an investigation on cognition and ethical practice of nurses at national hospital of pediatrics and results of some interventions

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.



11



Table 3.3. Customers’ feedback on nurses’ discrimination

Area

Feedback
Outpatients Inpatients Total
No % No % No %
Discrimination
Yes 3 1,9 14 6,6 17 4,6
No 153 98,1 198 93,4 351 95,4
Fair treatment
No 19 12,2 59 27,8 78 21,2
Yes 137 87,8 153 72,2 290 78,8
Respect
No 2 1,3 17 8,0 19 5,2
Yes 154 98,7 195 92,0 349 94,8
TOTAL 156 100 212 100 368 100

There exists high rate of nurses treating unfairly with patients (21,2%), in which the
rate at inpatient wards is much higher than that in outpatient clinic.

Table 3.4. Customers’ feedback on moral violation of nurses
Percentage

Feedback
Outpatients Inpatients Total
No % No % No %
To be provided
with explanation
No 21 13,5 37 17,5 58 15,8
Yes 135 86,5 175 82,5 310 84,2
To be chosen

health care service
No 24 15,4 46 21,7 70 19,0
Yes 132 84,6 166 78,3 298 81,0
To be reassured
when getting hurt
No 13 8,3 21 9,9 34 9,2
Yes 143 91,7 191 90,1 334 90,8
Keep secret
for patients
No 3 1,9 8 3,8 11 3,0
Yes 153 98,1 204 96,2 357 97,0
Suspect of misleading

in treatment
Yes 4 2,6 15 7,1 19 5,2
No 152 97,4 197 92,9 349 94,8
TOTAL 156 100 212 100 368 100

There is violation of moral regulations at the hospital. Specifically, 19% of
customers do not have right to choose health care service; then comes 15,8% of them
who are not provided with information; 9.2% of them is not reassured when the
patients get hurt; 5,2% of them suspected misleading of nurses. Feedback on keeping
secret for patients accounts for the lowest rate of 3%.

12



Table 3.5. Customers’ feedback on nurses’ shouting
Information

Feedback
Outpatients Inpatients Total
No % No % No %
Having been
shouted by nurses
Yes 9 5,8 74 34,9 83 22,6
No 147 94,2 138 65,1 285 77,4
Having seen
nurses shouting
Yes 10 6,4 81 38,2 91 24,7
No 146 93,6 131 61,8 277 75,3
TOTAL 156 100 212 100 368 100

According to customers’ feedback, nearly ¼ s of nurses shouting at patients’
family, in which 22,6% of them has been shouted and 24,7% of them has seen nurses
shouting.

Table 3.6 Customers’ feedback on nurses’ receiving bride/money
Percentage

Information
Outpatients Inpatients Total
No % No % No %

Having
given money
to nurses
Many times 12 7,7 56 26,4 68 18,5
First time 11 7,1 10 4,7 21 5,7
Never 125 80,1 140 66 265 72,0
No respond 8 5,1 6 2,8 14 3,8
Having seen
patient’s family

giving money
to nurses
Many times 13 8,3 66 31,1 79 21,5
First times 9 5,8 9 4,2 18 4,9
Never 121 77,6 129 60,8 250 67,9
No respond 13 8,3 8 3,8 21 5,7
TOTAL 156 100 212 100 368 100

There exists giving and receiving bride/ money between customers and nurses, in
which the rate of customers having given money to nurses accounts for 24,2%, and 26,4%
of customers having seen this circumstance.

