Diversity and Equality in Health and Care (2016) 13(4): 302-308 2016 Insight Medical Publishing Group

Research Paper
Ethical Issues Faced by Nurses during Nursing
Research Article Open Access

Practice in District Layyah, Pakistan

Saima Hamid*, Rabia Kanwal, Mohammad Hamza Bajwa, Sadaf Khalid*, Henna Mubarak
Health Services Academy, Ministry of National Health Services Regulation and Coordination, Government of Pakistan, Pakistan

ABSTRACT
Different Ethical issues encountered in daily nursing practice care, and deficiency in amenities, patient’s expectations and
draw little consideration but can produce a stressful working cultural barriers. In addition, poor teamwork, inequitable
environment for the nurses. This qualitative study was designed workload, and poor value of nursing profession added to the
to explore the ethical issues confronted by nurses in their practice challenges at the workplace.
and to identify gaps using the Pakistan Nursing Council’s
To our knowledge, this is the first study that has specifically
(PNC) Ethical code framework. The study was conducted in
addressed ethical issues in the nursing practice of graduate
six government hospitals of district Layyah, Pakistan. In all
nurses in District Layyah. Nurses were aware about their
six focal group discussions (FGDs) with 6-8 participants in
ethical responsibilities but were unable to practice them
each were conducted. Content analysis identified three themes,
because of the multiple constraints. The findings of this study
namely; compromised professional accountability to patient,
cannot be generalized to other nurses in Pakistan, but the
uncooperative behaviour of peers and poor image of a nurse
richness of the data suggests explanations for the difficulties
in society. Nurses reported that they were unable to act on the
which many nurses face in public sector health facilities while
PNC code fully because of many constraints in clinical practice.
performing their duties and adhering to ethical principles in
The reasons identified by the respondents were conflict in
clinical practice.
hospital admission procedures of patients, non-availability of
medicines, conflict in informed and voluntary consent, false Keywords: Nursing ethics; Nursing moral and ethical aspects;
accusations by patients, care imbalance, compromised nursing Ethics; Ethical analysis; Patient relations

Abbreviations: address the issues resulted in distress, poor professional care,

stress, conflict, compromised nursing care and violation of the
FGDs: Focus Group Discussions; PNC: Pakistan PNC code.
Nursing Council; DHQ: District Headquarters; THQ: Tehsil
Headquarters; PI: Principal Investigator; BHU: Basic Health Abstract
Unit; MPA: Member Provincial Assembly; LHV: Lady Health
Visitor; EDO: Executive District Officer; ICU: Intensive Care Different Ethical issues encountered in daily nursing
Unit; MNCH: Maternal New-born and Child Health practice draw little consideration but can produce a stressful
working environment for the nurses. This qualitative study
Key Points: was designed to explore the ethical issues confronted by
nurses in their practice and to identify gaps using the Pakistan
Health professionals face ethical challenges in their daily Nursing Council’s (PNC) Ethical code framework. The study
practice, especially the nurses, the largest workforce in health. was conducted in six government hospitals of district Layyah,
They are required to provide autonomous and collaborative care Pakistan. In all six focal group discussions (FGDs) with 6-8
to individuals of all ages, while adhering to the ethical principles. participants in each were conducted. Content analysis identified
The situation becomes particularly complex for nurses who three themes, namely; compromised professional accountability
work under severe resource constraints. Ethical issues in the to patient, uncooperative behaviour of peers and poor image of
nursing practice attract little attention, resulting in the creation a nurse in society. Nurses reported that they were unable to act
of moral distress, poor professional care, unproductivity and on the PNC code fully because of many constraints in clinical
conflict. practice. The reasons identified by the respondents were conflict
This study has described ethical issues encountered by in hospital admission procedures of patients, non-availability
of medicines, conflict in informed and voluntary consent,
Pakistani nurses of one district under three themes: compromised
false accusations by patients, care imbalance, compromised
professional accountability to patient, uncooperative behaviour
nursing care, and deficiency in amenities, patient’s expectations
of peers and poor image of a nurse in society. Nurses despite
and cultural barriers. In addition, poor teamwork, inequitable
being well aware of the ethical codes, were not able to practice
workload, and poor value of nursing profession added to the
it fully because of constraints. The findings showed that nurses
challenges at the workplace.
were not the decision makers in many situations; they were
subordinates in their working environment. The inadequate To our knowledge, this is the first study that has specifically
equipment and instruments, shortage of staff, stereotypes of addressed ethical issues in the nursing practice of graduate
the nursing profession, poor management and poor support to nurses in District Layyah. Nurses were aware about their ethical
303 Saima Hamid

