A Study of the Awareness of the Nursing Students with the Ethical Codes of Clinical Care at Jahrom University of Medical Sciences

As an essential part of nursing, nurse ethics can be defined as the professional ethical codes that nurses must adhere to while providing care. One of the major concerns in nurse education is improving nurses’ ethical performance. The present study aims to assess the Awareness of the nursing students with the ethical codes of clinical care at Jahrom University of Medical sciences. This cross-sectional study was conducted in 2016 on 85 thirdand fourth-year nursing students at Jahrom University of Medical Sciences, Jahrom, south of Iran. Data were collected using a questionnaire based on Iranian Nurses’ Ethical Codes: Nurses and Clinical Care. The content validity of the questionnaire was confirmed by a number of experts, and its reliability was proved through retest. The questionnaire was designed to be self-administered; for data analysis, SPSS v.15 was employed. 49.4% of the participants were female, 48.1% were male, 75.3% were single, 22.2% were married, 50.6% were junior, and 33.3% were senior nursing students. 67.9% of the respondents rated nurses’ Awareness with ethical codes as average, 27.2% as unsatisfactory, and 4.9% as satisfactory. The mean score and standard deviation of the nursing students’ Awareness with ethical codes was found to be 56.13±11. Based on the statistical test of chi-square, the relationship between the students’ genders and Awareness with ethical codes was insignificant (p=0.78). Moreover, the results of Pearson’s correlation coefficient showed that the relationship between the students’ ages and Awareness with clinical ethical codes was insignificant (p=0.65). The findings of the study show that the majority of students have only average or unsatisfactory Awareness with clinical ethical codes; hence, the importance of teaching nursing ethical codes to nursing students at college.

Ethics consist of principles and values that influence individual and group behaviors by determining whether they are right or wrong 1 .Today, humans are returning to reason and ethics: after many years, humanity is beginning to satisfy its material and spiritual needs based on a reasonable and ethical basis.Thus, ethics lie at the core of future developments.The influence of this new trend will be more tangible in fields that have to do with providing services.The new developments necessitate attention to ethics in medical professions 2 .Nursing ethics is defined as adherence to professional ethical codes while providing care, and has come to be regarded as essential to the nursing profession.Nursing is an independent profession whose objective is to provide high-quality sanitary, medical, clinical, and rehabilitation services in order to maintain and improve health in a society 3 .Encouraging professionalism through emphasizing the importance of ethical principles is the only way of obtaining people's trust in medical and health professions.This is especially important in the field of nursing which plays a major role in the treatment of patients.Training nurses who exercise professional ethics constitutes the foundation of nursing 4 .One of the major issues in nurse training is how to enhance nurses' Awareness with ethical matters 5 .The ability to work according to ethics is a requirement for present and future nurses.The ethical codes for nursing were formulated many years ago, which fact proves the importance of ethics as one of the main elements in the nursing profession 6 .The reason for the formulation of nursing ethical codes was to set standards for the performance of nurses, inform the society of the standards, and create a unified professional system 7 .
Sokhanvar's study shows that nurses' attention to ethical principles in clinical decisionmaking is not satisfactory and nurses lack the ability to practice their knowledge of the ethics in reality 8 .Accordingly, it is necessary that observance of nursing ethical codes be studied at the source of nurse training-colleges-so that administrators can identify students' weaknesses and provide complementary education.The importance of nursing schools in teaching the nursing code of ethics is emphasized by Kelly: he concludes in his study that colleges constitute the most effective power to form ethics in nursing students 9 .
An assessment of the extent to which nursing ethical codes are observed can function as a major source for evaluating and making decisions about the performance of nursing students who are the future employees of the healthcare system.In order to identify the shortcomings in teaching ethics and evaluate students' education in ethics, there is need for an analysis of students' awareness of ethical codes.Once the gaps in students' awareness of the ethical codes are identified, measures can be taken to fix them.Moreover, by determining the basic factors, authorities can significantly improve the development of ethics.A review of the available literature shows that few studies have addressed nursing students' awareness of nursing ethical codes.Thus, the present study aims to explore the Awareness of the nursing students with the nurses' professional code of ethics in junior and senior nursing students at Jahrom University of Medical sciences.

METHODS
This is a descriptive study which was conducted at the School of Nursing and Midwifery of Jahrom in 2016.The entire junior and senior nursing students at the college constituted the study population.Based on previous studies and the advice of the experts, the size of the population was set at 85 students, 4 of whom were excluded due to unwillingness to participate.Sampling was performed based on the census method.
Since the majority of nursing students in Iran start to work in clinical environmentshospitals and clinics-after graduation, the researcher focused on two of the five areas of ethical codes: nurses, and clinical services.The questionnaire designed by the researcher consisted of two parts: demographic characteristics and items related to ethical codes.Initially, each of the clauses in the clinical code of ethics was transformed into a questionnaire item.This part consisted of 26 questions, which were scored based on a four-point Likert scale: never (0), occasionally (1), often (2), and always (3).Scores between 0 and 50 were considered as poor, between 51 and 75 as average, and above 75 as satisfactory.
The content validity of the questionnaire was verified by five nursing professors who had access to both the questionnaire and the nursing ethical codes.The reliability was confirmed with a correlation coefficient of 0.9.The questionnaires were completed by the participants independently.SPSS v.15 was used for data analysis.To describe the demographic characteristics and the collected data, the researcher used descriptive statistics, including frequency, mean, percentage, and standard deviation; analytical statistics, e.g.chisquare, were used to explain the relationships between the variables and the differences, and Pearson's correlation coefficient was used to analyze the correlation between the scores and the personal and professional characteristics.

