1 INTRODUCTION According to World Health Organization in 2006, there was high percentage of nurses per 10,0000 people in developed countries. For example, in Netherlands it was 137,3; UK 122; Japan 77,9; Singapore 42; in Vietnam the rate was low at 6,7 [4]. Nurses are the people who frequently contact with patients in nursing care process. The relationship between nurses and patients not only lies in nursing technique but in moral issue as well. At present, moral rules have been built at some nursing associations such as International Council of Nurses (ICN) and National Nursing Organizations. In Vietnam, a moral standard has been built for nurses by Vietnam Nursing Association [32],[106],[123]. A study done at Phu Tho General Hospital showed that 12,5% of medical staff caused troubles for patients [69]. At Ninh Thuan hospital, there was 13,6% of medical staff shouting, threatening and being frigid with patients [43]. At Viet Duc hospital in 2009, 13,9% of medical staff shout at patients and care givers, in which nurses accounted for the highest rate of 59,5% [46]. Therefore, moral issues of nurses are attracting lots of attentions from medical practitioners [41]. National Hospital of Pediatrics (NHP) is the highest referral hospital giving intensive care for children, which belongs to the Ministry of Health. It is hospital overloading, communication attitude, behavior of nurses that makes some customers unsatisfied. A research carried out in 2009 at the hospital showed that dissatisfaction accounted for 18,3% [23]. However, the above researches only took a survey on morality of medical staff as an element while it is fact that nurses are the people who directly contact with patients at NHP and other hospitals. Their attitude and morality will have the first and thorough effect on customers’ satisfaction as well as reveal health care quality of the hospital. In order to improve the two elements, we need to evaluate morality of nurses and find the solution to the problem. Hence, we carried out a project: “An investigation on cognition and ethical practice of nurses at National Hospital of Pediatrics and results of some interventions”. In this study, moral issues are considered and evaluated from two sides for the first time: from nurses and from customers (patient’s family include: father, mother, grandfather, grandmother and care givers) with subjective questionnaire and interviews. Some reasons causing violating medical ethics were carefully analysed, even including sensitive reasons. Therefore, researchers gained detailed, subjective data and then some effective interventions, which were being applied, were evaluated thoroughly so that practical recommendations can be made and carried out at many hospitals. 2 RESEARCH OBJECTIVES 1.Describe the reality of cognition and ethical practice of nurses at the National Hospital of Pediatrics and identify some relating factors in 2012 2.Evaluate the result of some interventions to enhance cognition and ethical practice of nurses from 2012 to 2013 NEW FINDINGS AND SOME CONTRIBUTIONS OF THE THESIS - This is the first time the nurses’ cognition and ethical practice have been described from different point of views (nurses and customers). - The research result has shown some remaining drawbacks in terms of cognition and ethical practice of nurses in relation to customers (shouting, receiving money/ taking bribe, differentiating, ect.), with colleagues and in nursing practice. - Some nurses’ violation of morality has been pointed out; however, these issues have not been regulated or stated clearly in legislative documents or in some regulations of medical ethics for medical staff in general and for nurses in particular. - Some factors relating to medical ethics practice of nurses include knowledge, experience, career passion, the number of patients, working extra hours. - Medical ethics of nurses have been improved by applying interventions including training, observation, discussion, professional support. STRUCTURE OF THESIS This thesis consists of 126 pages (not including index), 4 chapters, 13 tables, 24 graphs, 17 bar charts, 159 references (96 documents in Vietnamese; 63 documents in English; > 70% of documents have been published in the last 5 years) Here is the detailed structure: Introduction: 02 pages; Literature review: 35 pages; Research objective and methodology: 20 pages; Research result: 36 pages; Discussion: 30 pages; Recommendation: 02 pages; Conclusion: 01 page. 3 CHAPTER 1 LITERATURE REVIEW 1.1. Position, function and roles of nurses Nursing is an art and a science that studies the way to take care of oneself when necessary and take care of others when they could not care for themselves. Nevertheless, the definition of nursing is given differently depending on different periods in history. Nursing theory includes grand nursing theory, nursing theory relating to people’s basic need, nursing theory about health and health care, psychological & social theory, Nightingale theory, Henderson theory, and so on. Nurses play an important role in giving care for patients, recognizing patient’s condition, limitations and demands for care. Their main functions include dependent function, cooperative function and independent function. Like other medical staff, nurses have responsibilities of nursing care, leadership in hospitals, community and doing research. 