responsibilities but were unable to practice them because of Participants themselves decided the venue and time of the
the multiple constraints. The findings of this study cannot be FGDs at their convenience. Each FGD was hence held at the
generalized to other nurses in Pakistan, but the richness of proposed venue i.e. the office of the Head Nurse after duty
the data suggests explanations for the difficulties which many hours. The co-author, a registered nurse and resident of Layyah,
nurses face in public sector health facilities while performing with a deep understanding of the local culture moderated the
their duties and adhering to ethical principles in clinical practice. FGDs using a FGD guide. Probing was done where needed.
Another local nurse who was trained to take notes during the
Introduction FGDs took notes. Each FGD commenced with some general
queries from the respondents about their background. This
An ethical issue can arise in any healthcare situation where
helped in developing a rapport between the moderator and the
profound moral questions of “right” or “wrong” underlie
respondents and generated a fair amount of confidence among
professional decision-making and the care of patients [1,2].
them. The participants shared different issues and experiences
Health professionals especially nurses face ethical challenges in
concerning clinical practices at the hospital. On average, a
their daily practice as they are required to provide autonomous
FGD lasted for one hour. Notes were expanded within two days
and collaborative care to individuals of all ages, while adhering
of conducting the FGDs. FGDs were conducted in the native
to the ethical principles [3,4]. The situation becomes particularly
language.
complex for nurses who work under severe resource constraints
[5-7]. Additionally due to the demographic, social, scientific The individual team members read the transcripts several
and technological aspects of health care, there has been an times to familiarize themselves with the data. The transcribed
increase in complexity of ethical issues faced in the health care data was analyzed using content analysis. Codes were
service delivery [5]. Ethical issues in the nursing practice attract categorized and themes identified.
little attention, resulting in the creation of moral distress, poor
The Ethical Review Committee of Health Services Academy,
professional care, unproductivity and conflict.
Islamabad, approved the study. Written approval was taken
The Pakistan Nursing Council (PNC) adopted its own from the Department of Health, Punjab to conduct the study.
professional code of ethics in 1999 for registered nurses [8]. The Informed consent was taken from all participants.
current study was undertaken to identify adherence of nurses to
the Pakistan Code of Professional Ethics, with an aim to improve Results
patient care. It also explores the ethical issues faced by nurses
The age of the respondents ranged from 23-30 years, with
in their clinical setting and how they work through difficult
work experience ranging from 3-7 years. All participants were
cases. The study draws on thematic areas that are intrinsic to
local residents and permanent employees of the Department
any clinical encounter, namely: Medical Indications, Patient
of Health, Government of Punjab. Table 1 shows the analysis
Preferences, Quality of Life, Contextual Features, Teamwork
process moving from the themes to categories. The results were
and value of nursing profession. These issues were reviewed in
reported under the three themes (Table 1).
light of the professional ethical code prescribed by the Pakistan
Nursing Council, inclusive of professional accountability with Compromised professional accountability to patients:
reference to the clients, colleagues and one self.
Accountability is an essential component of professional
Methodology nursing practice and patient safety [11]. Nurses shared that their
duty to provide patient care was compromised due to managerial
A qualitative study using content analysis was conducted issues as elaborated in the following sub-sections.
[9] in District Layyah, Punjab, Pakistan. The district had one
District Headquarter (DHQ) Hospital and 5 Tehsil Headquarter Lapses in medical care: Many gaps in patient care were
(THQ) Hospitals in the public sector. The total numbers of identified. Nurses had no authority to admit a patient. However,
nurses working in these hospitals were 103 (63 from DHQ in reality, they were doing so in the interest of the patient because
and 8/THQ). The five THQ hospitals and DHQ hospital with the concerned doctor, on call, was not available during evening
240 beds capacity were providing emergency, medical, general and night shifts, especially in the obstetrics and gynaecology
and minor surgery, obstetrics and gynaecology, homeopathic department.
and diagnostics services. Common health problems of patients
seen at the THQ level included anaemia, common infections, “Patient comes with labour pains and fully dilated. We
diarrhoea, and accidental injuries. However, in case of admit the patient and conduct a normal delivery so as to save
complications, patients were referred to the DHQ hospital. the mother and child. If we do not do so, such a patient would
need to travel further to another facility that may have a higher
Using purposive sampling technique [10] nurses with a risk for her.”
work experience of at least two years in the DHQ and THQ
hospitals were included in the study whereas nursing students However, when patients did develop complications, nurses
and managers who were not involved in direct patient care were had to face all the consequences. None of the hospitals took any
excluded. Nurses willing to participate in the study were invited action when this issue was brought to the notice of the hospital
for Focal Group Discussions. In all forty-eight nurses participated managers. Another ethical issue identified by respondents
in the study, with 6 to 8 nurses participating in each FGD. was the non-availability of medicines and equipment at THQ
 Ethical Issues Faced by Nurses during Nursing Practice in District Layyah, Pakistan 304

