NURSE ATTITUDES IN RELATION TO HEALTH CARE ETHICS AND LEGAL REGULATIONS FOR NURSING

The nursing environment is full of situations under ethical and legal constraints. Therefore this study focused on the knowledge, position and attitudes of nurses in relation to healthcare ethics and nursing legal regulations. We conducted a pretest and posttest study using a specific questionnaire administered to a convenience sample of nurses who worked in a healthcare system in Principado de Asturias, a northern state of Spain and were enrolled in a continuing nursing education program about ethical and legal aspects in the nursing profession. The main findings suggest that nurses are very concerned about situations that create ethical and legal conflicts but do not feel sufficiently trained. In general, they demonstrated sufficient knowledge to address the most frequent ethical and moral situations of nursing work, and the training received during a postgraduate course in ethics and legislation provided them with greater knowledge and tools to solve the dilemmas In conclusion, although the nurses have university-level education about professional deontology, bioethics and nursing legislation, they require periodic continuing education.


Background
Ethics is taking an increasingly prominent place in nursing education (1)(2)(3).It has been generally accepted that nurses are confronted with unique ethical problems that arise from their participation in patient care (4).Ethical knowledge helps professionals justify what is or is not correct and appropriate professional conduct.It also promotes respect for and promotion of the principles of bioethics and the rights of health services users, which are crucial elements in humanized care (5).Insufficient exposure to and/or inadequate knowledge of ethics in nursing education programs has been cited as contributing to poor socialization of nurses to their ethical responsibilities and a lack of commitment to ethics as a professional priority (6).A legal disaster can occur every time they walk into a patient care area.Many staff nurses still have minimal training in the legal aspects of healthcare regarding issues such as patient confidentiality and informed consent (7).Fortunately, when a nursing curriculum sufficiently addresses ethics and legal aspects and provides nurses with the tools to help them reflect critically on what nursing care implies, nursing education can contribute to the development of nurses as skilled companions (8).Nurses have a clear and undisputed legal, professional and ethical duty to provide their patients with competent and safe care (9).Healthcare professionals have always been encouraged to update their knowledge and maintain clinical competence.For that reason, continuing medical education is essential to the profession of nursing.The rapid changes currently taking place within healthcare systems have increased the pressure from direct care providers, professional bodies and the general public for nurses to participate in continuing education programs.Despite a growing body of empirical research on this topic, the effectiveness and impact of continuing education remains underexplored (10).It is important not only to investigate the prior knowledge of nurses about ethical and legal aspects, but also the impact of postgraduate training on these issues.
The purpose of this article is to identify the knowledge, position and attitudes of nurses in relation to healthcare ethics and nursing legal regulations and secondarily to evaluate the impact of an educational program about ethical and legal aspects in nursing profession.

Design and setting
The study was a pretest/posttest study using a descriptive survey administered to a convenience sample of nurses who worked in hospitals and primary care in Principado de Asturias, a northern state of Spain and enrolled in a continuing nursing education program about ethical and legal aspects in the nursing profession.This 5-day course was held in the continuing education program of The Official and Professional College of Nurses at Principado de Asturias-Spain and certified by a national educational agency.The course consisted of a number of theoretical sessions about legal principles, regulations and ethical decisionmaking in nursing followed by a practical session with real cases.

Participants
Subjects were drawn from nursing staffs of different hospitals and primary care health services and who members of the Official and Professional College of Nurses at Principado de Asturias-Spain, the institution through which nurses are registered in this state.The study took place from July 1, 2011, to February 29, 2012.
Nurses were included in they were one of the 50 participating nurses and had worked for a minimum of one year in adult or pediatric services in a public or private healthcare system.Nurses were invited to participate in this research study by voluntarily completing the survey prior to beginning the course and at the end of the course.Nurses were excluded if they were retired or off duty due to illness for more than one year at the time of the survey of if they did not complete both surveys.The final sample using the inclusion/exclusion criteria was 43 nurses.

Data collection tools
The survey instrument piloted and validated for health professionals (11) consisted of a 28 self-administered, structured questions about with 95% confidence intervals (CI).

