuscitation, most commonly because they thought that it would be too distressing for them to watch a medical procedure which could perhaps end in death. However, only one patient believed that family attendance would be an invasion of privacy (Grice et al., 2003).

Mortelmans and colleagues (2009) interviewed adults hospitalized due to life-threatening illnesses, asking if they would prefer to have their family members present should their condition deteriorate and require resuscitation. A majority indicated that it would be their preference, despite the possibility of the experience being traumatic for their relatives.

Professional considerations of family presence during resuscitationMany nurses and healthcare providers, familiar with family presence, have argued that there are more advantages than disadvantages for the patient, family, and healthcare providers (Davidson et al., 2011; Nibert , 2005). Harteveldt (2005) suggested that healthcare providers should be aware of both the pluses and minuses of family-witnessed resuscitation so they can make evidence-based decisions. The literature has shown that FPDR has multiple benefits for patients (e.g., reports that having family members at the bedside comforted, helped, and aided them) (Eichhorn et al., 2001), for healthcare


providers (e.g., statements such as “I felt my performance actually improved during resuscitation”, or “I felt a more ‘human’ attitude” rather than treating the incident as a “case of cardiac arrest”; reports that FPDR helped staff provide more holistic care to the patient; encouraged professional behavior among staff; focused staff’s attention on the patient’s privacy and dignity) (Meyers et al., 2000; Nibert , 2005); and for family members (e.g., presence at the bedside helped remove doubt about the patient’s condition by witnessing that everything possible was being done; and decreased their anxiety and fear about what was happening to their loved one; facilitated their proximity need to help and support their loved one, and helped them reach closure. In case of death, family presence facilitated the grief process and increased the sense of being spiritually connected with the patient) (Al-Mutair et al., 2013; Davidson et al., 2011; Doyle et al., 1987; Hanson & Strawser, 1992; Holzhauser et al., 2006; Fulbrook et al., 2005; Knott & Kee, 2005; MacLean et al., 2003; Meyers et al., 2000; Nibert , 2005).

Studies of the practice found that the fears of disruptions or negative outcomes were not fulfilled: no adverse psychological effects were reported among family members who were present at the ICU patient’s bedside during resuscitation measures (Doyle et al., 1987; Hanson & Strawser, 1992; Meyers et al., 2000; Sacchetti et al., 2005).

Despite the majority of healthcare professionals’ expressed support for the concept of family member presence during resuscitation and procedures, several themes have emerged which express reservations regarding the practice. These themes included the fear that families would interfere with the process and disrupt care (Al-Mutair et al. 2013; Basol et al., 2009; Demir, 2008; Fernandez et al., 2009;Koberich et al., 2010; Madden & Condon, 2007; McClement et al., 2009; Walker, 2008); increased performance anxiety and stress on the part of clinicians, the interference with the process of teaching (Basol et al., 2009; Demir, 2008; Fernandez et al., 2009; Madden & Condon, 2007; McClement et al., 2009; Walker, 2008); compromise patient confidentiality (Badir & Sepit, 2007; Critchell & Marik, 2007); possible trauma for the family from witnessing the event (Al-Mutair et al. 2012; Basol et al., 2009; Demir, 2008; Fernandez et al., 2009; Gunes & Zaybak, 2009; McClement et al., 2009; Walker, 2008); misinterpretation of procedure and increased risk of medical malpractice suits by families present during resuscitation and other procedures (Demir, 2008; Fernandez et al., 2009; Gunes & Zaybak, 2009; Madden & Condon, 2007; McClement et al., 2009; Walker, 2008).

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Ethical issues arising from FPDRThe presence of family members during resuscitation of an adult patient is an ethical issue debated among healthcare providers who routinely face life-threatening situations and end-of-life issues common to critically-ill patients in the adult ICU. Because many patients who undergo resuscitation do not survive, the debate over family presence during what may be their loved one’s final moments deserves further ethical considerations (Haddad, 2002; Lederman et al., 2014). However, while most would agree that the primary responsibility of nursing and other healthcare professionals is to the patient, there are conflicting issues when considering what is in the patient’s best interests (Harteveldt, 2005; Lederman et al., 2012), and whether the benefits of family presence outweigh the risk (Thomas, 2007).

