ORIGINAL ETHICAL CHALLENGES IN HOSPITAL DUTY: NEPALESE NURSES’ LIVED EXPERIENCE

Background : Nursing is ethically grounded profession. Nurses work in proximity with patients where they may encounter ethical problems too. However, little is known about the ethical chal lenge of nurses working in Nepal. Therefore, this study was undertaken to explore lived experience with ethical challenges among nurses working in government hospitals of Kathmandu, Nepal. Methods: Qualitative phenomenological design was carried out among nurses working in the five government hospitals of Kathmandu, Nepal. Twelve nurses who had greater than 5 years of work experience in patient care were selected purposively for the study. Data was collected through face to face interview method using in-depth interview guideline. All interviews were recorded in a digital voice recorder. The collected verbatim was transcribed and analyzed thematically. Results: All nurses experienced ethical challenges and perceived stress from those challenging situations. Three main themes derived from the participants’ experiences of ethical challenges were: errors in patient management; justice to the patient; burn out from duty. Nurses found inappropriate service to the patients, limited access of treatment and care to the patients, errors in procedure, autonomy and confidentiality issues, compromised respect and dignity of patients. When nurses found stressful working situation and conflicting legal and moral obligations, they felt burnout that leads to compromised quality of patients care. Conclusions: Nurses experience different ethically challenging situations in their duties. Experi - ences of these challenging situations are stressful and it affects nurses’ ability to deliver quality service. Hence, attention should be given to address ethical challenges of nurses.


INTRODUCTION
Despite having good knowledge and skill regarding ethics, health professionals have chances of encountering with ethical problems. 1 Nurses frequently face ethical challenges 2 however the intensity of their experience may be different. 3,4 Ethical challenges in nurses' working situation cause diminished workplace satisfaction that lead to physical and emotional illness, burnout, and staff turnover, 5 hence ineffective health service. Nurses try to compensate quality care 6 by prioritizing routine work than patient centered care, and do not respond to patients in time. 3,7 In some situations, there may be violation of law. 8,9 This might contribute to decreased quality of nursing care. In Nepal, medicine and technology are advancing in parallel with rising public expectations to have high-quality nursing care. At the same time, unethical behavior of health workers including nurses have frequently been reported in Nepal's National daily newspapers. Therefore, researchers intended to explore Nepalese nurses' lived experience of ethical challenges in their hospital duty.

METHODS
Qualitative phenomenological approach was carried out in hospitals of Nepal Government namely; Bir Hospital, Kanti Children Hospital, Patan Mental Hospital, Teku Hospital and Bhaktapur Hospital. These hospitals were the major government hospitals located in Kathmandu Valley of Nepal. Twelve nurses with more than five years of work experience, involved directly in-patient care, and expressed interest to take part were purposively selected as study sample. Data was collected through face to face interview method using in-depth interview guideline. It consisted of 11 open-ended questions and probing was done as needed. E.g. "I want to know from you why the situation you considered a problem, how you perceived them, can you give me an example?" Digital voice recorder was used to record the interview.
Prior to data collection, ethical clearance and administrative approval were obtained. Nurses meeting the inclusion criteria were identified with the help of hospital administration. Afterwards, nurses were approached individually to ensure their voluntary participation. Then consent was taken and contact details were obtained to set date, time, and place for the interview mutually. Interview was conducted in Nepali language as it was their mother language and was initiated with broad open-ended questions so that nurses could speak freely. To maximize comfort of physical environment and privacy, inter-views were arranged in a quiet room of their hospital and home setting where they felt comfortable. In order to maintain confidentiality, the recorded information had access only to the researcher. Rights of the participants were maintained by respecting the participants' decision to stop interview even in the middle. All the interviews were audio-taped on a digital voice recorder. For subsequent interview, date, time, and place were fixed with the participants. On the day of interview, a reminder call was given to them. When data sufficiency was achieved the interview was ended. Interviews were lasted for 45 to 75 minutes and the recordings were downloaded to a passwordprotected personal computer. The data was collected on 2015.
Data collection and analysis was done side by side. All the recorded information was labeled by giving code number, date, and time. The verbatim was transcribed. Following transcription, each tape recorder was listened at least twice by the researcher to verify accuracy of the transcription and then on at least one other occasion in the context of subsequent interviews with the participants. Initially, the information provided was confirmed with the participants then the data was analyzed thematically. After repeated reading of the transcripts, data was coded and major themes were emerged. During thematic analysis, individual data meaning was stored and restored as codes, and then patterns began to emerge. Patterns were combined and consolidated into common themes.
Ethics approval for this study was granted by the Institutional Review Committee, Institute of Medicine (Ref: 277(6-11-e5/070/071). Administrations approval was obtained from the hospital administrations for the permission of data collection. A rigorous informed consent process was followed: all participants were given verbal and detailed written information about the nature and purpose of the research before their participation; participants were made aware of their right to decline to answer questions and were assured that measures were in place to maintain confidentiality of the information.

