Assignment: Ethical violations in the pakistani clinics

Assignment: Ethical violations in the pakistani clinics ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Ethical violations in the pakistani clinics Ethical Violation. Read the following article about Ethical violations in the pakistani clinical setting . Prepare a one-page (250-word) research paper in which you describe the ethical violation and explain how it could have been avoided. Be sure to follow APA style and include in-text citations where appropriate and a references page. Assignment: Ethical violations in the pakistani clinics attachment_1 Jafree et al. BMC Medical Ethics (2015) 16:16 DOI 10.1186/s12910-015-0011-2 RESEARCH ARTICLE Open Access Ethical violations in the clinical setting: the hidden curriculum learning experience of Pakistani nurses Sara Rizvi Jafree1,2, Rubeena Zakar1, Florian Fischer3* and Muhammad Zakria Zakar1 Abstract Background: The importance of the hidden curriculum is recognised as a practical training ground for the absorption of medical ethics by healthcare professionals. Pakistan’s healthcare sector is hampered by the exclusion of ethics from medical and nursing education curricula and the absence of monitoring of ethical violations in the clinical setting. Nurses have significant knowledge of the hidden curriculum taught during clinical practice, due to long working hours in the clinic and front-line interaction with patients and other practitioners. Methods: The means of inquiry for this study was qualitative, with 20 interviews and four focus group discussions used to identify nurses’ clinical experiences of ethical violations. Content analysis was used to discover sub-categories of ethical violations, as perceived by nurses, within four pre-defined categories of nursing codes of ethics: 1) professional guidelines and integrity, 2) patient informed consent, 3) patient rights, and 4) co-worker coordination for competency, learning and patient safety. Results: Ten sub-categories of ethical violations were found: nursing students being used as adjunct staff, nurses having to face frequent violence in the hospital setting, patient reluctance to receive treatment from nurses, the near-absence of consent taken from patients for most non-surgical medical procedures, the absence of patient consent taking for receiving treatment from student nurses, the practice of patient discrimination on the basis of a patient’s socio-demographic status, nurses withdrawing treatment out of fear for their safety, a non-learning culture and, finally, blame-shifting and non-reportage of errors. Conclusion: Immediate and urgent attention is required to reduce ethical violations in the healthcare sector in Pakistan through collaborative efforts by the government, the healthcare sector, and ethics regulatory bodies. Also, changes in socio-cultural values in hospital organisation, public awareness of how to conveniently report ethical violations by practitioners and public perceptions of nurse identity are needed. Keywords: Clinical setting, Ethics, Ethical violations, Hidden curriculum, Nurse Background The clinical setting is recognised as being the place where the hidden curriculum is absorbed by medical practitioners during training and practice [1-3]. The hidden curriculum is the undocumented part of medical education which dictates professional practice and processes through strong and sustained socio-cultural forces [4-6]. Medical trainers, instructors and senior licenced * Assignment: Ethical violations in the pakistani clinics Correspondence: [email protected] 3 School of Public Health, Department of Public Health Medicine, Bielefeld University, P.O. Box 100 131, 33501 Bielefeld, Germany Full list of author information is available at the end of the article practitioners influence the future ethical practices of both students and other work colleagues through the hidden curriculum [7-10]. Patient safety and optimal role delivery in the clinical setting is highly dependent on nurse training and professional ethics [11]. Nurses are front-line practitioners, known for spending the most time with patients and also being the main coordinating force for all other medical practitioners [12]. Consequently, nurses have substantial knowledge of the hidden curriculum and the practice of ethics in the clinical setting [13]. © 2015 Jafree et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated. Jafree et al. BMC Medical Ethics (2015) 16:16 The issue of the hidden curriculum is highly relevant in Pakistani society due to strong socio-cultural forces that control healthcare organisational practices and medical ethics [14-16]. Pakistan is an underdeveloped nation, fraught with grave political, economic and regional difficulties [17]. The healthcare system is hampered by extremely low expense allocation (less than 2% of the government budget), unstructured planning and an absence of policies on many health-related issues, and corruption within the medical administration [18,19]. There is a paucity of literature in this field in Pakistan. The