UNIVERSITY OF MALAWI

Kamuzu College Of Nursing

Author : Glory Wezi Sopera Mwafulirwa

Paper title: How to improve work ethics among health workers

Program of study: Master Of Science in Community health nursing

Date: 24th March 2016

Table of Contents

INTRODUCTION...........................................................................................................................................2

POSSIBLE CAUSES OF LACK OF ADHERENCE TO WORK ETHICS BY HEALTH WORKERS IN MALAWI.............3

WHAT CAN BE DONE IN MALAWIAN CONTEXT TO IMPROVE ADHERENCE OF WORK ETHICS BY HEALTH WORKERS....................................................................................................................................................5

Establishing and strengthening ethics committees.....................................................................................5

Managing moral distress and burnout among health workers....................................................................7

Strengthening implementation of performance appraisals and supervision by management..................10

SUMMARY.................................................................................................................................................12

REFERENCE................................................................................................................................................14

INTRODUCTION There is at least anecdotal evidence that there is violation of work ethics by health care

professionals in Malawi. Malawi is a country with a population of over 11 million people.

Administratively, the country is divided into 28 districts with each district subdivided into

smaller administrative units that are meant to access health facilities across the country (National

Statistical Office (NSO) [Malawi] & ORC Macro, 2011). These health facilities are managed by

trained heath personnel s and other disciplines that offer direct health care as well as

administrative services. The health workers in these institutions are required to offer care to

patients that is in line with their professional code of ethics.

Marquis & Huston, (2006) defined ethics as the systematic study of what a persons conduct and

actions ought to be with regard to self, other human beings and the environment; it is the

justification of what is right or good and the study of what a person’s life and relationships ought

to be and not necessarily what they are. Ethics is also distinguished from morality which refers to

any relatively immutable system of values and beliefs that generally determine what is good and

bad behavior (Ndetei, Szabo, Okasha, & Mburu, 2006). In relation to that, a professional code of

ethics is described as a body of rules, principles, and standards, which govern the conduct of its

members.

Each profession may adopt a code of ethics to self regulate the conduct of its members and thus

it establishes the group as a profession, and promotes a certain image of that profession to the

public. Physicians, Nurses, Respiratory Care Practitioners, and many other professional

healthcare providers have adopted their own code of ethics. For healthcare providers, the code of

ethics generally includes the following: assure the public that their healthcare needs are met and

healthcare is provided in a caring, safe, and effective manner (Corning, 2005).

Therefore, the various health care workers conduct and actions when delivering health care are

expected to be based on what their professional code of ethics expects of them but looking at the

current anecdotal observations in Malawi, there is an indication of poor work ethics. A study

done by Msiska, Smith, & Fawcett, (2013) on Emotive responses to ethical challenges in caring,

found that there is a tendency among some of the nurses to shout at patients and display negative

attitudes over simple things, sitting In the nurses’ station in the busy ward leaving clients

unattended to and sleeping all night during night shift. These actions clearly prove or show that

there is indeed poor adherence to work ethics by health workers as also stated in the study that

such conducts is a consequence of the well-documented phenomenon of ‘burnout’ first coined by

Freudenberger, and Grigulis reports its occurrence among Malawian nurses as cited in (Msiska et

al., 2013).

This paper thus seeks to discuss possible causes of violation of work ethics and ways of how to

improve work ethics among health care workers in Malawi thereby promoting rendering of

quality services to clients.

POSSIBLE CAUSES OF LACK OF ADHERENCE TO WORK ETHICS BY HEALTH WORKERS IN MALAWIIn an article from The Nation Newspaper by Mzungu (2016) it was stated that there are only 10

000 nurses against a population of 16 million people. Furthermore, it was stated that Malawi has

the highest ratio of Nurse to Patient of 1 to 1600 as compared to the one nurse to six average sick

people as recommended by the International council of Nurses. The diminishing number of

nurses against the increasing workloads puts both patients and health worker at risk of infection

and unprofessional conduct such as use of bad language to clients due to fatigue and other

disappointments among others. Thus this shows that work overload is a possible cause of lack of

adherence to work ethics.