13



3.1.2.2. Medical ethics of nurses through observation
Researching on 214 nurses through observation of researchers, combined with
colleagues’ feedbacks, we evaluate ethical practice of nurses. Here is the result:
Table 3.7.Evaluate nurses’ attitude at reception
Data

Information
Outpatients Inpatients Total
No % No % No %
Warm
attitude
Sometimes 0 0 15 7,8 15 7,0
Usually 22 100 177

92,2 199 93,0
Thoughtful
attitude
Sometimes 0 0 12 6,3 12 5,6
Usually 12 54,5 180

93,8 202 94,4
Respond
adequately

Sometimes 0 0 29 15,1 29 13,6
Usually 22 100 163

84,9 185 86,4
Ask customers
to wait
Sometimes 0
0 25 13,0 25 11,7
Usually 22
100 167

87,0 189 88,3
TOTAL 22 100 192

100 368 100

Most nurses are supposed to obey the regulations of welcoming customers;
however, the levels are not the same. There is 93% of nurses usually expressing warm
attitude at welcoming period; 94,4% of them answers customers’ questions politely and
thoughtfully; 86,4% of them provides adequate information about health care service;
88,3% of them politely invites customers to wait for the doctor.

Table 3.8. Evaluate serving attitude of nurses
Number

Information
Outpatients

Inpatients Total
No % No % No %

Listen to patient’s
parents report
Sometimes
0 0,0 25 13,0 25 11,7
Usually
22 100 167

87,0 189 88,3
Guide to do
administrative procedures

Sometimes
0 0,0 25 13,0 25 11,7
Usually
22 100 167

87,0 189 88,3
Obey professional
regulations
No
0 0,0 1 0,5 1 0,5
Yes
22 100 191

99,5 213 99,5
Sympathize
with patients
Sometimes
3 13,6 32 16,7 35 16,4
Usually

19 86,4 160

83,3 179 83,6
Encourage, reassure
No
2 9,1 26 13,5 28 13,1
Yes
20 90,9 166

86,5 186 86,9
TOTAL
22 100 192

100 214 100

There is 88,3% of nurses usually guiding patients to do administrative
procedures; 13,1% of them does not encourage or reassure customers.



14




Table 3.9. Some reflected moral violations
Number

Information
Outpatients

(n=22)
Inpatients
(n=192)
Total
(n=214)
No % No % No %
Abuse, get profit 0 0 7 3,6 7 3,3
Authoritarianism, arrogance 0 0 6 3,1 6 2,8
Differentiate rich and poor 0 0 5 2,6 5 2,3
Not respect customers 3 13,6 7 3,6 10 4,7
No respect for honor 1 4,5 11 5,7 12 5,6
Reveal patient’s information 1 4,5 3 1,6 4 1,9
Unfair treatment 0 0 6 3,1 6 2,8
No thoughtful attitude 0 0 1 0,5 1 0,5

There exist nurses violating moral issues at NHP, in which the highest rate lies in
not respect, honor and dignity of patients accounting for 5,6%; then comes nurses
who do not respect self decision of customers, making up 4,7%. Other issues account
for more or less 3%.

3.1.2.3. Ethical practice of nurses in relation to colleagues
Table 3.10.Relationship of nurses with colleagues
Data

Colleague’s feedback
Outpatients Inpatients Total
No % No % No %
Truthful, sincerely

Normal

3
13,6
30
15,6
33
15,4
Good
14
63,6
139
72,4
153
71,5
Very good
5
22,7
23
12
28
13,1
Respect, preserve
colleague’s honor
Normal
0
0
20
10,4
20
9,3
Good

19
86,4
139
72,4
158
73,8
Very good
3
13,6
33
17,2
36
16,8
Willing to give
help, share
experiences
Normal
0
0
20
10,4
20
9,3
Good
20
90,9
126
65,6
146
68,2

Very good
2
9,1
46
24
48
22,4
Pass the buck
Very bad
0
0
1
0,5
1
0,5
Bad
0
0
1
0,5
1
0,5
Normal
2
9,1
25
13
27
12,6
Good

17
77,3
130
67,7
147
68,7
Very good
3
13,6
35
18,2
38
17,8
Split into faction,
cause disunity
Yes
1
4,5
12
6,3
13
6,1
No
21
95,5
180
93,7
201
93,7
Reflect

untruthfully
Yes
1
4,5
5
2,6
6
2,8
No
21
95,5
187
97,4
208
97,2
TOTAL
22
100
192
100
214
100

15



Some of nurses violate moral issues with colleagues. Especially there is 6.1%
of them causing disunity 6,1%; 2,8% of them reflects untruthfully affecting
colleague’s honor, and there exists shirking responsibility and passing the buck.