The family presence during CPR may cause a moral conflict because of the existing of three opposing obligations: to the family members who desire to be present with their loved one during CPR; the obligation of maintaining the patient’s privacy and confidentiality; and the obligation to the clinical considerations of the healthcare providers who do not want patients’ family members to witness resuscitation efforts because they may disrupt the resuscitation team’s work (Badir & Sepit, 2007; Critchell & Marik, 2007; Lederman et al., 2012; Nibert, 2005). Ethical questions arising from the desire to preserve the dignity of the patient, protect family members, and assist healthcare providers, focus on determining which obligation takes priority.

Family Member Presence Policy in ICUsThe literature indicated that in order to make family presence more beneficial, the nursing leadership must establish clear protocols before initiating such a substantial change in practice (Al-Mutair et al., 2012; Madden & Condon, 2007). The survey by MacLean et al. (2003) showed that only 5% of units had active family presence policies in place. Further research showed that almost all nurses and physicians had no knowledge of international guidelines published on the topic of FPDR in the ICU (Demir, 2008; Madden & Condon, 2007).

Nevertheless, the majority of healthcare providers have reported that they would prefer to have a clear policy in place (Basol et al., 2009; Demir, 2008; MacLean et al., 2013). Further studies endorsed the need for written policies to guide staff during family presence in selected situations in routine treatment or resuscitation (Al-Mutair et al., 2013; Madden & Condon, 2007). Others suggest that a nurse familiar with the procedure, and with good communication


skills, should be designated as the team member who would evaluate family members’ readiness to be present (Al-Mutair et al., 2013).

Recently, family presence is highly recommended by many health organizations worldwide. Several professional organizations have published position statements supporting family presence, including the American Academy of Pediatrics (AAP), American College of Emergency Physicians (ACEP), American Association of Critical-Care Nurses (AACN), Emergency Nurses Association (ENA), and the Society of Critical Care Medicine (SCCM) all support family presence (Davidson et al., 2007).

Implications and recommendations for nursing practiceHospitals should consider establishing formal programs outlining the rules governing FPDR. Such programs should ensure that their healthcare facility has culturally competent written policies, and procedures that support FPDR (Basol et al., 2009; Demir, 2008; MacLean et al., 2013; Madden & Condon, 2007), and which ensure the patient’s confidentiality and their wishes, if known (Davidson et al., 2007). These policies should develop proficiency standards for all staff involved in family presence to ensure patient, family, and staff safety, and to develop a variety of communication strategies to alert and remind staff about the family presence option. It should also develop documentation standards for family presence and include a rationale for excluding the option of family presence; the benefits of family presence for the patient and family; and criteria for assessing family readiness to ensure uninterrupted patient care.

An integral part of all family presence protocols is a designated family facilitator with good communication skills, to be the team member who stands with the family, attending to their needs and describing what is happening in appropriate terms. Many times this role is given to the staff nurse, who is involved in the resuscitation. It is important that the family facilitator be someone who is not actively involved in the resuscitation process. It could be a different nurse from the same unit who is familiar with the patient, or, alternatively, a physician, social worker, chaplain, child life specialist, respiratory care practitioner, family therapist or nursing student (Harteveldt, 2005). The role of the family facilitator in preparing families for being at the bedside and supporting them before, during, and after the event, includes handling the development of unsuitable reactions by family members present, and support for the decision to exclude family members, whether made by the patient or the family, and other contraindications to family presence.