The other possible cause of poor adherence to work ethics by health workers is moral distress

and burn-out. According to Wilkinson, (1987) moral distress is when one knows the right thing

to do but institutional constraints make it nearly impossible to pursue the right course of actions.

Maluwa et al., (2012) conducted a study to explore the existence of moral distress among nurses

in Lilongwe District of Malawi. In this study they pointed out that moral distress leads to poor

quality patient care as nurses feel powerless, helpless and hopeless leading to job dissatisfaction

and burnout that come due to inadequate resources and lack of respect from patients and

guardians. This therefore leads to health workers to put up their frustrations on patients through

bad language and other forms of unethical practice.

Furthermore, they pointed out that adequate skills and knowledge in nursing ethics are lacking

among Malawian nurses, mainly due to the way that the subject is taught in the nursing schools

and colleges. Curricula in most nurse training institutions in Malawi have put less emphasis on

the aspect of moral distress, thus students graduate with little knowledge on the phenomenon.

For example, nursing ethics is taught during early days of the student nurse training program.

The curriculum mainly focuses on the principles of ethics, while the course content puts more

emphasis on how to manage patients’ stress without adequately addressing the issue of nurses’

moral distress.

The problem is further compounded by the fact that the records of practical experience for

students during training which are prescribed by the Nurses’ and Midwives’ Council of Malawi

do not spell out clearly the ethical skills that nurses should acquire. These factors have some

implications on the understanding and application of ethics to nursing practice and decision

making. Most nurses are not confident with their ethical and moral decision making skills,

consequently, they are prone to suffer from moral distress leading to poor adherence to work

ethics when they qualify as nurses due to lack of adequate knowledge and skills in ethical

practice (Maluwa et al., 2012).

In relation to that, Burnout is another factor that leads to unethical practice in the health care.

Raiger (2005) described burnout as a unique type of stress syndrome that pervasively affects the

nursing profession cited in (Espeland, 2006). In a study done by Duxbury et al, (1984), , do not

cope as well with moral and ethical dilemmas as nurses who are not burned out. Jones, (1981)

cited in Cameron, (1986) found that nurses that are most likely to lapse into unauthorized break

time scored significantly higher on a burned out scale than nurses who strictly adhered to their

work break schedules. A psychological scale for burn out reliably predicted the likelihood of

theft among hospital nurses tended to steal more hospital supplies and drugs than those who

weren’t burned out. Theft is also a type of unethical practice among health workers that

according to this research comes due to burn out thus showing that burn-out does lead to poor

adherence to work ethics by health workers.

Lack of boundaries keeps nurses from protecting their own time. An example of having no

boundaries is nurses who do not have the courage to say no when given extra task or shifts when

they are already exhausted. According to Robinson (2003), Not setting boundaries at work can

lead to burnout cited in Espeland, (2006) which leads to unethical practice due to stress that

comes after developing burnout.

WHAT CAN BE DONE IN MALAWIAN CONTEXT TO IMPROVE ADHERENCE OF WORK ETHICS BY HEALTH WORKERS Looking at the possible causes of the poor adherence to work ethics by health workers, the

author came up with a number of possible interventions that can help to address these issues.

These interventions include; establishment and strengthening of ethics committees in all health

facilities and managing moral distress and burnout, and strengthening implementation of

performance appraisals and supervision by management.

Establishing and strengthening ethics committees Edge & Groves, (2005) described ethics committee as an interdisciplinary body of health care

providers, community providers, community representatives, and non-medical professionals who

address ethical questions within the health care institutions, especially on the care of patients.

Burkhardt & Nathaniel, (2014) described that ethics committee is generally made up of

representatives from various disciplines such as Nursing, medicine, social work and chaplains.