3.1.2.4. Ethical practice of nurses in relation to customers
Customers’ feedback on ethical practice of nurses
Table 3.11. Customers’ feedback on negative behavior of nurses
Data

Information
Outpatients
(n = 156)
Inpatients
(n = 212)
Total
(n = 368)
No % No % No %
Have right to shout
at customers
Yes 6 3,8 27 12,7 33 9,0
No 150 96,2 185 87,3 335 91,0
Give money to
nurses
Right 6 3,8 7 3,3 13 3,5
Wrong 150 96,2 205 96,7 355 96,5

The percentage of customers supposing that nurses have right to shout at them
accounts for 9%; 3,5% of customers has right point of view on bribe.

Reason for giving money/ bribe to nurses
There is nearly 60% of customers giving money to thank for the nursing care ;
40% of them giving money to receive good health care quality; 2,7% of them giving
money because they saw other did that; 1,9% giving money due to nurse’
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’ cognition about the relationship with colleagues
93% of nurses supposes that they should be unified with their colleagues; more
than 86% supposes that they need to cooperate in profession ; nearly 82% supposes that
they need to be responsible for their team; 60% supposes that they need to care for their
colleagues and more than 50% supposes that they need to support one another in their
profession.





16



3.1.2.6. Nurses’ cognition about their profession
Table 3.12.Cognition, ethical practice of nurses about their career
Area

Cognition
Outpatients Inpatients

Total
No % No % No %
Understand morality

in profession
Do not understand

4 18,2 49 25,5

53 24,8
Understand 18 81,8 143 74,5

161 75,2
Necessity
of medical ethic
of nurses
Very necessary 9 40,9 66 34,4

75 35,0
Necessary 10 45,5 110 57,3

120 56,1
Do not care 3 13,6 12 6,3 15 7,0
Do not need 0 0 4 2,1 4 1,9
TOTAL 22 100 192 100 214 100

The result showed that more than 3/4 of nurses having knowledge about
medical ethics in their profession; Regarding attitude towards morality in their
profession, 91,1% of them supposes it be necessary and very necessary.

3.1.3. Some factors affecting ethical practice of nurses
The research result showed some factors affecting ethical practice of nurses
which has statistical significance (p < 0,05):
+ Factors affecting serving attitude of nurses include working experiences,
passion, cognition of medical ethics, extra working hours and the number of patients.
+ Factors affecting negative behavior of nurses include passion, cognition of
medical ethics, extra working hours, the number of patients.
+ Factors affecting relationship with colleagues 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
nurses and hospital managers, factors affecting morality of nurses.
* Interventions include training on medical ethics for nurses, enhancing
hospital observation, assigning suitable tasks for nurses, installing camera.








17

Table 3.11 Improvement of serving attitude of nurses
Indicator %

Information
Before
(n=214)

After
(n=214)

p
Levels of
changes
(%)

Welcoming customers
with warm attitude
93,0 99,1 <0,05

6,56
Frequently answer
customer’s questions
94,4 98,6 <0,05

4,45
Frequently provide customers with
information about health care service
86,4 97,7 <0,01

13,08

Frequently politely
invite customers to wait
88,4 99,1 <0,01

12,10
Frequently listen
to customers and give explanation
88,3 96,3 <0,05

9,06
Frequently guide admission procedure,
take severe patients to the testing room
88,3 97,2 <0,01

10,08
Obey
nursing procedures
99,5 100,0 >0,05

0,50
Frequently understand
psychological mental of patients
83,6 95,7 <0,01

14,47
Polite, encouragous
and respectful
86,9 98,6 <0,01

13,46

The indicators of serving attitude of nurse have good improvement with
statistical significance (p<0,05), excepting for the criteria of obeying nursing
procedures (p>0,05) because indicator before intervention had reached nearly 100%.
The highest performance indicator lies in understanding psychology of patients and
patient’s family (increase 14,47%) and the lowest lies in obeying nursing procedures
(increase 0,5%).



