Ethical considerations
Ethical approval for the study was obtained from the Ethical Committee of Official and Professional College of Nurses at Principado de Asturias.
Participants were asked to read/discuss the consent form prior to completing the surveys.Confidentiality by the investigator was assured, and all identifiers were removed from questionnaires.Data was kept secure, and pseudonyms were used for pretest/posttest questionnaire identification.

Characteristics of the sample
The sample consisted of 43 nurses, mainly female (84%).The mean age of the nurse respondents was 34.8 years (SD 1.14), and the mean total years of employment in nursing was 13.4 (SD 1.91).Primary areas of practice were hospital care (70%), primary care (16%) and nursing home care (14%) (Table 1).The importance of ethical and legal knowledge and the source of knowledge Almost half of the respondents answered that legal and ethical problems arise daily and weekly.A majority (74.4%) of nurses considered ethics knowledge of law and ethics and the role of an ethics committee in the healthcare system.The questionnaire included a full variety of response options, designed to identify the practitioner's knowledge, beliefs and attitudes towards patient care in relation to healthcare ethics and law.
The questionnaire consisted of questions regarding the importance of knowledge of ethics and law to work, the source of knowledge of ethics and law, and the preference for consultation regarding an ethical or legal problem should one arise.The questionnaire also collected data on selected socio-demographic, professional, and occupational characteristics.
Some replies were a choice of 'yes', 'no or 'not sure' to respond to this particular question.In the final part of the questionnaire, nurses were asked to answer questions on everyday ethical issues concerning ethical conduct, autonomy, paternalism, confidentiality, informing patients about illegal behavior, informing relatives of a patient's condition, informed consent, treating non-compliant or violent patient, religious beliefs that influence treatment, abortion and euthanasia.The respondents were required to answer if they agree or disagree with the statements made on these issues, and the response was provided using a Likert scale ranging from 1 to 5 (1-strongly disagree, 2-disagree, 3-not sure, 4-agree and 5-strongly agree (11).

Statistical analysis of the survey
Statistical Package for the Social Sciences version 17.0 for Windows (SPSS Inc., Chicago, IL) was used to analyze the data.Descriptive statistics (means, SD, and percentages) were used to describe the nurse sample and all answers to the survey.
Also the following statistical procedures were employed: chi-square test, Student t analysis and ANOVA test, and for pretest/posttest analyses we used the McNemar test and Wilcoxon test.The appropriate test was used based on the type of response (dichotomic or ordinal data).Statistical significance was determined using the P value having statistically less knowledge of legal issues (Chi² = 0.036).
Remarkable differences were found between nurses of different ages and how they obtained their knowledge.Young and old nurses reported having statistically different amounts of ethical (P<.001) and legal knowledge (P<.001).Nurses less than 30 years old obtained knowledge in legal and ethical issues through their university nursing studies, while older nurses obtained knowledge through experience, courses or seminars, and on their own effort.

Preference for consultation on ethical or legal problems and the importance of ethics committees
Almost 70% of total sample had no idea about whether there was an ethics committee in their workplace.For nurses who were aware of their ethical committee, 80% did not believe that the committee fulfills its mission.
Analyzing the answers before and after completing the legal and ethical course (Table 3), overall the sample in the pretest group had less knowledge about the ethical codes.The most widely known were the Hippocratic Oath (55.8%) and the Code of Ethics for Nurses (48.8%), and nobody knew of the existence and the main content of the Helsinki Declaration.In the post-test group, 88.4% of nurses knew about the Hippocratic Oath and the Code of Ethics for Nurses, almost 50% for the Helsinki Declaration, and 37.2% for the Nuremberg Code.
In the pretest responses regarding with whom nurses would prefer to consult or discuss an ethical issue, the nurses evenly divided between talking with an ethics committee, nursing supervisor (11) or a partner (12), and the McNemar test showed high significance.Comparing pretest and post-test preferences for whom to consult on legal problems, there were no significant differences, and the preferred choice for both was "Professional College".Nobody marked the options for nursing director, physician, administrative staff, priest, internet or relatives/friends.
Regarding the role of an ethics committee, the vast majority knew that ethics committees guar-to be very important for their work.More than 50% reported having poor knowledge about legal regulations and that their current knowledge was based on experience and university training (Table 2).We found no differences between the responses of males and females using chi square test.
Nurses who worked in nursing homes reported "A patient who refuses to be treated for religious or other reasons should seek another doctor or accept treatment", many nurses were undecided (44 and 48% respectively) in the pretest.After the course, 50% of nurses disagreed with the statement regarding a patient's wish to die, and the responses were evenly divided with 30% agreeing or disagreeing in the matter of patients who refuse care.
We found a significance difference in the pretest/ post-test responses to the statement "The patient's wishes should always be respected" (P=,013) with the level of agreement increasing from 50% to 80%.A strong statistical difference (P= ,001) was observed after the course regarding the statement "The law states a physician or nurse cannot refuse to participate in an abortion".Before the course 50% of the sample was not sure or agreed, but after the course, only 13% were undecided or agreed.