Table 1: Analysis process – Moving from categories to themes.

Themes Sub-Themes Categories

• Conflict in hospital admission procedure of

1. Compromised Professional patients conflict
a. Lapses in Medical
accountability to patients • Non availability of medicine

• Conflict in Informed and voluntary consent

b. Patient preferences vs. Nursing • False accusation by patients
Care Requirements • Influential patients and patient care
imbalance
c. Quality of care and • Compromised nursing care
responsiveness of health system Deficiencies in Amenities
d. Barriers to Ethical Clinical • Patients’ expectations from health care providers
Practice in local context • Cultural Barriers
a. Poor team work
2. Uncooperative behaviour of peers • Additional tasks due to the national programs
b. Inequitable workload
• Image of nursing profession
a. Poor value of the Nursing
3.Poor image of a nurse in society • Autonomy in nursing profession
profession
• Professional development

hospitals, due to which the staff nurses were unable to provide Another respondent voiced concern on the way the written
full nursing care. When patients/attendants were explained consent was phrased:
about lack of hospital resources and requirement of getting
“The statement we’ve been instructed to use in obtaining
medicine from private stores, nurses faced undue criticism, and
informed consent is deficient. It states ‘I am willing for
often-abusive behaviour from the patients’ attendants.
treatment and I (the patient) am responsible for any benefit and
“Patient and attendant perception is that the government’s risk (the treatment entails). I will not object in case of risk.’ This
medicine supply has been sold by nurses and other health care statement is not in favour of the patient’s interests.”
providers. The reality is that these medicines are not available
The consent statement was a standard document of hospital.
and when we request patients to buy them and explain to them
When any complication resulted during the treatment, patients
the reasons, they do not take us seriously and rebuke us.”
blamed nurses and other health care providers.
Patient preferences vs. nursing care requirements: The
respondents reported disconnect between patients’ preferences The respondents reported that they treated their patients with
and nursing obligations. They shared that nurses as a policy dignity and respected patients’ confidentiality. However, they
were required to obtain informed consent of each patient prior would not expect the same from patients. Narrating an incident,
to treatment. Most of the male patients gave consent of their one of the respondents explained an unusual delivery case in
own accord. For incapacitated patients, a male surrogate took which nurses were blamed for no reason.
decisions. The problem however, arose while treating female “Patient came in labour and was admitted through the
patients. One respondent in an FGD explained a situation she proper channel in a THQ hospital. A traditional birth attendant
faced: had handled her previously. The ultrasonography report showed
“A female patient was willing for a bilateral tubal ligation an intra-uterine death of foetus. Patient was fully dilated and
and came with her mother who consented for the procedure she delivered the dead foetus. Her attendants refused to accept
as well. Her husband turned up after an hour in the operating the dead foetus and ran away with the patient. When this
room, and started shouting at the staff nurses, asking us why we was brought to the notice of the Manager and probed further
took consent from his wife. He said that he was responsible for with other staff, it came to our notice that it was an illegal
her and his wife had no such right to decide on her own. As a pregnancy. On orders from the Manager the dead foetus was
result of this disturbance, management has instructed that no buried. Unfortunately, media came to know about it and it then
future ligations will take place without the consent of a male portrayed a notion that the nurses had killed the infant after
attendant”. birth. As a consequence, an Inquiry Committee was asked to
investigate the matter and the duty nurses were penalized for
Nurses started dealing with such cases as per the verbal no real reason.”
instruction of the management i.e. if a female patient came
without a male attendant; they would call her husband, brother Another problem nurses encountered while dealing with
or father and take a written consent prior to tubal ligation. patients with political or influential background was undue
This caused delay in treatment of female patients who showed pressure to provide special care to them at the expense of care
aggression towards nurses for prying into their personal matters. to other patients. Nurses therefore could not work according to
305 Saima Hamid