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Another crucial component of a family presence policy is education (Madden & Condon, 2007). Bassler et al. (1999) showed that after training sessions for 46 nurses on the benefits of family presence, the percentage of nurses who would be comfortable offering the option increased from 11% to 79%. Demystifying the fallacies surrounding family presence and increasing the level of confidence with the practice are two of the important aspects of the continuing education of critical care nurses.

Nursing support for family presence has increased over the past decade. Nurses working in hospitals with clear protocols on family presence during resuscitation have reported that the practice has led to increased care for the patient, a higher level of professional behavior, has provided psychological assistance in relatives’ bereavement process, and led to opportunities for increased patient and family education. The research findings highlight and demonstrate the need for core principles of FPDR model especially during critical episodes in adult ICU.

However, we recommend that the hospital professional and ethics committees first address and resolve cultural and ethical issues before instituting an institutional policy on FPDR, as well as set protocols for establishing critical care patients’ preferences in advance.

References Al-Mutair, A.S, Plummer, V., & Copnell, B. (2012). Family presence during resuscitation: a descriptive study of nurses’ attitudes from two Saudi hospitals. Nursing in Critical Care, 17, 90 – 98.

Al-Mutair, A.S., Plummer, V., O’Brien, A., & Clerehan, R. (2013). Family needs and involvement in the intensive care unit: a literature review. Journal of Clinical Nursing, 22, 1805 – 1817.

Badir, A., & Sepit, D. (2007). Family presence during CPR: a study of the experiences and opinions of Turkish critical care nurses. International Journal of Nursing Studies 44, 83–92.

Basol, R., Ohman, K., Simones, J., & Skillings, K. (2009). Using research to determine support for a policy on family presence during resuscitation. Dimensions in Critical Care Nursing, 28(5), 237-247.

Bassler, P.C. (1999). The impact of education on nurses’ beliefs regarding family presence in a resuscitation room. Journal for Nurses in Staff Development, 15, 126-131


Benjamin, M., Holger, J., Carr, M. (2004). Personal preferences regarding family member presence during resuscitation. Academic Emergency Medicine, 11(7), 750 – 753.

Browning G, & Warren N (2006) Unmet needs of family members in the medical intensive care waiting room. Critical Care Nurse Quarterly. 29, 1, 86-95.

Critchell, C.D. & Marik, P.E. (2007). Should family members be present during cardiopulmonary resuscitation? A review of literature. American Journal of Hospice & Palliative Care, 24(4), 311-317.

Davidson, J.E. (2009). Family centered care – meeting the needs of patients’ families and helping families adapt to critical illness. Critical Care Nurse. 29, 3, 28 – 34.

Davidson, J.E., Buenavista, R., Hobbs, K., Kracht, K. (2011). Identifying factors inhibiting or enhancing family presence during resuscitation in the emergency department. Advanced Emergency Nursing Journal Vol. 33, No. 4, pp. 336–343.

Davidson J.E., Powers, K, Hedayat, K.M., et al (2007) Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Critical Care Medicine. 35, 2, 605 – 622.

Demir, F. (2008). Presence of patients’ families during cardiopulmonary resuscitation: Physicians’ and nurses’ opinions. Journal of Advanced Nursing, 63(4), 409-416.

Doyle, C.J., Post, H., Burney, R.E., Maino, J., Keefe, M., & Rhee, K.J. (1987). Family participation during resuscitation: An option. Annals of Emergency Medicine, 16(6), 673-675.

Eichhorn, D.J., Meyers, T.A., Guzzetta, C.E., Clark, A.P., Klein, J.D., Taliaferro, E., & Calvin, A.O. (2001). Family presence during invasive procedures and resuscitation: hearing the voice of the patient. American Journal of Nursing, 101(5), 48 – 55.

Fallis, W.M., McClement, S., Pereira, A. (2008). Family presence during resuscitation: A survey of Canadian critical care nurses’ practices and perceptions. Dynamics, 19(3), 22-28.

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Fernandez, R., Compton, S., Jones, K.A., & Velilla, M.A. (2009). The presence of a family witness impacts physician performance during simulated medical codes. Critical Care Medicine, 37(6), 1956-1960.