The usefulness and effectiveness of different teaching methods
This nurse sample considered all the proposed teaching options to be useful for achieving knowledge about the ethical and legal aspects of nursing.Learning from presentations of real cases was the most favoured method, followed by focus groups, workshops, lectures, specialized journals, books, mass media and encyclopedias.
When the age of respondents was considered, we found statistically different preferences for the methods of "encyclopedias" (P<.001) and "mass media" (P=.002).Nurses who were age 51 years and older considered these types of tools more useful when compared to younger nurses.Similar preferences by age were also found for learning about legal issues in the nursing profession.
No nurses in the sample considered teaching based on real cases, focus groups and workshops to not be useful for both ethical and legal topics.

Discussion
The goal of this research was to identify the knowledge, positions and attitudes of nurses in relation to healthcare ethics and nursing legal anteed ethical standards in clinical situations and provided ethical counselling.There was no significant difference in pretest and post-test responses.
Before the course, the majority of the nurses did not realize one responsibility of the ethics committee is to approve and monitor clinical research involving human subjects, and post-test knowledge of this was statistically different (P=.019).
After the course, statistically more nurses understood that ethical committees must inform staff about institutional ethical and legal regulations (P=.025).
For nurses, it was not clear that the ethics committee plays a role in resolving conflicts between professionals and between professionals and families, with almost 80% of sample answering "no" or "I don't know".After the course, responses were statistically the same on this matter, indicating some doubts about this role.Also after the course, nurses had unchanged views as to whether ethics committees should conduct ethics training for students (P=.644)and professionals (P=.189).