Edge & Groves, (2005) elaborated further that these ethic committees in the health institutions

play various roles such as policy and procedure development. Morrison, (2008) stated that on

this role of policy formulation by ethics committees, they guide in establishing perdurable

policies regarding ethical issues and ethical decision making and these policies are a form of

prescriptive or directive ethics.

The other role of the ethics committees is to educate their institutional staff, patients, families

and the larger community on ethics, ethical principles, and ethical issues in order to promote an

understanding of ethical problems and an awareness of the desire and responsibility of

physicians and hospitals to respond in an ethical manner. Existing ethics committees have

discovered that the faculty of nearby colleges might include professionals interested in

discussing ethical problems in health care thus these can assist in educating the health workers in

collaboration with the ethics committees. Case consultant is another role of the ethics committees

where they are responsible for giving advice on cases that involve ethical issues that may arise in

the institution (Morrison, 2008). Resource allocation is another role of ethics committees where

they assist hospitals in developing policies for resource allocation so as to maintain quality of

care in the face of cost-containment measures (Morrison, 2008).

Therefore looking at the above literature that has stated what ethics committees are and their

role, the author recommends that there is need to establish and maintain ethics committees in all

hospitals in Malawi. These committees will help to change the current work ethics of health

workers for the better. When the committees are established, they will help to conduct in-service

trainings to the staff (health workers) on work ethics, this can be done by the committee

members themselves if they are competent enough or they can ask for assistants from for

example Health related colleges that have Lecturers that are more conversant with ethics as

recommended by Morrison (2005). This will help in that the staff will gain knowledge necessary

for them to use when caring for their clients so as to work in an ethical manner.

Furthermore, the ethics committees will assist in formulation of policies that will be the guide for

managing ethical issues that are prescriptive and directive thereby helping the staff to work as

stated in the policies that will or were formulated to prevent from behaving unethically when

carrying out their duties or caring for clients. On case consultant as a role of ethics committees,

this role will help the health workers to seek advice from the right people which are the ethics

committee that will definitely assist in managing ethical issues the health workers might face but

failing to manage them, thus the ethics committee would give advice to the involved person on

the possible ways to manage the problem so that they act ethically right. Currently, due to lack of

the ethics committees most health workers fail to know who to consult to seek help on how to

manage ethical issues they face so they prevent from behaving unethically.

Last but not least, if the ethics committees are established in the hospitals, they will have a role

on resource allocation at the hospital, this will help in that there will be policies made by the

hospitals in collaboration with the ethics committee on how resources should be distributed. This

will help provide and maintain quality of care to clients since both material and human resources

will be distributed as required leading to reduction of burnout by staff that comes due to lack of

rest due to overworking of staff as a result of shortage of staff that also comes due to poor

allocation of human resources. The burnout results into unethical practices by health workers

thus if there is proper allocation of the human resources at a hospital level, there will be

reduction of burnout and thus reduced cases of unethical conduct by the health workers.

In a study by Maluwa et al., (2012) in Lilongwe, on the part of sources of support in regards to

ethics, all (20) participants reported that they would like their health institutions to have ethics

committees so that the committee should remind them on issues concerning patient care, to help

resolving ethical issues in case something wrong happened to a patient, to discuss ethical issues

instead of discussing them in the matron’s office, to enhance better management of patients, to

assist nurses to update knowledge regarding ethical issues and patient care, to strengthen health

care ethics and to prevent and avoid misconducts. This is a clear proof that indeed these work

ethics committees are of great importance to help solve the issue of poor adherence to work

ethics in Malawi but first and far most, these committees when chosen will have to be

enlightened on these various roles they will have so that they are aware of them and use when

carrying out their duties as work ethics committees.

Managing moral distress and burnout among health workersAddressing moral distress and working to reduce the crescendo may slow the exodus of

healthcare professionals from their professions, preserve moral sensitivity and integrity among

skilled staff, and increase awareness of powerlessness in healthcare settings, ultimately

benefitting providers and patients alike (Gallagher, 2011).