ethical principle of ‘justice’ i.e. providing fair, equitable and Respondents expressed that some patients came with a certain
appropriate treatment mind-set and had certain expectations from the provider such
as getting an injection or intravenous (IV) fluids as treatment
Quality of care and responsiveness of health system:
for their ailments. Doctors would consider the preference of
Nurses were unable to provide quality care given the shortage
patients and switch oral medicine to injectable ones. Seeing this
of staff, lack of amenities and absence of clear hospital policy
pattern, many nurses too followed suit and obliged patients on
for patient’s attendants
their requests without consulting doctors.
“We cannot properly explain to the patient about their
The patients’ ethnic backgrounds largely determined
medical needs, medicines and inquire about their vitals as
expectations from the healthcare providers. An issue commonly
intake output record. There are many attendants around the
faced by the nurses was that the labour room patients did not
patient and it seems inappropriate to ask such questions. This
agree to be delivered by unmarried nurses, or if the patient
leads to delay in even recording patients’ vitals.”
was a “Pathan” (an ethnic group) when an older nurse was not
Hospital management did not take action to rectify these present, conflict arose, as narrated by one nurse:
problems. The patients’ attendants would get annoyed over
“These patients say that it is not good in our culture to be
issues and end up complaining about the nurses to senior
examined by an unmarried girl. ‘Where is your senior nurse?’
authorities and to the local Members of the Provincial Assembly
they’d ask. In such cases we have to call married older staff
(MPA). The respondents shared that they mostly were penalized
nurses for assisting us in delivering the baby even though we
and received official notices or warning letters.
could easily have managed on our own independently.”
They also shared that the THQ hospital was not fully
Such patients had more faith in traditional birth attendants
equipped to provide satisfactory facilities so most patients would
“Dais” as compared to trained nurses. Moreover, some younger
be admitted but never spend the night before the surgery in the
patients were embarrassed to be admitted in wards, as their
hospital. The patients would walk-in in the morning causing
privacy would be compromised. One example quoted was
a delay in their pre-operative preparations. When at times the
of a patient belonging to a prestigious family and observing
surgeon would ask the patient as to why they had not come in
‘purdah’; such a patient was not happy on being admitted in
earlier they would blame the nurses
the general ward. Conflicts arose in such cases when private
“Dr Sahib we had come at Fajr (after dawn-early morning) room was not available in the hospitals. No screens would be
time, only the nurse was not in the ward then” available in the ward to satisfy the patient by providing partial
privacy. The nurses understood that ethically they were bound
Nurses claimed that these patients had never showed up at
to respect patients’ religious and cultural beliefs, but practically
the nursing station in the ward. Similarly, the nurses complained
they could offer no solutions to them.
that the patients left the hospital when they were stable but would
remain admitted in the hospital. They would get the medicines Beliefs of the patients also hindered the nurses’ patient
for a few days and again come back after one or two days. care practices. When the IV line was to be maintained for the
During that time, dosage of medicines could not be regulated. children (with severe diarrhoea), the parents/guardians would
refuse the intravenous line to be passed on the veins on the head
“One time dose of medicine does not treat acute or chronic
saying that the ‘Daam’/prayers have been said on the head of
health problems, patients need regular medicine for healthy life.
the child and requested they find a vein elsewhere, which in
And they just leave the hospitals…”
most cases was very difficult.
Some patients would leave against medical advice either to
go home or seek advice from unskilled personnel or a general Uncooperative behaviour of peers
practitioner. Many patients attributed their illness to magic and Various issues identified by the respondents with respect to
would seek guidance from the spiritual leaders, getting amulets their peers are detailed hereunder:
from them (Dum, Ghanda, Taweez). Such misconceptions
greatly compromised their treatment. Poor team work: Teamwork was identified as a key
element for ethical practice and providing quality care. The
Nurses also reported that at other times due to shortage of respondents shared that they had to work with fewer number
supplies and equipment service delivery was almost impossible. of staff due to sanctioned educational leaves, delay in hiring
Examples given by them included availability of only one set against vacant posts and absenteeism. As a result, the pressure
of safe delivery kit at times; simple equipment as BP apparatus of work increased day by day on the remaining few.
was not fixed due to budget constraints for prolonged periods,
which affected patient care. The response of theadministration All respondents complained of the non-cooperative support
on raising concern would suggest inform them of the budgetary staff (ward boy, gatekeeper, sanitary worker, sweeper and Aya,
constraints: etc.). As the support staff did not attend to their assigned work,
it led to considerable increase in nurses’ workload.
“Staff there is no budget for this year – if it was so all the
supplies would be available.” When dealing with emergency cases the nurses needed
additional pairs of hands, but could not count on the support
Barriers to ethical clinical practice in local context: staff for help.
 Ethical Issues Faced by Nurses during Nursing Practice in District Layyah, Pakistan 306