RESULTS
The participants were working in medical, surgical, ICU, psychiatric and maternity care units ( Table 1).
The findings regarding nurses' lived experience with ethical challenges are presented under the heading of total 4 themes and 16 subthemes (Table 2).

Errors in Patient Management
All nurses experienced errors in patient care management. In some instances, they experienced malpractices. Following sub-themes describes how the nurses experienced errors in patient management.

Service to Patients:
Participants witnessed patients' suffering due to ignoring care needs of the patients. Sometimes health professionals shouted on patients and their relatives who visited hospital instead of listening to their problems.
Padma shared ……..said to a visitor "go to your bed, there is no problem, you are seeking unnecessary attention". …… the patient had high fever i.e.104 degree Fahrenheit.
Nurses described their working condition as physically and mentally demanding and seriously ill patients were in need of considerable care. But it was impossible to provide care due to insufficient staff.
Shanta reported: couple of days ago, I was alone in duty. A patient developed febrile convulsion, but I could not take care of the patient immediately, because I was looking after another critical patient. By the time I approached him, he was already unconscious ….very distressing event.
Participants felt that patients admitted in academic hos- Oncology PBN pitals were used as a tool for learning. According to them, some procedures were performed in patients solely to increase skill and knowledge of health personnel.
Gyani narrated A mother was in labour pain and was waiting for normal delivery. One ......year PG student rushed in labour room and tried forceps delivery but he was placing the forceps incorrectly. Although the mother had longer waited with labour pain, but there was no indication for the need of instrumental delivery, but it happens with medical students.
Nalina also shared similar experience …. Patient had no indication for lumber puncture, but …student …performed the procedure. I think it is a waste of money for the patient to buy ……..
The working situation became stressful when nurses could not contact duty doctor, or the doctors could not respond to their calls in time for various reasons while patient's condition became critical. In such situations, sometimes nurses tried to alleviate patients' suffering and save their patients' lives by acting upon procedures beyond their duty and authority. Inappropriate facility and health service contributed to patients suffering within health facility and these conditions challenge goal attainment of public health.

Errors in Procedures:
Participants shared that health service is teamwork and it is not possible to be good alone in duty. Health professionals had to face consequences of inappropriate actions of their colleague. Omni narrated: Some of our staffs do not take care of the infused blood and I/V drip of patient. You know, sometimes they transfuse one-pint blood within two hours and sometimes in eight hours. As a rule, one-pint blood is transfused between three to four hours in normal condition.
Nurses were aware about constraints, which sometimes cause it difficult to adhere to the protocols. Nevertheless, not following protocol intentionally was unfair to patients. Position of bed bound patients as required is not done, and pressure area care intravenous line was also missing. These all resulted to increased risk of developing pressure sore, phlebitis and infection. However, nurses took strategies to prevent adverse reactions of medications when they were aware of a mistake.
Dik stated: …..I injected injection diclofenac instead of injection ranitidine through the intravenous line of the patient. Suddenly I became conscious about my mistake and called the consultant doctor……for the necessary action.

Justice to the Patients
How the participants perceived justice in health facility to their patients is described under following sub-themes.
Autonomy and Confidentiality Issues: Participants experienced occasions where patients' rights to know their own disease condition and treatment plan, right to choose treatment options and rights to refuse treatment were neglected by health care providers. Protocol of informed consent was not followed. It was also shared that informed consent was only a formality of taking signature from patients. Participants shared that patient's confidentiality was tried to respect but not possible to maintain privacy in special wards/ units. But in general ward, where patients share common room, it was not possible to maintain confidentiality and privacy of patients. time they do not respected patients' dignity it happens due to work overload, argument in some issues with patients and visitors etc.

Padma reported: …… talk politely to patients admitted in paying ward and rudely to patients admitted in general ward. ….admitted in paying wards and they need special care
Different opinion was given by Bin: There is no discrimination of care on the basis of socio-economic condition, position, and power of patients. However, more attention is given to the VIPs and relatives of health professionals. I think it is natural.
Verbal abuse is also observed in the clinical setting. Few short tempered health personnel verbally abused innocent patients whereas some health workers could not control their anger and misbehaved with their patient's family.

San reported: We do not write name and diagnosis in information board of ward with patients having serology positive.
Gyan shared: Parents request us not to disclose their children's ….. diagnosis to others. Unfortunately, I feel that in this general ward, confidentiality cannot be maintained, because many people will be around ……… Perception of confidentiality was different for the nurses working in infectious disease hospital. They faced ethical challenges especially when patient diagnosed with HIV/ AIDS requested them not to inform his diagnosis to his wife.