As stated that one of the causes of unethical practice by nurses is that their college curriculum

does not cover the part of how they can deal with moral distress which directly affects the way

the nurses provide care to clients. (Crawford, 1926) stated that for one to be an ideal ethical

nurse they are to have a qualities such as good manners, courtesy and unselfish consideration of

others, teachable with an open mind attitude about facts and criticism, Sound moral principles,

health by respecting human body, acceptance of authority especially for the young adults, spirit

of loyalty to the thing one is engaged in doing, adaptability to new and adverse conditions such

as living conditions if one is to live in an institution, industry, there is no place in a hospital for a

lazy nurse, neatness and personal cleanliness, honesty, willingness to face issues and not passing

blame to others, responsibility and dependability, where under responsibility is on the patients,

hospitals and guardians property to be kept safe and dependable when she is wanted to always be

found and lastly, judgment in the use of the tongue since nurses mostly ill use their tongue when

communicating to patients. Therefore, if these are included in the curriculum and taught

comprehensively to the students it would help them be fully equipped with knowledge and skills

to use when they start working as qualified nurses that will help them know what to expect and

deal with various ethical issues in the health sector and adapt thus prevent them from being

overwhelmed with work and end up burned out due to work load.

It is also very important that line managers or the management of the hospital should make sure

that they allocate human resources well into the wards so that staff should not experience moral

distress due to lack of enough human resources to provide quality care to clients. Quality of care

to clients also includes incorporation of ethics in rendering care, is possible when there is enough

human and material resources. A study done by Vahey, Aiken, Sloane, Clarke, & Vargas, (2004)

showed that patients cared for on units that nurses characterized as having adequate staff, good

administrative support for nursing care, and good relations between doctors and nurses were

more than twice likely as other patients to report high satisfaction with their care, and their

nurses reported significantly lower burnout. The overall level of nurse burnout on hospital units

also affected patient satisfaction.

To manage or prevent burnout, nurses need to develop goals that are achievable, not goals that

are downright impossible. Lafferty and Lafferty (1997) recommend prioritizing to make

workload and stress levels more manageable. Striving for perfection at work can actually

compromise job performance because perfectionists equate their self-worth with flawless

performance, they often dwell on trivial details and devote too much time to projects, which

slows productivity (Lafferty & Lafferty, (1997) as cited in Espeland, (2006). This can easily be

applied in our Malawian setting where staff can be given the opportunity to set goals that are

realistic and attainable to not cause one to be overwhelmed and be supervised in doing so, so that

when they are implementing them they will do so without being strained of work if they were to

be hard to achieve goals. This will help them to work at a pace of their optimal level without

being strained of work and thus prevent burnout and unethical practice.

As it was pointed out that one cause of burnout among nurses is not being able to say no to work.

This can be managed in that nurses should learn to be autonomous and refuse to work when they

feel they have already worked at the highest level. According to Robinson (2003), too many of

us are putting jobs above all else in life with dire consequences for our health, our loved ones,

our happiness, and even our quality of work cited in (Espeland, 2006). Thus when one works

without exceeding their optimal level, they are preventing from unethical conduct are also caring

for their own health as a person so that they do not experience stress due to overworking.

Forgiving oneself is instrumental to prevent burnout. Sometimes nurses feel so bad about what

they have done in the past or for not meeting their expectations or their managers’ expectations

that they start to talk to themselves negatively. Harsh self-criticism decreases self-esteem,

inhibits courage and confidence, and creates tension, anxiety, and stress. Just as we forgive

others, we need to forgive ourselves (Espeland, 2006).Thus on this, there would be need to

conduct in-service trainings that will enlighten the health workers on importance of forgiving

self to prevent burnout which if not will cause unethical practice due to stress.