“If we give them (support staff) work to do, they still won’t us thus. They openly state that you don’t know about medicine
finish it and then we will have to complete it. Then what it is the and other health interventions --- we will just obey the order
point (of the support staff) when we handle all the written work of doctors. They neither believe in our abilities as a health
and any other problems patients have. And if there is a problem, professional nor do they trust us as other health providers.
then we will be held responsible.” There is no respect in our society for nurses”
The respondents stated that according to PNC code nurses “The government has labelled us as BPS-16 level officers
were considered responsible to carry out the orders advised but in reality we are not facilitated as any other officer in the
by doctors but the reality was different. Some doctors would Health Department.”
leave signed blank prescriptions slips with the dispenser so that
patients coming in their absence would get the medicines. When Autonomous decision-making was considered an important
nurses questioned the advice of some medicines, the patients aspect of nursing by the respondents but it was seen to be
would defend the doctors and dispensers. Dealing with such lacking in their practice.
issues led to conflict between co-workers. “We are not able to inform patients about what treatment
“But conflict arises if any medicine which is not necessary or intervention is best. This is because in our training we have
for patient is prescribed and if we explain the same to patient… been told to follow doctors’ orders. When doctors are not
they do not trust us and they think that the dispenser is a doctor present on duty, we have to manage patients on their behalf.
and is right. Extra time is taken in clearing such issues as we When a patient comes in emergency, we have no option but to
have to go find a doctor, get his advice on it and then have the wait for the doctor. Sometimes we act on our own and there is
correction made on the medicine slip.” always a conflict concerning whether we should intervene or
not. This results in patients being mismanaged.”
Inequitable workload: Many additional duties were given
to nurses, which added to their workload. Many activities There were only two staff nurses present in the morning shift
under the public health programs such as MNCH (Maternal in most of the hospitals. The doctors posted would attend to the
Neonatal Child Health), Dengue fever control, Polio eradication outdoor patients all day and at times would not have time to take
programs were conducted in the wards. This resulted in delayed round for the indoor patients. As per the PNC ethics code, the
patients’ admissions and patient care. Moreover, the support respondents shared that they were to follow the advice of doctors’
staffs was assigned additional duties in public health programs standing orders. However, in practice because of these constraints,
that resulted in further compromised patient care patients were neglected, ignored and poorly managed.
“We have to suffer because patient load is high and most of The nurses felt that they needed to be trained further and
the support staff has been hired for public health programs. We craved for support for higher education but the system did not
then provide clinical care without any assistance. The public support such career growth. They were not satisfied with their
health program activities create burden on clinical tasks due to training and education as a nursing graduate.
prolonged absence of the workers…... this amounts to at least
“We cannot receive further education because of many
one week every month.”
reasons as lack of support for study leave, or working at bigger
Poor Image of a nurse in society facility on deputation, no time given during routine work and
distant learning opportunities for nursing education are not
The respondents with reference to professional accountability
recognized by Pakistan Nursing Council.”
to them referred to issue of poor value of nursing profession.
One respondent shared:
Poor value of nursing profession: The respondents
shared that they had invested in their career and training which “Our education and further training is not a priority for our
demanded respect from the medical professionals. However, seniors due to shortage of nursing staff”.
many a times it was very disheartening to receive derogatory “We want to take classes after duty hours but we are so tired
statements from patients and at times even colleagues.
after this hectic job that it is not possible. When we go home,
“Even our colleagues at times use abusive language. They family commitments do not allow us to pursue higher education
sling mud on our character. Mostly this is done by male peers/ in our own time. We are always ready to give attention to all
colleagues.” patients as well as to families. Also we have no say on further
education after marriage.”
The respondents expressed that the perception of the nursing
profession was stereotypical; patients did not trust nurses to be The nurses felt that facilitation of management by ensuring
competent as they were less educated than doctors and mostly presence of adequate staff would help them realize their
came from poor families. They felt that they were not valued by aspirations for higher education.
the society:
Almost all respondents pointed out the need to make their
“When the patients see us in our white uniforms, they create workplace safe. Security was a major issue for them especially
an image about us that we are subordinate and belong to poor at night. Security guards or ward boys posted at the entry points
uneducated families and that is the reason we have chosen this were not at their appointed places at all times. Nurses continued
profession. Even less privileged and uneducated patients see to work full time under these circumstances.
307 Saima Hamid