1.2. Definition of medical ethics and moral standards Medical ethics is an issue belonging to the scope of morality. It is a branch of morality mentioning about moral issue in medical practice. Medical ethics are regulations or standards that are expected to obey by medical workers. According to WHO, like other careers, medical ethics is reflected through passion, ability and self- decision. However, medical workers are expected to have higher moral standard than others. The present regulation of medical ethics was declared by WHO in 1999. Nursing profession was built and developed at the end of 19 th century. Nurses’ moral regulations were inherited and developed from moral rules. Nevertheless, their regulations have unique characteristics which are suitable to the requirement of nursing practice. At the moment, the moral regulations being applied consist of the ones by ICN, the ones at each country and area. Nurses’ moral regulations in Vietnam are controlled by Prevention of Corruption Act; Law on Medical Examination and Treatment; Nursing capacity standard by Ministry of Health; Nursing moral regulations by Vietnam Nursing Association (VNA). 1.3. Some studies on medical ethics of nurses In the world: Nightingale did make a big impact on environment and health care in order to reduce mortality rate among war invalids from 42% to 2%. According to Shimaoka Nobuki, there was 67,2% to 70,2% of people desiring to be cared by nurses. According to Roderick, who did a research in the US showed that 73% of patients felt satisfied with nursing care. It was fact that patient’s complications would reduce from 2% to 25% if nurses were assigned tasks which were suitable to their qualification and 4 ability. Shimzutani in Japan pointed out that there was relation between nurses and exhausted conditions due to stress, bad behavior and attitude toward patients. In Vietnam, many studies showed that most of patients feel satisfied with nursing care, in which the rate is often above 80%. Although the matter of shouting, causing troubles for patients accounts for only a low rate, it is frequently seen in researches of medical ethics. The researches also reveal that carrying out adequately nursing procedures is very important in nursing care. Some studies also believed that nurse’s attitude can be improved and reduce moral violation due to some interventions: training, education, communication lessons, knowledge in law. To sum up, these studies on medical ethics of nurses have not had an overview and seen in different aspects in terms of customers/patients, nurses and management. Since this is an sensitive issue, the approach of researches often leaves at training activities without any general evidence – based interventions (basing on customer’s, nurses’ and managers’ recommendations). These studies have not met the demand of improving nursing care quality at present. 1.4. Some introductions about National Hospital of Pediatrics (NHP) Medical examination and treatment at NHP It is fact that hospital overcrowding tends to increase, in which bed capacity at national hospitals went up from 116% in 2009 to 120% in 2010 and 118% in 2011. There existed high level of overcrowding at NHP with 119.8% in 2011 [6]. The number of outpatients in 2012 at NHP was 672.000, which increased to 8,96%. The percentage of outpatients tended to climb up to 34,4% in compared with the year 2011 [6]. Care services bring about effectiveness in reducing the number of inpatients and also make profits for the hospital. Patients have got many benefits from this kind of service in which health care quality is highly ensured. The General Pediatric Department A is serving this kind of service with the total of 53.703 turns of treatment; 5.176 inpatients, bed capacity reached 95% (5% increase in compared to the initial plan). These units always consider high quality of health care service as the highest standard in which the patients are the center of the service. Nursing care at NHP Hospital nursing personnel [3] The total number of nurses/ medical technicians in the hospital is 749 people, in which there is 0,9% of master of nursing; 15,5% of bachelor of nursing; 7,3% of associate degree; 75,7% of vocational degree. There are 10 bachelors of nursing pursuing nursing specialist I at Research Institute for Child Health. There are 46 head nurses. Hospital nursing care [3] - There are frequently overloading and severe patients at some departments, so nurses have to work under much pressure. 