Everyday ethical issues and ethical conduct
The majority of nurses disagreed with the statements that "ethical behavior is important only to avoid legal action" and ''if confidentiality cannot be maintained due to nursing care, it can be broken", with 80% pretest disagreement and 90% post-test disagreement.For "Patients only need to be informed and sign consent for surgery, but not for other tests and clinical situations", pretest (90%) and post-test (93%) agreement were similar.Nurses also agreed that "the patient should always tell if something is wrong" and "children (except for emergency situations) should never be treated without the consent of their parents or guardians".
For the statements, "Close family members should always be informed about the medical situation of the patient" and "Nurses should refuse to treat violent patients", there was great heterogeneity and dispersion in the pretest/post-test responses with no statistical difference.
For the statements "A patient who wishes to die must have support no matter what disease" and were not aware of the 1998 Human Rights Act (especially the older nurses), and thus they did not implement these rights to the same degree as younger, more knowledgeable nurses.Our study had similar findings with the youngest nurses reporting more knowledge, and this knowledge was acquired in a university setting, so their background was more fundamental.
In our study, prior to taking the course, the almost all of the nurses had moderate knowledge of the Hippocratic Oath and the Code of Ethics for Nurses, but they had poor knowledge about the Helsinki Declaration and the Nuremberg Code.We consider the contents of these codes to be very important, particularly the Code of Ethics for Nurses, which provides a framework for nurses to use in ethical analysis and decision making.In agreement with our data, Pang (16) studied the implementation of the International Council of Nurses code of ethics.She found that the nurses were aware of the code, but they did not have enough knowledge about it, and they had difficulty implementing the code in their cultural environment.
The development of universal ethical and legal standards, including the Nuremberg Code, the Declaration Helsinki, and the Universal Declaration on Bioethics and Human Rights of UNES-CO, seeks to limit and control the improper use of science and associated technologies and to promote and protect fundamental human rights (23).
Our sample did not have enough knowledge about the role of ethics committees in their work places, and the nurses did not believe that ethics committees fulfilled their mission.The nurses recognized the role of providing counselling, setting guidelines and guaranteeing the ethical standards.Before the course, nurses did not know that a major function was to guide and approve research, but the posttest indicated that the nurses successfully learned about this important ethical committee function.
regulations among a sample of Spanish nurses, to evaluate the impact of an educational program, and to determine any differences considering socio-demographic variables as a gender, age, etc.In this study, nurses were described according to social, personal, and labor characteristics.
This study shows that most nurses recognize that ethical and legal problems arise daily or weekly and understand that these problems are very important for their clinical practice.However, they also feel that they are not sufficiently trained in these areas.In particular, nurses who work in nursing homes more frequently report having a lack of knowledge about legal regulations.In our sample, the youngest nurses reported having more knowledge than the older burses, and this knowledge and training was acquired through their university-level nursing degree.
It is remarkable that nurses working in nursing homes report less knowledge considering their unique work environment in which patient autonomy is limited by cognitive aging and dependency (12).Nursing home care is complicated by numerous regulations, since nursing home residents have complex medical and social problems, some issues are unique to the long-term care setting and may present in unfamiliar ways.Some issues frequently encountered in this setting are advance directives, competency and decisionmaking capacity, decisions about life-sustaining treatment, resident abuse, restraints, psychotropic medications, risk management, participation in research, and ethics committee oversight.With these challenges, nurses working in long-term care settings could benefit from more training in legal and ethical rules (13).
The education of ethics in nursing has become increasingly important year by year.While it was an important part of early nursing education, it disappeared from the nursing curriculum during the 1950s and 1960s (14).Perhaps our data reflects this history in that older nurses expressed that their knowledge had been acquired outside of the university setting.
In 2005 Woogara(15) qualitatively studied the aspects of protecting the dignity and privacy of patients.This author found that many nurses responsibility is always a concern for healthcare professionals.In Spain, the Professional College of Nurses provides legal advice to all collegiate nurses and also coverage through civil and criminal liability insurance up to 3,500,000 Euros per claim.Professional liability coverage is for any professional errors or omissions which may arise for the nurse in relation to nursing practice, and in addition, coverage is provided for alternative or complementary methods of acupuncture, ear acupuncture, osteopathy, reiki, yoga, color therapy, iridology, herbology, reflexology, naturopathy, homeopathy, Bach flower remedies, massage, magnet therapy, kinesiology, craniosacral therapy, mesotherapy and piercing(30).
For everyday ethical issues and ethical conduct, our sample of nurses considered that ethical behavior is not important only to avoid legal actions.This view agrees with a qualitative research study (22) concerning physician opinions about the Patient's Rights Law which concluded that knowing regulations is very important and positive, that it does not negatively affect work, and that it contributes to improved relationships with patients.However, some fears were expressed about possible abuse of the law by patients and their lawyers, which could put medical providers on the defensive.In another study, Siegal et al. (31) demonstrated a level of misunderstanding of the law's norms and regulations leading to subjective attitudes and misperceptions.In order to ensure the medical community's participation in augmenting patients' rights, we proposed increased efforts focused on improving legal and ethical education.
In a study among nurses, Guix Oliver et al. (32) found the most important patient rights were "the right to information" and "patient autonomy".Patient's rights were sufficiently understood, and the right to information was valued more highly than the right to exercise autonomy.In our study, nurses also considered it important to provide good information about the medical situation to the patient and the family.Regarding patient autonomy, our nurses think that patients not only need only be informed and sign a consent for surgery, but there are many other tests, nursing procedures and clinical situations when expressed consent is required.Other issues in which impli-This sample of nurses indicated they doubted whether ethics committees had the responsibility to teach ethics or mediate in the conflicts between professionals and families.Their post-test responses indicated the course did not resolve these doubts.
From the first time in 1976 when the New Jersey Supreme Court recommended using an "ethics committee" to confirm the prognosis of a comatose woman, Karen Ann Quinlan, whose family requested termination of life support (24) until now, the importance of ethics committees is constant.
Nurses must identify the role of ethics committee in balancing reasonable treatment and guidance with patients rights to respect and dignity (25).An ethics committee is defined as "A group of multidisciplinary and independent professionals from healthcare and other fields of knowledge, and members of the community, which aims to help safeguard the dignity, rights and welfare of current and potential research subjects, ensuring that the benefits and inconveniences of research be distributed equally among the groups and classes of society, and guarding the relevance and correct the research protocols submitted for consideration" (26).
After completing the training course in our study, most nurses preferred to consult and discuss the ethical dilemmas of daily work with the ethics committee, nursing supervisors, or even with a partner.After the course, the vast majority of nurses understood that the ethics committee is responsible for advising on these issues.In the literature, we found that healthcare professionals who encounter an ethical dilemma at work tend to resolve the problem within the same workplace.Also, nursing professionals, in particular, show more empathy and tend to give more guidance than other professionals (27,28).The nurses in our sample showed similar preferences in seeking counsel from ethical committees, supervisors and fellow nurses, but not outside of work.
For legal problems, our sample strongly preferred the Professional College of Nurses as a resource both the pretest and posttest.Legal problems involving negligence or malpractice are a frequent situation in healthcare (29).Civil and criminal tion of the social, personal and labor characteristics of our sample reveals a fairly homogenous group with a profile similar to those in relevant international studies (36).Moreover, the attitudes of respondents may have differed from those of non-respondents, thus these findings may be subject to response bias.There may be other associated factors that were not evaluated in the present study.The study was also limited to those questions or situations that were included in the survey, which may not reflect all ethical or legal situations.Therefore, additional observational research is needed.