available literature indicates high levels of ethical violations in clinical practice [20]; including the absence of informed consent, a lack of patient rights, unprofessional guidelines, and the deliberate withdrawal of treatment [15,21-25]. Reasons for ethical violations in the Pakistani healthcare system have been discussed in terms of inadequate training of medical and nursing practitioners, long duty hours and low pay-scales, the absence of legal protection for patients, a lack of professional assessment of practitioners and the nonexistence of compulsory registration of medical and nursing practitioners [20,26,27]. Since public-sector hospitals are understaffed, medical and nursing practitioners are overburdened and as a resultant they put less emphasis on following structured care plans, reporting errors and observing medical ethics practice [16]. Like other sectors in the country, the healthcare sector is highly male-dominated; with patriarchal, paternalistic and conservative belief systems influencing working relations and output [26]. Because nursing is a feminised profession in Pakistan, it bears the brunt of patriarchal practices, with female nurses evidenced to be victimised, abused and professionally sidelined in the absence of laws and policies ensuring their protection and professional autonomy [28,29]. Assignment: Ethical violations in the pakistani clinics Ethics in Pakistan’s healthcare sector Regulatory bodies The National Bioethics Committee (NBC) was established in 2004 by the government of Pakistan, with the aim of promoting ethics in the healthcare sector through two subcommittees: the Research Ethics Committee (REC) and the Medical Ethics Committee (MEC). The Pakistan Medical and Dental Council (PMDC) and the Pakistan Nursing Council (PNC) are, respectively, the statutory regulatory and registration authority for medical and nursing practitioners in the country. The PMDC and PNC are both independent of the government, and administered by medical practitioners. Medical and nursing curricula are also revised and supervised by the Higher Education Commission (HEC), a government body which licenses educational institutes and verifies degrees. Despite the presence of designated regulatory bodies for ethics promotion, the healthcare sector in Pakistan is hampered by the absence of ethics courses in the curriculum, the Page 2 of 11 non-existence of hospital ethics committees or Institutional Review Boards (IRBs) in most hospitals, and the existence of only one non-indexed ethics journal (Pakistan Journal of Medical Ethics) [15,30]. Ethics education To qualify as a registered doctor or surgeon in Pakistan, medical students need to complete five years of a bachelor’s degree in medicine and surgery (referred to as an MBBS) and one year of clinical training (referred to as a ‘House Job’). Registered nurses must have either a twoyear Nursing Diploma or a three-year bachelor’s degree in Nursing (BSc Nursing). Although the PMDC and PNC have made ethics education compulsory, the majority of medical and nursing institutes in the country do not teach compulsory courses in ethics or conduct formal examinations on ethics [27,31,32]. In addition, there is no monitoring or assessment of ethical compliance during clinical training and practice. In developing countries, including Pakistan, where there is weak regulatory infrastructure and curriculum exclusion, medical practitioners usually rely on international ethical documents as broad guidelines for ethical awareness [27,33]. Objective of this study Given that ethics training is only superficially covered in the formal medical and nursing curricula, and that the regulation of ethics is also weak in the country, research about how the hidden curriculum may be teaching ethical violations became an important topic for us to pursue. To the best of this researcher’s knowledge, nurses’ perceptions and experiences of ethical violations in the region have not been researched. There is a danger that if the ethical violations that are taught through the hidden curriculum remain neglected by researchers, this will reinforce cyclical violations in the future [5]. In addition, nurses’ experiences of ethical violations in the clinical setting need to be identified before they can be resolved [34,35]. Vaughn’s structural secrecy theory has been used in nursing research to propose that each region must separately ascertain its native layers of the hidden curriculum, which influences practitioner position and output [36,37]. The aim of this study was to identify those aspects of the hidden curriculum which encourage ethical violations in the clinical setting, through the ‘life-world’ experiences of nurses, during clinical training and practice. Methods Study This study is part of a doctoral dissertation entitled “Nurses’ perceptions of organisational culture and its association with error reporting: A study of tertiary-care public sector hospitals in Lahore”, written by the first author. Since there was an absence of literature on nurses’ Jafree et al. BMC Medical Ethics (2015) 