5 - There are many administrative procedures, so many nurses do not have time to do their nursing care. - There is a shortage of personnel, especially at Neonatology, ICU and Emergency department. - The proactiveness of nurses has not been enhanced; nursing procedures have not been adequate. - Nurses’ communication skill is sometimes unsatisfactory. - The percentage of young female nurses is high, together with hard working hours, so their psychological health is not so good and stable, affecting their work. Like other national hospitals, NHP is facing up with hospital overcrowding with low quality infrastructure. Besides, personnel capacity, nurse capacity has not met the higher requirement of health examination and treatment. Moreover, nurses are dealing with pressure and workload, so they often feel stressed and exhausted. This issue has been a big challenge in providing health care treatment for children as well as for meeting customers’ satisfaction. CHAPTER 2 RESEARCH OBJECTIVES AND METHODOLOGY 2.1. Research site, time and subjects - The study was performed at NHP from June 2012 to June 2013 - Research subject: Nurses, customers (patients’ family: father, mother, grandfather, grandmother, legal representative of children at NHP). 2.2. Research Methodology 2.2.1. Research design - Cross – sectional analysis, combined with qualitative and quantitative research to evaluate medical ethics of nurses. - Before and after Intervention study design is used to evaluate the result of application of interventions 2.2.3. Sample size - The sample size is calculated basing on the formula of random sample size (software Simple size 2.0 by WHO). )1()1( *)1( 2 )2/1( 2 2 )2/1( ppZNd NppZ n        For nurses: N = 481; p = 0,50 ( percentage of nurses having unsatisfied behavior); Z = 1,96; d = 0,05 there are n = 214 nurses. For customers: N = 8.210 avarage population size in 1 week; p = 0,50 (percentage of customers’ feedback on nurses’ negative behavior); Z = 1,96, d = 0,05; there are n = 368 customers. - Sample size of intervention study is calculated basing on the formula of sample size calculation of comparing two proportions (software Simple size 2.0 by WHO): 6   2 21 2 2211)1()2/1( )( )1()1()1(2 PP PPPPZPPZ n      Nursing intervention: supposing the percentage of nurses who do not meet the requirement of moral standard before intervention is 1 P =0,5; 2 P =0,64; )2/1(   Z = 1,96; )2/1(   Z take 80% we get n = 196 nurses. In reality, 214 nurses are interviewed. Evaluate interventions through customer’s opinion: supposing the percentage of patient’s family reflecting negative behavior of nurses is 1 P = 0,5; 2 P = 39%; )2/1(   Z = 1,96. take β = 80%, we get n = 320 customers. In reality, 364 customers are interviewed. 2.2.3. Sampling method - Make a random list of 481 nurses having adequate standard who are numbered from 1 to 481. In 7 random nurses, choose 3 consecutive nurses and remove 4 nurses next. In case of refusal, continue to make lists until the sample size is enough. - Choose sample size at outpatient group and inpatient group basing on the percentage of patients at two areas. Time of collecting data is 1 week, including weekend. At outpatient clinic, choose customers randomly to draw according to frequency of cases in a day (morning, afternoon). Inpatient group is chosen basing on the number of discharge cases, make a list to confirm sample size before interview. 2.3. Research content and variables - Characteristics of research subjects: for customers (hometown, age, relationship with children, kind of healh care service, times of treatment); for nurses (age, gender, marital status, qualification, experience, income, extra working hour, time of working extra hour, average hours of doing procedure, number of patients, other works beside nursing care) - Cognition and medical ethical practice of nurses: + Attitude of nurses towards customers + Nurses’ morality in relation with customers + Nurses’ morality in performing assigned tasks + Nurses’ morality in relation with colleagues + Reality of cognition of medical ethics of nurses - Ethical practice of nurses through customers’ reflection: + Customers’ satisfaction with nurses’ attitude at Outpatient clinic + Customers’ satisfaction with nurses’ attitude at Inpatient wards + Customers’ reflection on nurses’ morality. 