How Much of Professional Ethics are Applied by Medical Staff ? A Descriptive Cross-Sectional Surveyin South of Iran

Offering services for health, care, treatment and rehabilitation with an acceptable quality in order to provide, preserve and improve the total society health is the main goal of medical staff. In this way, principles of professional ethics make the staff more capable to concentrate on health, rights and comfort of the patients and keep their professional performance and finally their profession status at the highest level. This study is going to evaluate the rate of codes of ethics applied by the medical staff of the tertiary health care centersaffiliated with Jahrom University of Medical Sciences in south of Iran. Two hundred and eleven members of the medical staff collected by census from 8 different wards of tertiary health care centers affiliated with Jahrom University of Medical Sciences in south of Iran, participated voluntary in this descriptive cross-sectional survey. A questionnaire of 41 questions adding to demographic information (age, gender, job experience, and ward) was designed according to 5 degrees Likert scale. Validity and reliability of the questionnaire was proved by previous studies. Collected data analyzed by dependent T-test, Fisher’s exact and SPSS.17 using descriptive and deductive statistics. From the 211 samples, 137 (64.9 %) were female and 74 (35.1%) were male. One hundred and thirty one (62%)were in the range of 20 to 30 years old. One hundred and twenty four (58.8%) had 5 to 10 years of job experience and 36 members (17.1%) were from gynecology ward. Rate of observance to the codes of ethics was 3.82 ± 0.75. The highest scores were: Empathy towards the patients possessed the score 4.36 ± 1.15, patients care 4.12 ± 1.09, ignorance to the illegal cares 4.10 ± 1.17 and justice in offering services 4.10 ± 1.15. Except the ward (p=0.03) and age (p=0.003), there was no other significant difference between applying ethical codes and studied factors (p> 0.05). Medical staff used a medium level of ethical behaviors in their daily job. So, improving the professional ethics by long term policies and giving proper teachings to the treating personnel in order to improve the medical services efficiency may be suggested.


INTRODUCTION
Ethics surveys honest or bad behaviors and studies the stimulants of the behavior (Breen, 2007).Ethics has been noticed as a basic content of clinical and medical sciences for more than a quarter of century and ethical researches developed rapidly since last 2 decades (Hodges et al., 2011).Professional ethics is the principle concern of medical educators due to its importance (Ghobadifar & Mosalanejad, 2013).Discussions around the medical ethics has counted into account since the beginning of medical ethics itself (Aghakahni, 2013).
According to the significant state of ethics, some programs has been set for students and medical staff (Jha, bekker, Duffy, & Roberts, 2006).Offering the best quality of hygienic, caring, rehabilitating and treatment services to produce, preserve and promote the health for society is the main goal of medical staff (Hunter, 1996).The purpose of professional ethics is to make the staff professional.The principles of professional practice determine how the staff should act and how to behave the society (Cohen, 2006).Commitment to these principles make the medical staff more aggressive to elevate the quality of medical services and put the satisfaction of the patient in the spotlight (Roth, 1974).
Experts say that ethics has become an important part of art of medicine and all of medical staff are responsible to act on the path of ethics which is not divided from the medical procedure (Maarefi, Ashktorab, Abaszadeh, Alavimajd, & Eslamiakbar, 2014).Nevertheless, ethical errors are seen repeatedly which are not acceptable because a simple mistake can lead to death of patient (Hilton & Slotnick, 2005).Lack of attention to the ethics may have various origins, including three followings: the staff are not aware of the principles, they know the principles but have no idea how to apply them, and finally they know the principles but don't care (Plochg, Klazinga, & Starfield, 2009).
Ethical behavior causes the medical services more effective and more pleasant to the patient, so to separate the ethical and non-ethical behaviors in any place, the same values should be defined (Swick, 2007).These equal values are known as ethical codes.Codes of professional ethics cause the ideal performance of medical staff, awareness of society about the ethical standards and totally making a coherent medical system.It is necessary to know that social values should be noticed besides the main ethical values which are equal all around the world (Milton, 1999;Fulford, 2004).So every society should have its own codes of ethics due to the people's culture and belief in addition to the international codes.
In Iran, there is no codified ethical rules so medical staff may not obey the same instruction; so the staff used to act on their religious and social beliefs or according to some international statements like principles of professional ethics of medical staff society.The phenomenon led to Bewilderment in action (Limentani, 1999).In such situation, even the patients would not know what to expect from the medical team.Since few researches have indicated that how many of codes of ethics are in use among the medical staff, the present study is about to measure the rate of observation of codes of ethics in medical staffof the tertiary health care centers affiliated with Jahrom University of Medical Sciences in south of Iran.

METHOD Participants
The present descriptive cross-sectional surveywas conducted in autumn and winter of 2013.The census samples included 211 members of health care staff in 8 different wards of gynecology, pediatrics, surgery, orthopedic, internal medicine,coronary care unit (CCU), neonatal intensive care unit(NICU), and the emergency department of tertiary health care centers affiliated with Jahrom University of Medical Sciences in south of Iran.

