Code of ethics practice and associated factors among healthcare professionals in public hospitals in central Gondar, northwestern Ethiopia, 2021: a mixed-method study design | BMC Medical Ethics

Study design, setting and participants

A cross-sectional quantitative facility study supported by a qualitative approach was conducted from March to April 2021 to assess the practice of the code of ethics among health professionals working in public hospitals in the central area of ​​Gondar. The central area of ​​Gondar is located 738 km from Addis Ababa, the capital of Ethiopia, and 180 km from the regional capital, Bahir Dar. It had 94 health centers, 154 health posts, ten hospitals and within these institutions, 430 doctors and 772 nurses served the community. The hospitals served about 7 million people as centers for diagnosis, treatment and education.

For quantitative and qualitative data, all doctors and nurses working in public hospitals in the central area of ​​Gondar were the source population. While all the doctors and nurses working in the selected public hospitals in the central area of ​​Gondar constituted the study population. But those with less than six months of work experience were excluded from this study.

Sample size and sampling technique

The sample size for code of ethics practice was determined using a single population proportion formula with a 95% confidence interval (CI), population proportion of 45.6% (at from a study result in the Bale Zone Oromia region) [23]margin of error of 5%, design effect of 1.5 and non-response rate of 10% n =(frac{(mathrm{Z}upalpha/2)2mathrm{ p }(1-mathrm{p}) }{mathrm{d}2}=frac{(1.96)2*0.456 (1-.456) }{0.0025 })

n = 382*1.5= 573 with a non-response rate of 10%, it becomes 631.

A multistage sampling technique was used to obtain study participants. A simple random sampling method was applied to select the top five hospitals (50%) from all hospitals in the area. [24]. Second, the list of health professionals (nurses and doctors) was identified from the human resources registration in each hospital selected to consider a sampling frame. Then, the sample size was assigned proportionally to each selected hospital based on the number of nurses and doctors available. Simple random sampling (Open Epi Random Program version 3) was used to select among professional nurses and physicians in each hospital (Fig. 1).

Fig. 1

Schematic sampling procedure of health workers in central Gondar, Ethiopia, 2021. Caption: UGCSH; University of Gondar Comprehensive and Specialty Hospital, A/Giwergis; Amba Giworgis, MD; Doctors

For qualitative data, sample size is determined by information saturation and samples were purposefully selected based on their work experience and position in hospitals. Based on these criteria, medical directors, metron nurses, and case managers were included for the KII.

Variables and measurement

Practice of the health care code of ethics was the dependent variable. It was measured using 26 standardized item questions with a 5-point Likert scale (Table 1). The response related to the practice of the code of ethics was categorized as good practice when the score was greater than or equal to 75%, and as poor practice if it is less than 75%. [8].

Table 1 Practice of issues related to code of ethics in public hospitals in North West Gondar Central Zone, Ethiopia, 2021

Whereas, Socio-demographic factors (age, gender, religion, occupation, level of education, monthly income, and work experience), Institution-related factors (training, type of health facility, availability of policy, access to guidelines ), factors related to the individual (knowledge, attitude, work experience and job satisfaction) and factors related to professional ethics (ethical dilemma, ethical problem) were the independent variables.

Knowledge of the code of ethics: assessed by questions of nine items yes or no related to the practice of the code of ethics (Table 2). Participants who answered greater than or equal to 75% were informed, while less than 75% were not informed [8].

Table 2 Questions related to the knowledge of health professionals regarding the practice of health care ethics in public hospitals in the central area of ​​Gondar, North West, Ethiopia, 2021

Attitude towards the code of ethics: evaluated by questions of 14 items with a response on the 5 Likert scale. Among the 14 item questions related to professional ethics attitude, participants who answered greater than or equal to 75% of the questions had favorable attitudes, if not unfavorable attitudes (Table 3). [8].

Table 3 Questions related to health professionals’ attitudes towards health care ethics in public hospitals in Central Gondar, North West, Ethiopia, 2021

job satisfaction: assessed by nine-item questions related to job satisfaction. Participants who answered greater than or equal to 50% are considered satisfied; otherwise not satisfied [25].

Health professionals: those who graduated from a university or college known as doctors or nurses.

Ethical dilemma: hindrance to good decision-making and poor working relationships between staff. Resource constraints, poor attitude of some staff towards work, conflicts between ethical codes, religious beliefs and personal values.

Data gathering

Quantitative and qualitative data were collected in parallel. Two BSc nurses and a health worker participated respectively in quantitative data collection and as a supervisor. The data collectors and supervisor had good experience in data collection activities. The principal researcher collected the qualitative data.

Data quality control

Two days of training were given to data collectors on primary data collection techniques. A pre-test was also carried out on 5% of the participants at a nearby hospital. During data collection, the principal investigator and supervisor checked the completeness of the questionnaire daily. The principal investigator transcribed and checked the consistency of the information with the initials. Interviews with key informants (KII) were conducted until information saturation.

Data processing and analysis

Data were entered into Epi-Info version 7.0 and exported to SPSS version 20 for analysis. Data were cleaned and checked for errors and missing observations to ensure data accuracy and consistency. For the qualitative study, audio recordings and notes from the interviews were used and transcribed manually. Finally, the data was read to identify key themes and synthesized thematically.

A variety of descriptive statistics were presented using tables and narratives. Binary logistic regression models were used. Model fitness and multiple collinearity were checked using the Hosmer and Lemeshow test and the variance inflation factor, respectively. Finally, in multivariate logistic analysis with adjusted odds ratio (AOR), 95% CI and p value ≤ 0.05 were declared statistically significant variables.

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