18

Table 3.12. Improvement in customer’s satisfaction with serving attitude
of nurses at outpatient clinic
Indicator %

Information
Before
(n=156)

After
(n=153)

p

Levels of
changes
(%)


Say hello, invite to sit,
ask for patient’s name
77,6 94,8 <0,01 22,16
Introduce name, give reason
for contact with patients
34,0 81,7 <0,01 140,29
Ask for reason for taking
children to the hospital
96,2 98,7 >0,05 2,60
Pay attention to the feeling
of patient’s family
67,3 85,0 <0,01 26,30

Ask for more
relating manifestations
82,1 95,4 <0,01 16,20
Guide patient
to the testing room
92,3 97,4 <0,05 5,53
Accompany patients
to the testing room
17,3 64,7 <0,01 273,99
Explain how
to care for the child
63,5 86,9 <0,01 36,85
Guide
how to use drug
76,3 96,7 <0,01 26,74
Explain how to prevent
children from diseases
71,8 94,1 <0,01 31,06
Guide to the next
examination room
74,4 96,1 <0,01 29,17

At outpatient clinic, there is improvement in customer’s satisfaction with
serving attitude of nurses, which has statistical significance (p<0,05). The highest
performance indicator lies in the criteria of accompanying patients to the testing room
with 273,9%, the lowest one lies in asking for the reason for taking the child to the
hospital with 2,6%.

19



Table 3.13. Improvement in customer’s satisfaction with serving attitude of
nurses at inpatient wards
Indicators %

Information
Before
(n=212)

After
(n=211)

p
Levels of
changes
(%)

Say hello to patient
and patient’s family 77,8 91,0 <0,01

16,97

Politely ask patients
to lie in suitable way 84,4 96,2 <0,01

13,98
Take pulse,
blood pressure, temperature 75,5 89,1 <0,01

18,01
Ask for more relating manifestations 79,7 92,9 <0,01

16,56
Explain
how to care for children 81,6 97,2 <0,01

19,12
Explain
procedures performed on patient 83,5 94,8 <0,01

13,53

At inpatient wards, all indicators of customer’s satisfaction with serving
attitude of nurses has improved, having statistical significance (p<0,01) . The lowest
performance indicator is explaining procedures performed on patient (increase
13,53%), the highest one is the indicator of taking pulse, blood pressure, temperature
(increase 18,01%).
Table 3.14. Improvement in some moral violations
Indicator %

Information
Percentage

% (n=368)
Percentage
% (n=364)
p
Levels of
change
(%)
Be shouted
22,6 5,8 <0,01

-74,34
Give money to nurses
5,7 1,1 <0,01

-80,70
Discriminate
4,6 0,5 <0,01

-89,13
Treat unfairly
21,2 2,2 <0,01

-89,62
Right to choose health care service
19,0 4,4 <0,01

-76,84
Not encouraged when getting hurt
9,2 2,2 <0,01

-76,09
Not be kept secret
3,0 0,8 <0,05

-73,33
Not be respected
5,2 1,6 <0,01

-69,23
Suspect in using drug
5,2 2,2 <0,05

-57,69


After intervention, customers’ feedbacks shows a reduction in violating moral
issues, which has statistical significance (p<0,05). The performance indicator that
decreased most is fair treatment (decrease 89,1%), The lowest one lies in misleading
in treatment and drug use (decrease 57,6%).


20



CHAPTER 4
DISCUSSION

4.1. Cognition, ethical practice of nurses and some relating factors
4.1.1. Features of research subject

It is common that most children at NHP are under 6 years old, so customers of
the hospital consist of patient, parents and caregivers. NHP is the leading pediatric
center; thus, a large number of patients are referred from provincial hospitals.
Moreover, most of parents of child patient are mothers who play a very important
role in looking after children, especially when the child gets sick. Most of them have
directly contacted with medical staff, which means their feedback on nurse’s morality
will be more correct and practical.
Regarding gender of nurses, 86% of them are female which is suitable to
nursing profession now. Professional requirements for a nurse should be hard
working, patient, gentle, flexible and fast. There is more than 60% of nurses getting
married, nearly 39% is single. More than 70% of nurses has to rent a house for living,
so difficulties that they have to deal with can be seen. Most of the nurses graduated
from vocational school with nearly 60%, which shows that we started to run full –
time courses of bachelor degree in 1995. Nurses mostly are at young age, in which
those below 35 years account for nearly 90%, more than 50% of them has less than 5
years of working experiences.
4.1.2. Reality of cognition and ethical practice of nurses
4.1.2.1 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 to
take over all the tasks.
Our research study shows 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 to customers