“It’s never happened that nurses leave the ward because we The most frequently voiced issue was the inequitable
can’t leave the patients alone. We are alone in the evenings and workload. There was high turnover of patients and less number
during night duty with no other staff present. We are doing our of nurses available. These findings are similar to those identified
work in the absence of any security measures ensured by the by Hussain and Buchan [16,17]. Another contributing factor
administration. If we refuse to perform duty at night in such identified in the current study was the pressure exerted on nurses
conditions, we are given threats by the Medical Superintendent by influential patients to attend to their needs on priority, which
who threatens to report us to the higher authorities and to have further hindered equitable patient care.
us transferred to another facility. There is no one who tries
Due to overburdened hospital staff, non-availability of
to understand the actual reasons of refusal to work in these
private rooms and screens the nurses also faced issues of breach
circumstances.”
of confidentiality and privacy. Even though nurses were aware
of the ethical principles, they could not do much to improve care
Discussion
for the patients.
The current study brought out situations, which nurses
Majority of nurses were not aware of their job description
encountered during clinical practice in resource constraint
and became entangled in departmental procedures, which
settings and identified areas for future strategies to improve
left them less time for their primary duty of providing care to
working conditions for nurses. The findings of the study were
consistent with other studies, showing that nurses face ethical patients. To ensure patient safety and quality care provision
issues at work routinely, which contribute to their distress [6,12]. roles and responsibilities of hospital staff and accountability
systems need to be defined and implemented.
Nurses of the district Layyah were well aware of the PNC
code of ethics. Although the ethical issues brought out in the The main strength of this study was the rich data collected
study warranted action but hospital management did not consider using a qualitative approach from nurses working in secondary
them a priority. The most common issues faced by the nurses level health care facilities of the government. FGDs proved to
were regarding admission procedure, compromised nursing care, be a valuable method that allowed the participants to freely
dissatisfaction of patients due to inadequate equipment, deficient carry out lively discussions and bring out issues pertaining to
supply of medicines, uncooperative support staff, stereotypes their clinical practice. Since the moderator was a nurse too, a
about nursing profession, professional incompetence of nurses, friendly environment enabled participants to openly voice their
security issues and undue political interference in their work. thoughts and feelings about ethical issues faced by them.
Jafree et al. [6] identified similar ethical violations in practice The findings of this study were based on a limited number of
in two tertiary care hospitals in Lahore, Pakistan. Nurses were focus group discussions. They can thus not be generalized, but