16:16 Page 3 of 11 perceptions of medical negligence in Pakistan, a qualitative phenomenological approach was considered appropriate to capture the organisation-specific and culturally relevant experiences of nurses [38]. Assignment: Ethical violations in the pakistani clinics Additionally, within empirical research in clinical ethics, there is a growing recognition that qualitative methods are beneficial in identifying the sociocultural forces driving the hidden curriculum [39,40]. Ethics committee permission was obtained from the hospitals and nursing institutes where data collection took place, and also from the Institutional Review Board, University of the Punjab. Setting The study was conducted in two prominent tertiary-care public-sector hospitals in Lahore, both of which have affiliated medical and nursing schools. The hospitals were randomly sampled from a list provided by the Pakistan Institute of Medical Sciences, which shows a total of nine tertiary-care public-sector hospitals listed for Lahore. The hospitals will be referred to as Hospital A and Hospital B, to preserve the anonymity of the participants. Both hospitals cater to a large number of patients from both the rural and urban Lahore District and also from the surrounding villages of Lahore City. Combined, the two hospitals have a daily out-patient turnover rate of 3,800 patients and an in-patient capacity of 1,890 beds. Sample The sampling inclusion criterion was all willing female registered nurses and registered nurse students who had been working in the clinical setting for more than one year. Nurses from all five designations were included, i.e.: nurse supervisor, nurse instructor, nurse ward head, staff nurse and student nurse. Both hospitals combined have a total of two nurse supervisors, 33 nurse instructors, 250 nurse ward heads, 1,250 staff nurses and 735 student nurses. Nurse supervisors and nurse instructors were asked for interviews personally by the first author. Both nurse supervisors were asked and they showed an interest in participating in the study. A total of 14 nurse instructors were approached for interview, but only nine showed any interest and finally eight participated in the study. Informed consent was obtained from all respondents. Nurse ward heads, staff nurses and student nurses were invited for interviews through notices placed on bulletin boards in the nursing school corridors, nursing school libraries, and in the offices of nurse ward heads (which all nurses have to visit daily to sign attendance registers). Notices were displayed on boards for a period of five weeks. Additionally, nurse ward heads were requested by the first author to encourage staff nurses and student nurses to participate in the study. All the nurses who responded to the notices and demonstrated a willingness to participate in the study, by texting the first author, were interviewed. Finally, a total of 42 participants were sampled, consisting of two nurse supervisors, eight nurse instructors, ten nurse ward heads, 11 staff nurses and 11 student nurses. Twenty of the nurse participants had a Nursing Diploma, 19 had a BSc in Nursing and three had an MSc in Nursing. Interviews The research question for this study was designed to discover whether any ethical violations are taught through the hidden curriculum, as experienced by nurses during clinical training and practice. Although this question was phrased in a ‘leading’ manner, it was considered important to do so, as collecting data on sensitive topics in conservative and male-dominated societies does not invite open discussion, due to fears of retribution and job loss [41,42]. The PNC code of ethics [43], the ICN code of ethics [44], and the UNESCO core values of medical ethics [45] were consulted and summarised to distribute to participants in semi-structured interviews (Appendix A). Participants were asked what kind of ethical violations, if any, they might have experienced during clinical practice, with specific regard to: 1) professional guidelines and integrity, 2) patient informed consent, 3) patient rights, and 4) co-worker coordination for competency, learning and patient safety.Assignment: Ethical violations in the pakistani clinics Twenty interviews and four focus group discussions (FGDs), with 5–6 members each, were conducted (Table 1). Confidentiality and anonymity issues were discussed with all participants before the start of the interviews and FGDs. The participants were assured that they could leave the discussion at any point during the proceedings. Discussions lasted between 35 and 65 minutes. All interviews were carried out in the English language, as English is both the official working language and the academic language for medical and nursing students in Pakistan. In Table 1 Focus group discussions and interviews Nurse supervisors Hospital A FGD (2) Hospital B FGD (2) Interviews Interviews Total participants 1 Nurse instructors 5 Head nurses Staff nurses Student nurses Total participants 6 6 12 5 5 10 11 11 6 1 3 4 2 8 10 12 8 42 Jafree et al. BMC Medical Ethics (2015) 