* Behaviors obeying moral issues of nurses in relation to customers
The research result shows that there is no discrimination due to religion, belief,
and gender of children. Nevertheless, there exist nurses who differentiate with
different diseases. When being interviewed, nurses explained that they did that
because they wanted to classify patients and to give better care for them. In some
21



cases, nurses do that to prevent children from hospital infection. Therefore,
explaining for customers is essential.
There come nurses who give unfair treatment due to their priority to their
acquaintance or relatives. It is not easy to provide customers with enough information
because of overloading condition of the hospital. Besides, if they skip patients, they
are considered to violate profession regulations. That is the contradiction that nurses
have to deal with, in which among these choices, they have to keep up with
profession regulation and avoid spending time explaining for customers.
Most of customers told that their children are encouraged and reassured when
being hurt due to injection or operation, etc. These are good images of nurses,
preserving the proverb “a doctor is like a mother”. Although nurses are told to not
keep treatment secret, but there is no clear sign of this. There exist nurses who do not
expect honor, dignity, mainly shout at customers. However, there is no standard/
criteria of moral issues regulating/ defining what shouting is.
* Nurses’ behaviors causing pressing to customers
There exist nurses taking money/ bribe of patient’s family. This result is
similar to other studies done at district, provincial and national hospitals. Depending
on different circumstances, nurses can violate moral issues and can lead to legal
issues. In case of providing health care service after working time or patient’s family
thank for their help after hospital discharge, there is no rule regulating this issue.
Nevertheless, hospitals need to give some regulations and penalty.

Some nurses are suspected to cheat at the hospital, which makes customers feel
unreliable. This issue is a severe problem in medical sector, which needs to be solved
immediately to ensure morality and reputation of medical workers.
4.1.2.3. Cognition of medical ethics of nurses
The result reveals that there is a shortage in knowledge of nurses in terms of
medical ethics. Acknowledging customer’ benefits and nurse’s responsibilities would
help them to clarify which right behaviors are expected. Although the regulations of
moral issues for nurses are controlled and adjusted by law, moral standard of Ministry of
Health, Vietnam Nursing Association (VNA), they are not clear and detailed enough.
Customers’ feedbacks sometimes are based on their feelings. Therefore, such laws like
Prevention of Corruption Act; Law on Medical Examination and Treatment, rules of
behaviors by VNA should be concretized the notions regarding moral issues of
nurses, regulations of penalty and encouragement, etc.
4.1.3. Some factors relating to medical ethics of nurses
According to the result, factors that affect nurses’ attitude are working
experiences, passion, knowledge in medical ethics, extra working hours and the
number of patients. Factors that affect negative behaviors of nurses include passion,
knowledge in medical ethics, extra working hours, the number of patients, which has
statistical significance. The study shows that it is hospital overloading with a large
22



number of patients that affect nurses’ attitude. Hence, nurses should be assigned
suitable tasks and working condition to maintain good relationship with customers.
Some factors having statistical meaning in relation to colleagues include
suitability to their ability, satisfaction with colleagues, passion, and knowledge in
medical ethics. The hospital needs to ensure each nurse develops his skill and ability.
There should be meeting, clubs outside the hospital to enhance relationship, unity
among nurses. The hospital also needs to improve profession values, give