Tim: ……patient requested to keep his diagnosis from his wife………I was confused …….what is the wife's right?
Access to Treatment and Care: Participants perceived that treatment and care to the patients is not timely accessible even if they arrived in hospital.it is due to inadequate nursepatient ratio. Work Overload: Participants shared that they had high workload that increased pressure in caring situation. So despite consistent efforts, most of the time patients lacked basic care. In addition, they reported that they had given other tasks such as keeping records, and managing equipment/supplies, need to engage more in written work than caring to their patients. When nurses had to work with high level of stress, their behavior could not be professional with the patients, hence decreased quality of care.
San shared: In my night duty at 7 PM I took handover, a patient was gasping. I made a call to on-duty doctor multiple times, but there was no response. I did my best effort to save the patient's life, but at 8pm, the patient passed away. You know by then the patient's family became angry with me and blamed me that I could not bring the duty doctor……. What can I do?
Conflicting Legal and Moral Obligations: Nurses were duty bound in their respective working wards/units as a front line care provider. When their moral obligations clashed with their authority, the situations became stressful and disappointing to them. However, in some instances nurses forgot their authority and took risk to themselves from their unauthorized job only for benefit of patients. Sometimes situations forced health personnel to act against their ethics. Despite great stress and risk, they took some actions to save the life of patients.
Tim stated: It was three years ago in a ….hospital of a remote area. …….A mother with obstructed labor. Health facility with caesarian delivery was very far to refer patient and we had not facility. We health personnel took bold decision to and did operation in labor bed. I gave spinal anesthesia although I was not authorized………….
Participant felt that nursing care was not being respected which decreased their self-esteem and burn out in duty. Feeling less powerful, being not respected, having no authority to influence health care system were sources of frustration and burn out from duty. Quality of care was compromised by not listening to patients' problems, not maintaining personal hygiene, and not recording temperature of patient. Adequate attention to the needs of patients was not given 8 and it was difficult to maintain quality of nursing care. 12,19 It was shared that patients had to wait in a long queue; restrooms and water supply to patients were inadequate. Supporting this, Chinese nurses showed their concern regarding prolonged treatment waiting time and discharge process of patient in their hospitals. 20 Sometimes flow rate of transfused blood/ intravenous fluid, need of bladder and bowel movement, positions of bed patients were not considered. Reported in literature, "a patient comes to hospital with a single problem and leaves with dozens of bed sores and infection". 17 Sometimes patients were used only as a learning tool especially in academic hospital and some procedures were performed only to enhance knowledge and skill of health professionals. Supporting this, literature showed that patients were treated as a tool of experiments. 18,21,22 Patients' right to know their disease condition and treatment plan, right to choose treatment options, right to refuse treatment was neglected and the consent became only a formality. Literature showed that autonomy and confidentiality of the patient's information was not respected. 3,8,21,23 Finding showed patients' dignity was not respected; they were behaved rudely, shouted upon and verbally abused. Supportive study suggested that institutionalized client were abused physically and psychologically, were humiliated by shouting, swearing, verbal offending, and slapping. Women were more frequently abused than male 24 and in some instances, abuse on minor were not reported. 25 In this study, nurses felt sandwich between patient and doctors when patients' condition turned serious and duty doctor could not answer to the nurses' call in time and they had to handle situation without authority. Similarly, a nurse of Iran expressed that 'she attempted five times to have resident see the patient, but he didn't come' 17 and nurses were forced to act contrary to their own opinion, superior knowledge, and prudent medical reasoning in many situations. 20 With limited very basic supplies such as bed sheet, blanket, patient's gown, intravenous needle, syringe, nursing care would be challenging. Because of this, some health professionals would not touch patient due to perceived risk to acquiring infection to themselves. Various studies supported that scarce human and material resources in health care setting made difficult to ensure quality nursing care. 12,16,17,19,26 Since only two nurses usually had to look after for 30 to 40 patients, nurses in this study believed that actual nursing care was missing.
In such situation they were worried and concerned that it becomes habit of some nurses to avoid nursing procedures even if they had free time to care their patients. Another study showed that a nurse had too many patients and had no time to care for 20 so they could not maintain proper attitude towards patients and exhibited incorrect behavior. 25,27 In this study, nurses were not assigned to duty according to education, expertise and area of interest. They were not promoted timely, felt disrespected, neglected. That caused decreased self-esteem, demoralized, less motivation to work, feeling burn out thus increased errors in caring situation. Supported literatures showed nurses had mandatory overtime, rigid division of daily work, and work scheduling regardless of the nurses' experiences and preferences 28 and felt underappreciated and respected as professionals 16,28 that increased frustration. 29 Nurses found gap between nursing education and practice, they could not implement what was learnt in their class. Similar to this finding, nursing students in their clinical posting found gap between theory learnt at college and the moral course of action in practice. 30 Nurses found their job description unclear and not specific to practical situation. They perceived high responsibility on duty without authority that created role confusion. Ambiguous nursing job description caused nurses to face ambiguous nursing role and confusion in their duty. 17

CONCLUSION
It can be concluded that nurses perceive ethically challenged when they could not accomplish their professional obligations in their work with what they believed they must do and when they have to witness these situations. All nurses experience ethical challenges in their duty and experience of such situation is painful. Work overload and stressful working situations hinders delivery of quality care. Ethical challenges in nurses' duty need to be recognized and has to be supported through continuous professional development program.

ACKNOWLEDGEMENT
Authors would like to thank Prof. Sarala Shrestha, and Prof. Sarala Joshi for their guidance to complete this study as well as study participants.