RESULTS
49.4% of the participants were female, 48.1% were male, 75.3% were single, 22.2% were married, 50.6% were junior, and 33.3% were senior nursing students.The results showed that 67.9% of the respondents rated nurses' Awareness with ethical codes as average, 27.2% as unsatisfactory, and 4.9% as satisfactory (Table 1).The mean score and standard deviation of the nursing students' Awareness with ethical codes was found to be 56.13±11(Table 2).Based on the results of the statistical test of chi-square, there was no significant relationship between the students' genders and Awareness with ethical codes (p=0.78).In terms of gender, 30%, 65%, and 5% of the female participants achieved unsatisfactory, average, and satisfactory scores, respectively; on the other  3).The results of Pearson's correlation coefficient showed that the relationship between the students' ages and Awareness with clinical ethical codes was insignificant (p=0.65).

DISCUSSION
The results of the study show that according to the nursing students, awareness of ethical codes is average (56.13).In the study of Aghdam et al. (2013), 51.8% of the patients rated nurses' performance with regard to ethical codes as average, and 41.8% rated it as satisfactory 10 .According to another study, nurses believed that the overall observance of ethical codes was average 11 .The results of a study in the U.S. showed that only half of the studied nurses were following the ANA code of ethics or some other ethical framework during their practice, which finding stresses the absolute need for continuous education in ethics and enabling nurses to observe the ethical codes as a framework for their performance 12 .A study in Ghana shows that nurses' treatment of ethical issues does not always agree with the codes established by the International Council of Nurses: the studied nurses were working according to their own ethnic code of ethics and both their awareness and practice of the international codes were defective 13 .It appears that concern over nurses' ethical competence is increasing.Studies on nurses' observance of ethical codes show that both nurses' Awareness with and practice of ethical codes are inadequate 14,15 .It also appears that such factors as the disproportionate number of nurses to patients affect their adherence to ethical codes.Bennett et al. (2003) cite insufficient time and personnel (the great number of patients) as the primary barriers to nurses' practice of professional ethical codes 16 .
The results of the present study showed that the students were more familiar with the items of complete respect for the patient and respect for the patient's privacy than with the other items.The students rated nurses' introduction of themselves and their roles to their patients as unsatisfactory, which finding agrees with the study of Maarefi et al. (2013)  17 , but conflicts with the study of Sawada (1996) in Brazil 18 .The discrepancy can be attributed to the differences in the locations of the studies and the cultures of the participants.The researcher's own clinical experience corroborates the viewpoint that, due to cultural reasons, Iranian nurses are not willing to introduce themselves and often introduce themselves as "your nurse" to their patients.However, a proper introduction is the fist step in the establishment of an effective relationship between nurses and patients 19 .In their study, Torabizadeh et al. (2013)  conclude that from the patients' point of view, nurses' introduction of themselves is a major factor in the development of a proper relationship with patients and enhances patients' dignity 20 .An effective relationship is sometimes more important to patients than pure physical care: if nurses can establish a good relationship with their patients, the quality of clinical care and patients' satisfaction will increase 21 .
In the present study, respect for patients' privacy during nursing interventions was rated as satisfactory; however, the results of the study of Ebrahimi et al. (2012) show that disrespect for their privacy was one of main issues that the patients in the study repeatedly referred to 22 .Since personal territory has many different dimensions, including physical, social, and information dimensions, the discrepancy between the results of the two studies may be due to the fact that in the present study territory was considered in its general sense and the participants' perceptions of it was not unified.In view of the fact that the majority (95%) of Iranians are Muslim 23 and have strict ideas about personal territory and clothes, it is essential that observance of this cultural code be stressed.Thus, it is recommended that proper educational programs related to the rights of patients and respect for their privacy be developed and nurses' performance be regularly monitored by their managers.
Few of the students were aware of the code of informing patients of the hazards of a new medication.Likewise, the study of Mehdipour et al. shows that patient education is not taken seriously in the hospitals and patients consider it as a felt need 24 .In their study, Eshkevari et al. found that 52.7% of the time, patients are not properly informed about their diseases and treatments and their privacy and independence are not respected 25 .Failure to inform patients can lead to their dissatisfaction.Providing patients with the necessary information about their treatments and care plans and considering their psychologicalemotional needs can reduce patients' dissatisfaction.It appears that despite administrators and nurse educators' emphasis on respect for patients' rights and patient education, nurse education has failed to enable nurses in these two domains.Although ethical issues are addressed in the Iranian nurses' educational curriculum, there is need for a systematic plan to teach ethics and prepare students for dealing with ethical issues.If, alongside the advances in technology, educators train capable nurses who can provide holistic care, the profession of nursing will become more powerful and effective in the healthcare system, and, consequently, bring about the satisfaction of the beneficiaries.

CONCLUSION
The results of the study show that the Awareness of most nursing students with nursing ethical codes is average or unsatisfactory, hence the need for educating nursing students in nursing ethical codes at universities.

Table 1 .
Nursing students' awareness of the ethical codes

Table 2 .
Mean and standard deviation of scores for awareness of ethical codes

Table 3 .
Correlation between gender and scores for awareness of ethical codes