2.4. Technique and tool of data collection - Technique of data collection: interview with questionaire, deep interview, observation 7 - Observation procedure: Descriptive study, finding the relationship between factors and knowledge, ethical practice  Ask for permission and recommend solutions  Make intervention  Evaluate intervention. - Intervention tool and technique: training documents, working schedule, graphs, camera, management - Research standards were built basing on: Prevention of Corruption Act; Law on Medical Examination and Treatment; Nursing capacity standard by Ministry of Health; Moral issues by WHO, Nursing moral regulations by ICN and by VNA. 2.5. Data management - Use suitable date for data input - Use SPSS 17.0 and EPI Info 7.0 - The figures are calculated to average value or percentage %. - Compare average values using algorithm T-student. - Compare two or more percentage % using Chi–square algorithm (χ2), test rate (pretest) - Use OR, CI 95% to identify the relationship between medical ethics of nurses. Use performance indicators to evaluate intervention. - Qualitative study is classified according to the matters raised by nurses, customers, combined with N-vivo software to manage data. 2.6. Control and correct errors In order to limit errors, we performed the following steps: * Process of building toolkit: - Identify research variables and variable definition, method of variable measurement, method of collection - Test toolkit to identify unclear variables, variables which are difficult to collect, variables which are easy to be confused and errors to find solution. * Process of data collection: - Give training in interview technique, observation, data collection for researchers which is done by public health officers - Observe the process of data collection, re-interview and check accuracy of interviewers. - Each interviewee was identified by different code. * Process of data input, management and data analysis: - Build Epiinfo 7.0, eliminate variables that are not included in permitted range. - Check and identify unusual variables, validity and logic of data. When identifying errors, researchers re-interview according to the code that is only recognized by interviewer and researcher. 8 * Moral issue in research This study was only performed under the permission of review board at Thai Binh Medical University and participation agreement of NHP as well as voluntary participation of research subjects. The process of data collection and research result will be confidential to research participants, ensuring safety and voluntary participation in the research. * Some limitations of the study - In order to make sure objectivity in data collection process, questionnaires and checklists answered by nurses are not identified by their names. - Feedbacks on medical ethics- a sensitive issue consist of three elements: cognition, attitude and behavior. In order to get objective and accurate feedback, there need different approach and time at each research site. However, it is not easy for a short - time doctoral thesis with such a limited budget. - The research subjects before and after intervention are different customers at two different times, so the result can be incorrect due to heterogeneous objectives. To improve these limitations, the thesis combines different ways of collecting data such as combining quantitative with qualitative study; combining subjective opinions of research subjects with objective opinions obtained from parents and caregivers; combining interview, discussion with direct observation; associating fieldwork with expert method. 9 CHAPTER 3 RESEARCH RESULT 3.1. Cognition and ethical practice of nurses and some relating factors 3.1.1. Information about customers and nurses at NHP The study was conducted on 368 customers, in which 156 were customers of Outpatient clinic and 212 customers were inpatients. Table 3.1.Some features of customers Customers Feature Outpatient Inpatient Total Number (No) Percentage (%) Number % Number % Permanent residency Hanoi 73 46,8 77 36,3 150 40,8 Other provinces 83 53,2 135 63,7 218 59,2 Age Under 20 1 0,6 3 1,4 4 1,1 21-35 108 69,2 138 65,1 246 66,8 36-49 26 16,7 56 26,4 82 22,3 >49 3 1,9 5 2,4 8 2,2 Relationship with children Parents 139 89,1 192 90,6 331 89,9 Grandparents 6 3,9 4 1,9 10 2,7 Aunt, uncle 8 5,1 16 7,5 24 6,5 Others 3 1,9 0 0,0 3 0,8 Health insurance No 126 80,8 57 26,9 183 49,7 Yes 30 19,2 155 73,1 185 50,3 Times of examination & treatment Once 47 30,1 39 18,4 86 23,4 Twice 31 19,9 17 8,0 48 13,0 3 times 25 16,0 12 5,7 37 10,1 Above 4 times 53 