Procedure
The researcher obtained a license from the research council of the Iranian Ministry of Health and attended the hospitals in order to explain the goals of the study to the eligible staff and fill the questionnaires.After explaining the objectives of the survey to the authorities at the studied health care centers, the assistant visited all the wards to gather data.The questionnaires were distributed in different working shifts.The questionnaires, handed out all at once, were completed by the nurses at their leisure and returned.

Data Analysis
The sample size was calculated using 90% confidence intervals, with 2% precision.A sample size of about 175 individuals was suitable for this survey.To compensate for any refusal to provide data or nonvaluablesubjects the sample size (175 individuals)was increased by 20%.Results were reported as the means ± standard deviation (SD) or median for quantitative variables and percentages for categorical variables.The groups were compared using the Student's t-test and the chi-square test (or Fisher's exact test if required) for categorical variables.P values of 0.05 or less were considered to be statistically significant.All the statistical analyses were performed using SPSS version 17.0 (SPSS Inc, Chicago, IL, USA) for Windows.

Ethical Consideration
The study was undertaken after being completely approved by the Institutional Review Board of the Iranian Ministry of Health.Written informed consent was obtained from each participants before their enrolment to the study.

RESULTS
From the 211 samples, 137 (64.9 %) were female and 74 (35.1%) were male.131 (62%) were in the range of 20 to 30 years old.124 (58.8%) had 5 to 10 years of job experience.The distribution among different wards was as following: 36 members (17.1%) from gynecology ward, 30 (14.2%) from pediatric ward, 28 (13.3%) from emergency department, 27 (12.8)from surgery   Rate of observance to the codes of ethics was 3.82 ± 0.75.Among all the subcategories, the highest scores were: Empathy towards the patients possessed the score 4.36 ± 1.15 , patients care 4.12 ± 1.09 , ignorance to the illegal cares 4.10 ± 1.17 and justice in offering services 4.10 ± 1.15.According to the results of the questionnaire the highest score of the staff was in the improvement of services (4.60) and the least at secrecy (2.78) (Table 1).
There was significant differences between respecting the patient's rights and job experience (p=0.001),teaching the patient and age (p=0.001) and gender (p= 0.01) of staff, respecting the colleagues and job experience (p=0.03),justice and age (p=0.002) and job experience (0.001), and finally improvement of services and age (p=0.08) and ward (p=0.03) and job experience (p=0.001)(Table 2).
The average score of men in the category "management of conflicts" was 1.97 ± 0.16 (Table 3).Professional ethics has a meaningful relation with ward and age,but not gender and job experience (Table 4).The results show that 28 persons (13.3%) used medium levels of ethical codes and 183 (86.7%) performed in high and very high level.Non-of them evaluated their ethical performance as poor.

DISCUSSION
According to the results, most of the staff evaluate their own performance in professional ethics as fine, while their scores indicated a medium degree performance.In a similar study named "professional ethics in drug use by the nurses", Tafagh et al concluded that most of the staff showed a weak performance during the procedure of drug use.Moreover, no meaningful relationship was found between applying ethics and age, gender, ward and job experience (Tefag, Nikbakht Nasrabadi, Mehran, & Dinmohammadi, 2004).
In "perception of nursing students of barriers of ethics ; a qualitative study" , Borhani et al recognized that use of inappropriate techniques in teaching ethics, issues in evaluation the ethical factors, clinical limits and weak communications are main difficulties in the way of professional ethics (Borhani, Alhani, Mohammadi, & Abbaszadeh, 2011).In 1997, Meurier et al managed a study named "Learning from errors in nursing practice.Journal of Advanced Nursing" in which no meaningful correlations were found between appliement of professional ethics and age, gender and job experience ,but relations seen between ethics and the ward (Meurier, Vincent, &Parmar, 1997).
In "The comparison between nurses and assistants in principles of use of psychotic drugs in psychiatric hospital of Tehran" done by Haghi, results show a non-meaningful relationship between nurses knowledge in use of drugs and age but meaningful to job experience, gender and the ward.Female nurse were more familiar to the principles than males.Also the staff who passed the in-service courses were more cognizant (Haghi, 2009).Habibzadeh et al say that there is a strong relation between professional performance of the nurses and religious beliefs in "Morality and professional performance of Iranian nurses"(habibzade, ahmadi, & vanaki, 2010).

CONCLUSION
Present study shows positive correlations between applying the ethics and age and ward.Results of this study can be used in medical studies and management of medical services.Educators of ethics can improve the efficiency of treating services by finding the issues of ethics and also the way to solve the problems.Since the results showed a medium level performance, planning for further actions such as in-service courses done by medical managers to improve many categories during the health care services like rights of the patients, respecting the colleagues, justice, management of conflicts ,secrecy and responsibility is suggested.