opportunities for nurse’s development so that they feel more involved and passionate.
Understanding medical ethics helps nurses to adjust their behaviors, from which the
relationship with colleagues will be improved.
Some factors such as qualification, working experiences, suitability to their
ability, passion, and knowledge in medical ethics affect on nursing practice.
Therefore, nurses should have further study, get more experiences and have chances
to develop their ability. Besides, they should be praised and promoted professional
values. Furthermore, they should be trained medical ethics at the hospital.
4.2. Result of application of 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 customer’s feedback through hot lines
* Reducing working hours and workload; Improving management and
observation; Promoting emulation movement, reward and discipline for nurses
* Nurses recommend solutions to increase their passion in their job.
4.2.2. Result of some solutions to promote medical ethics
We have built criteria to improve attitude and reduce negative behaviors.
According to the result, 100% of the criteria built by researcher group has been
done and above the requirement. Therefore, morality of nurses in relation to
customers can be absolutely improved by enriching knowledge in direct training
courses. There should be meeting and observation to get feedback from nurses,
customers and hospital managers. Other studies also show the same result in training
courses. However, they just apply training courses without comprehensive solutions,
so the result is not very satisfactory.

CONCLUSION

1. 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, less than 6% of
nurses violates moral issues.
- In relation to colleagues: most of the nurses are reflected well; however, 6%
of nurses causes disunity, 2,8% of them are untruthful, affecting reputation of
colleagues. There is a small rate of nurses who do not understand relationship with
customers as well as customer’s benefits. There are different ideas of nurses regarding
receiving money from customers. 71,5% of nurses leaves one or more terms in 12
medical ethics terms.
- Morality in profession practice: 7,5% of nurses does not frequently report to
manager, 6,1% of nurses does not report colleague’s fault. Among 8 criteria of
evaluation, the highest one is the fact of irrespective attitude, accounting for 5,6% ;
then comes nurses who do not respect self-decision of customers with 4,7%. Other
criteria make up more or less 3%. 9% of customers supposed that nurses have right to
shout at them 9%; right cognition of giving money for nurses accounts for 3,5%.
1.2. Some relating factors
- Factors that affect serving attitude of nurses: working experiences, passion,
knowledge in medical ethics, extra working hours and the number of patients.
- Factors affect negative behaviors of nurses: passion, knowledge in medical
ethics, extra working hours, the number of patients per day. Improving these factors
also helps to promote the quality of health care and treatment.

2. Result of some interventions
The researchers have evaluated and compared the stage of before and after
applying interventions, from which significant improvement in serving attitude and
reduction in negative behaviors can be clearly seen.
2.1. Result of improvement in relationship with customers
- The indicators of serving attitude of nurses have clear improvement, which
has statistical significance (p<0,05). The highest levels of changes lies in
investigating and understanding psychology of patients and their family (increase
14,4%), and the lowest one lies in obeying professional regulations (increase 0,5%)
- At outpatient clinic, there is a good improvement in customers’ satisfaction
with nurses. The highest levels of changes lies in accompanying patients to the
testing room with 273,9% increase. The lowest one lies in asking for the reasons of
taking the child to the hospital with an increase of 2,6%.
2. Result of improving medical ethics
After intervention, there is a reduction in customers’ feedback on nurse’s moral
violation. The levels of changes that reduces most is unfair treatment (decrease
89,1%). The levels of suspecting misleading of nurses reduces to the lowest (decrease
57,6%).


24



RECOMMENDATIONS

1. Provide nurses with training courses that emphasize on communication skill,
psychology of children, customer’s psychology, nursing practice, enriching
knowledge in law, moral standards of nurses. Through discussion and training,
nurses can point out difficulties and challenges in ethical practice.

2. Enhance knowledge and 2-way information between nurses and customers to
reduce possible problems. Make use of loudspeakers, signals at seeable places,
which helps customers to understand hospital regulations and their benefits in
health care service.
3. Improve examination and treatment procedure, reduce waiting time, and reduce
administrative procedure. Besides, evaluate workload of nurses and assign suitable
tasks to reduce pressure for nurses, avoid bad behaviors of losing control in giving
care for patients.
4.
Apply information technology in reception, administrative procedure (especially
at outpatient clinic), observe sensitive behaviors, enhance two -way feedback
between customers and the hospital.