16:16 Page 4 of 11 general, audio recording was not used, except when the nurses allowed it (in some FGDs), because nurses were wary of recording devices, given the confidential and professionally sensitive topic of discussion. Due to seniority and time constraints, nurses belonging to the senior designations of nurse supervisor, nurse instructor and nurse ward head were interviewed according to their convenience in face-to-face private individual interviews. Staff nurses and student nurses were interviewed in FGDs. All interviews took place over a period of four weeks in private rooms in the nursing schools, located at a distance from the hospital setting, which allowed confidentiality and privacy from the busy and public clinical setting. Data analysis A deductive qualitative research design using content analysis was used due to the presence of an organised framework of categories for the nursing code of ethics [46,47]. Four broad nursing codes of ethics were used as preliminary categories to guide and prompt the participants to discuss issues specific to the study aim. Content analysis is commonly used in nursing research and has the benefit of flexibility to suit different research designs [48]. It has commonly been used to understand and identify meanings in communication and the processes of the hidden curriculum in the health sector [5,49,50]. The research process consisted of the following steps: the complete interviews were taken as the unit of analysis, all interview notes and audio interviews were transcribed, the text was read repeatedly to identify categories of relevance and importance, and the coding of sub-categories was developed under the four predefined categories of the nursing code of ethics [51,52]. Categories and coding were confirmed in context to identify hidden meanings and to consider nurses’ experiences [53]. An example of how sub-categories were developed and coded is described in Table 2. Reliability checks were conducted by seeking clarification during interviews and paying attention to details. Note transcripts were repeatedly analysed to identify significant categories of relevance. The reliability of findings and final drafts of categories was assured through multiple coding by the first researcher, researcher assistants and senior researchers, and finally through respondent validation [51,54]. Assignment: Ethical violations in the pakistani clinics Results From the four predefined categories in the nursing code of ethics, a total of ten strong and clear sub-categories were found (Table 3). All participants had knowledge of the nursing code of ethics and there was general agreement about the ethical violations taught through the hidden curriculum in the clinical setting. Under the category of ‘professional guidelines and integrity’, it was found that student nurses were used as adjunct staff, nurses had to face frequent violence in the hospital setting and patients were reluctant to receive treatment from nurses. The category of ‘patient informed consent’ revealed that there was a near-absence of consent taken from patients for most non-surgical medical procedures and an absence of patient consent taking for receiving treatment from student nurses. Under the category of ‘patient rights’, it was found that patient discrimination was practised on the basis of a patient’s socio-demographic status (literacy and socio-economic status) and that nurses practised withdrawal of treatment out of fear for their safety. Lastly, under the category of ‘co-worker coordination for competency, learning and patient safety’, it was found that nurses experienced a non-learning culture, blame-shifting from seniors and that they practised non-reportage of errors. Professional guidelines and integrity Student nurses used as adjunct staff All participants described how student nurses were commonly used as adjunct staff in the hospital setting. Participants stressed that student nurses were not trained or experienced enough for this, and that staff duties restricted students from having the time to study and observe during clinical training. A third-year student nurse described the situation thus: We hardly have time to read our course books or study for exams, there is so much clinical work pressure. Apart from clinical duty, we are even assigned jobs like recording pharmacy expenses during off-duty clinical hours. Table 2 Example of coding data into sub-categories Do you regularly take informed consent from patients? Consent taking Absence of consent-taking Only during surgeries, in writing Absence of consent-taking in writing, except for surgical procedures Not for emergencies, unless surgery required Not for out-patient medical administration Not for in-patient medical administration and all other non-surgical procedures Jafree et al. BMC Medical Ethics (2015) 16:16 Page 5 of 11 Table 3 Categories and sub-categories Categories Professional guidelines and integrity Patient informed consent P … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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