Fulbrook, P., Albarran, J.W., Latour, J.M. (2005). A European survey of critical nurses’ attitudes and experiences of having family members present during cardiopulmonary resuscitation, International of Nursing Studies, 42(5), 557 – 568.

Gunes, U.Y, Zaybak, A. (2009). A study of Turkish critical care nurses’ perspectives regarding family-witnessed resuscitation. Journal of Clinical Nursing, 18, 2907–2915.

Haddad, A. (2002). Ethics in action: family presence during codes. RN, 65(11), 31 – 34.

Hanson, C., & Strawser, D. (1992). Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. Journal of Emergency Nursing, 18(2), 104-106.

Harteveldt, R. (2005). Benefits and pitfalls of family presence during resuscitation. Nursing Times,101, 24 – 25.

Holzhauser, K., Finucane, J., & Vries, S. (2006). Family presence during resuscitation: a randomised controlled trial of the impact of family presence. Australasian Emergency Nursing Journal, 8, 139–147.

Howlett, M.S., Alexander, G.A., & Tsuchiya, B. (2010). Health care providers’ attitudes regarding family presence during resuscitation of adults: An integrated review of the literature. Clinical Nurse Specialist, 24(3), 161-174

Hung, M.S., & Pang, S.M.C. (2010). Family presence preference when patients are receiving resuscitation in an accident and emergency department. Journal of Advanced Nursing 67(1), 56–67.

Khalaila, R. (2013). Patients’ family satisfaction with needs met at the medical intensive care unit. Journal of Advanced Nursing. 69, 5, 1172 - 1182.

Kianmehr, N., Mofidi, M., Rahmani, H., & Shahin, Y. (2010). The attitudes of team members towards family presence during hospital-based CPR: a study based in the Muslim setting of four Iranian teaching hospitals. Journal of the Royal College of Physcians of Edinburgh 40, 4–8.


Knott, A., & Kee, C.C. (2005). Nurses’ beliefs about family presence during resuscitation. Applied Nursing Research, 18, 192 – 198.

Koberich, S., Kaltwasser, A., Rothaug, O., & Albarran, J. (2010). Family witnessed resuscitation – experience and attitudes of German intensive care nurses. Nursing in Critical Care, 15, 241-250.

Lederman, Z., Garasic, M., & Piperberg, M. (2014). Family presence during cardiopulmonary resuscitation: who should decide? Journal of Medical Ethics, 40, 315 – 319.

Lee, L.Y.K., & Lau, Y.L. (2003) Immediate needs of adult family members of adult intensive care patients in Hong Kong. Journal of Clinical Nursing. 12, 490-500.

Leung, N.Y., & Chow, S.K.Y.(2012). Attitudes of healthcare staff and patients’ family members towards family presence during resuscitation in adult critical care units. Journal of Clinical Nursing, 21, 2083–2093.

MacLean, S., Guzzetta, C.E., White, C., Fontaine, D., Eichhorn, D.J., Meyers, T.A., & Desy, P. (2003). Family presence during cardiopulmonary resuscitation and invasive procedures: practice of critical care and emergency nurses. American Journal of Critical care, 12(3), 246 – 257.

Madden, E., & Condon, C. (2007). Emergency nurses’ current practices and understanding of family presence during CPR. Journal of Emergency Nursing, 33(5), 433-440.

McClement, S.E., Fallis, W.M., & Pereira, A. (2009). Family presence during resuscitation: Canadian critical care nurses’ perspectives. Journal of Nursing Scholarship, 41(3), 233-240.

Meyers, T.A., Eichhorn, D.J., Guzzetta, C.E., et al. (2000). Family presence during invasive procedures and resuscitation: the experiences of family members, nurses, and physicians. American journal of nursing,100(2), 32-42.