Conclusions
In this study, nurses considered ethical and legal problems to be important in daily clinical practice, but at the same time, they considered themselves not sufficiently trained to resolve those situations.
Regarding knowledge about international ethical codes and ethics committees, there was great ignorance about the main code content and mission of the committees.In this respect, the ethical/legal training course presented to our sample of nurses provided them with new knowledge about ethical code content and committee functions.
Overall, our sample demonstrated adequate knowledge about the issues that cause ethical and legal dilemmas in nursing decision making.For nurses who felt they did not have enough knowledge, the course provided them with knowledge and tools to resolve such problems.
Training courses on ethics, ethical decision making, and professional legislation in nursing is necessary.Though any teaching method can be beneficial, nurses most strongly recommend learning through focus groups and workshops.
In conclusion, although the nurses actually have university-level education in professional deontology, bioethics and nursing legislation, they need periodic refreshing and updating of knowledge through nursing continuing education.
cations for the law arose were when what should be done if not enough information was given to patients or if the information compromised their autonomy.This was similar to Siminoff et al. (20) who showed that not all patients receive the same categories of information equally.
The opinions about respecting a patient's wishes anytime (including when they decline to be treated for religious reasons) and the ability of a provider to refuse to be involved in abortions changed after course.The specific training on the law relating to conscientious objection by healthcare workers taught the nurses that they can refuse participation for ethical or religious convictions without penalty, even in the public health system (33).
Our sample considered all learning methods to be useful for ethical and legal training, and none considered that teaching methods based on real cases, focus groups or workshops, to not be useful.Older nurses considered traditional methods of self-learning from sources such as encyclopedias or mass media to be helpful, though the younger nurses did not favor these methods.
In adult education there are different methods to promote learning.Numerous studies report the difficulty that some students have learning science.These difficulties are related to internal factors such as motivation, prior knowledge, student age and external factors, such as the role of teachers, the use of teaching strategies and the learning conditions (34).
This supports why students mostly prefer methods that encourages interaction with peers, such as focus groups.This form of education provides greater security in the understanding of the content and confidence in their ability to cope.Workshops are also successful, and research studies indicate that workshops increase student enthusiasm for knowledge and encourage them to participate in future workshops.In addition, a better understanding of theoretical content is developed in theoretical sessions (35).
A limitation of our research is that the sample was drawn from nurses volunteering to participate in a course on ethical and legal issues.The distribu-

Table 1 .
Characteristics of the sample (N= 43)

Table 2 .
Descriptive analysis for questions about knowledge of ethics and law to work