34,0 144 67,9 197 53,5 Total 156 100 212 100 368 100 10 Information about nurses participating in the study The study was conducted on 214 nurses, in which there were 22 nurses at outpatient clinic, 192 nurses at inpatient wards. Table 3.2.Some features of nurses at NHP Information Feature Outpatient Inpatient Total No % No % No % Age <25 years 5 22,7 70 36,5 75 35,0 25-35 years 15 68,2 102 53,1 117 54,7 35-45 years 1 4,5 15 7,8 16 7,5 45-59 years 1 4,5 5 2,6 6 2,8 Gender Male 3 13,6 27 14,1 30 14,0 Female 19 86,4 165 85,9 184 86,0 Marital status Single 4 18,2 79 41,1 83 38,8 Married 18 81,8 111 57,8 129 60,3 Divorce 0 0,0 2 1,0 2 0,9 Having house Yes 11 50,0 53 27,6 64 29,9 No 11 50,0 139 72,4 150 70,1 Qualification Vocational 14 63,6 122 63,5 136 63,5 College 4 18,2 27 14,1 31 14,5 Bachelor 4 18,2 37 19,3 41 19,2 Master 0 0 6 3,1 6 2,8 Working experience Below 5 years 7 31,8 107 55,7 114 53,3 5-10 years 14 63,6 64 33,3 78 36,5 10-20 years 0 0 15 7,8 15 7,0 >20 years 1 4,6 6 3,1 7 3,3 Income Below 4 million 4 18,2 48 25,0 52 24,3 Above 4 million 18 81,8 114 75,0 162 75,7 TOTAL 22 100 192 100 214 100 3.1.2. Cognition and ethical practice of nurses. 3.1.2.1. Customers’ feedback on ethical practice * Ethical practice of nurses in serving care Most of customers feel satisfied with serving attitude at outpatient clinic; however there exist some unsatisfied feedbacks, especially in explaining for family (63,5%) and in introducing name, giving reasons (34%). ¾ of interviewees supposed that nurses’ attitude is quite satisfactory at inpatient wards. [...]... Cognition, ethical practice and some relating factors 1.1 Cognition, ethical practice of nurses - Most of customers feel satisfied with the attitude of nurses at the hospital However, there exist some violations of moral issue; for instance, 22,6% of nurses 23 are reflected to shout at customers, 18,5% of customers giving money/bribe for nurses Basing on observation on nurses and colleagues’ evaluation,... that the rate of customer’s satisfaction with serving attitude of nurses is similar to or lower than that of colleague’s feedback However, it is necessary to enhance attitude of nurses to ensure comfort and satisfaction for patients and their family Communication skill and behavior also reflects the quality of health care service of the hospital 4.2.1.2 Violation of moral issues of nurses in relation... some interventions 4.2.1 Foundation of choosing interventions Basing on recommendations of patient’s family, nurses themselves, hospital director, we have collected some solutions to improve ethical practice of nurses *Enhancing knowledge in hospital regulation and relation with nurses for customers * Providing re-training courses on ethical practice and experience sharing * Encouraging and well- solving... consist of feeling of job suitability to their skill, satisfaction with the colleague relationship, passion, and knowledge in medical ethics + Such factors as qualification, working experience, feeling of job suitability, passion, and knowledge in medical ethics affected ethical practice of nurses 3.2 Evaluate some interventions * Solution application is based on customers’ opinion, recommendation of. .. recommendation 3.1.2.5 Nurses opinion in relation to customers Nurses opinion about customers’ interests Most of the nurses understand the relationship with customers, in which the percentage of patients having right to receive explanation, choosing health care service and knowing their condition accounts for more than 70% to more than 80% Cognition of nurses about the relationship with colleagues Nurses ... Reality of ethical practice of nurses * Customer’s feedback on serving attitude of nurses Most of patient’s parents feel satisfied with serving attitude of nurse at reception and guidance However, there still exist some limitations in serving attitude Working pressure often causes bad behavior This can be understood because the hospital overcrowding happens frequently, and there is a shortage of personnel... indicators of serving attitude of nurses have clear improvement, which has statistical significance (p . investigation on cognition and ethical practice of nurses at National Hospital of Pediatrics and results of some interventions . In this study, moral issues are considered and evaluated from two sides. nurses at the National Hospital of Pediatrics and identify some relating factors in 2012 2.Evaluate the result of some interventions to enhance cognition and ethical practice of nurses from 2012. that practical recommendations can be made and carried out at many hospitals. 2 RESEARCH OBJECTIVES 1.Describe the reality of cognition and ethical practice of nurses at the National