facing problems in providing care due to reluctance of patients it is plausible to think that what the participants shared is also
to receive treatment from them. Patients were discriminated valid for other nurses from similar backgrounds and in similar
based on their socio-economic status. settings [18].
In this study nurses underscored the problems encountered Certain limitations had been identified. The authors solely
during hospital admissions of patients with obstetrical relied on the participant’s own knowledge, perception, and
emergency when doctors were not available. This finding is experiences about ethical issues. The perspective of other
consistent with a facility based study conducted by Shamshad et health care providers, administrators and patients is missing.
al. in Pakistan which indicated that most of the maternal deaths This study was conducted in a relatively underdeveloped
in hospital admitted patient were preventable and could be district of Pakistan. There is a need to conduct empirical
prevented by provision of skilled care and timely management studies in developed districts and with larger samples by using
of complications [13]. Report of American Association of both qualitative and quantitative methodologies to assess the
Retired Person Public Policy Institute [14], recognized similar magnitude of the problem and diversity of ethical issues faced
barriers in another setting and allowed Advanced Practice by nurses.
Registered Nurse Practitioners (APRNs) hospital privileges
which resulted in benefits to consumers and improved the Conclusion
health care delivery system especially for Medicare patients.
Such measures potentially decreased costs and expedited This study identified various ethical issues faced by nurses in
treatment by eliminating the need for physician to sign-off on their clinical practice. To our knowledge, this was the first study
every service provided. This improved the quality of services that specifically addressed the ethical issues in nursing practice
as the physicians then could focus on specialized services. of graduate nurses in District Layyah. The study also clearly
Based on the same principle Ontario Hospital Association in indicated that nurses were aware about their ethical responsibilities
its guidelines [15], enabled the registered nurse practitioners but were often unable to practice them. The findings showed that
to have privileges to admit and discharge patient. Given the nurses were not the decision makers in many situations; they
shortage of skilled health care professionals in Pakistan, similar were subordinates in their working environment. The inadequate
privileges to registered nursing professionals may help improve equipment and instruments, shortage of staff, stereotypes of
quality of healthcare services. Jafree et al. [6] have reported the nursing profession, poor management and poor support to
problems due to patient preferences and informed consent from address the issues resulted in distress, poor professional care,
female patients as identified in the current study. stress, conflict, compromised nursing care and patient safety.
 Ethical Issues Faced by Nurses during Nursing Practice in District Layyah, Pakistan 308

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Submitted: June 30, 2016; Accepted: July 19, 2016; Published: July 26, 2016