Mortelmans, L.J.M., Van Broeckhoven, V., Van Boxstael, S., De Cauwer, H.G., Verfaillie, L., Van Hellemond, P.L.A., Van Colen, S., & Cas, W.M. (2009). Patients’ and relatives’ view on witnessed resuscitation in the emergency department: A prospective study. European Journal of Emergency Medicine, 17(4), 203 – 207.

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Nibert, A.T. (2005). Teaching clinical ethics using a case study: family presence during cardiopulmonary resuscitation. Critical Care Nurse, 25, 38 – 44.

Sacchetti, A., Paston, C., & Carraccio, C. (2005). Family members do not disrupt care when present during invasive procedures. Academic Emergency Medicine, 12(5), 477-479.

Thomas, T.L. (2007). Family presence: to stay or not to stay? Nursing 2007 Critical Care, 2, 19 – 24.

Walker, W. (2007). Accident and emergency staff opinion of the effects of family presence during adult resuscitation: critical literature review. Journal of Advanced Nursing, 61(4), 348-362.

Wanger, J. (2004). Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. American Journal of Critical Care, 13, 416 – 420.

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Med Law (2015) 34:163-165 Medicine and Law

Index Volume 34 No 1

AAcademic Dishonesty: 91-102, 107.

Adoption Law: 55-6, 58-60, 63.Age Discrimination: 21-3, 27.Allowing Natural Death: 135, 138, 142.Attitudes: 21, 26-8, 39, 55, 59, 61-4, 66, 78, 81, 91-2, 94-102, 106-8, 136, 138, 144, 148-50.Autonomous Care: 69.

BBehaviour: 91-102, 106-8.

CClosed Adoption: 55-7, 59, 62-5.Collaborative Care: 69, 80.

DDNR: 121-8, 135-7, 140, 145.

EEarthquake: 39-46, 50-4.End-of- Life: 69, 121, 126, 128, 135-7, 139, 153.End-Of-Life Directives: 121.Ethical Dilemmas: 40, 43-6.Ethics Issues: 147.Equitableness: 21.

FFertility Treatment: 55-6, 60-6, 68.Family Presence: 147-9, 151-5.



H Healthcare Providers: 6, 77, 121, 147-51, 153.Hospital Patients: 5-6, 26.Hospitalized Patients: 21-2.Human Rights: 21-2, 27, 40, 46, 110, 112.

IIntensive Care Unit: 23, 128, 147, 150.Israel: 6-8, 13, 16, 55-61, 65-6, 70, 74, 80, 82, 91-2, 95, 121-3, 128, 136.

J

Jews: 55, 58-64, 66, 68, 74, 76-7.

KKafala: 55, 57, 64.

MMedical Ethics: 21, 40, 45.Muslims: 55, 58-64, 66, 74, 76-7.

NNatural Disaster Problems: 4 0 .Nurse’s Image: 69, 71, 80.Nurse’s Status: 69. Nursing: 110-8, 120, 122, 125, 127-8, 135, 145, 153-5.Nursing Ethics: 69.Nursing Profession: 69-82, 90-92.Nursing Students: 69, 72, 74, 81-2, 91-5, 99, 101-2.Nursing Research: 110, 114, 116.

OOpen Adoption: 55, 57, 62-3, 65.Opinion: 71, 121, 124-5, 136, 150.

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PPatient’s Rights: 70, 91, 135.Perceptions: 69-70, 73, 75-8, 81-2, 90-2, 94-6, 98, 101-2, 107, 128, 139.Physicians and Nurses: 121, 125, 127, 137-8, 144, 150.Professional Considerations: 147, 151.

RResearch Ethics: 109-11, 115, 117-8. Resuscitation: 44, 121-2, 125-8, 131, 137, 143, 147-55.

SSexual Harassment: 5-14, 17-9.

TTriage: 39-40, 42-3, 45-8, 51.

WWomen: 5-7, 13, 22, 25, 27, 48, 56, 60, 62, 64, 75, 77-8, 81, 101, 130.

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