Strengthening implementation of performance appraisal and supervision by management. Dzimbiri (2015) defined performance appraisal as a systematic evaluation of present and

potential capabilities of employees by their superiors or professionals from outside the

organization. He further stated that a supervisor is the person most qualified to evaluate the

employee’s performance in a realistic and fair manner. Thus some supervisors keep performance

logs noting their employee’s accomplishments from time to time which provide specific

examples to use when rating the performance.

In Malawi, It has been the observation in all public and some private health facilities,

performance appraisals are not being done. Akrani (2011)stated that performance appraisals are

important since they give proper staff performance feedback that can improve the employees’

future performance. The appraisals are very important and useful since as stated above they help

give feedback to staff thus managers are obliged to supervise their staff in this case health

workers, to observe their work performance that includes ethical and moral standards which will

help in the performance appraisal meeting where areas that need improvement will be pointed

out to staff. This helps in goals and objectives to be set in the next period, be it for a year or

quarterly basis to assist the staff to improve in the areas they are weak in such as poor

communication to staff, absenteeism without excuses and labeling clients basing on their

conditions. This resulting in the health workers to be on their best behavior when rendering

services since there will be routine supervision by their seniors where their performance will

reflect on the appraisal meeting and document.

Omisore & Adeleke, (2015) stated in his journal on the challenges of work ethics, values,

attitudes and performance in the Nigerian public service, that performance appraisals are capable

of making an employee increase his/her performance, having known that there is time to evaluate

his/her efforts and to reward or punish, depending on the efforts he/she puts into the production

process. One practical example would be on the current practice at St John Of God Hospitaller

Services, which is a Non-governmental Christian health institution that provides various services

in relation to Mental health. This institution emphasizes the use of performance appraisal to their

staff members (health professions inclusive), done by line managers, to monitor, mentor and

promote the use of work ethics and other technical responsibilities in delivery of services to

patients/ clients.

It is recommended that the government should take serious measures which will lead to all health

professions to be appraised basing on their work ethics in providing care to clients and if their

performance is not satisfactory despite support through mentoring, then appropriate disciplinary

measures are to be taken up. This will be easier to implement and follow up if a task force is to

be put in place to be looking at this intervention which should include staff from human

resources management at Ministry of health.

Mahindi et al., (2012) reported that in Tanzania, there have been increase in reported cases of

non- adherence to professional ethics among health care workers at both public and private

health facilities. Issues of favoritism, petty corruption, use of abusive language and absenteeism

are especially common in most of public health facilities. The aim of the study was to assess the

level of adherence to professional ethics among health care workers at the point of public health

service delivery. The study results indicated that, cases of professional misconduct are, indeed,

widespread in the health facilities. For example, 69% of the respondents in Temeke district said

that some health care workers were not present at their health facilities all the time during work

hours. In Kondoa district, 63% of the respondents indicated that some health workers used

abusive language when communicating with their patients. Ilala district was found to be leading

other districts in corrupt practices and favoritism among health care workers as it scored 27%

and 56%, respectively, on these issues. On the basis of the findings, the study recommended that

the government should strengthen management and supervision of health care workers especially

those posted in remote areas.

Similarly this can be applied in Malawian health facilities, as mentioned earlier, for there to be

an improvement in work ethics among health workers, there is need to intensify supervision by

the line managers to note how the health workers are carrying out their duties and to find ways

on assisting the health worker as an individual to reach their highest potential whilst rendering

care to clients. The supervision and support is also reflected during the performance appraisals as

staff is seen to have improved.

SUMMARYAdherence to work ethics by health professionals has proven to be a serious problem in health

facilities within Malawi which has resulted in violation of patient’s rights such as right to dignity

and respect. A lot of possible causes have been isolated to causing the poor adherence to work

ethics by the health workers such as burn-out, moral distress and lack of assertiveness to refuse

work when exhausted by some of the health workers. These causes can be addressed through

introduction and supervision of ethics committees in health facilities that will be responsible for

supervising staff that they are adhering to their codes of conduct and be able to deal with all

ethical issues in the facilities. The other interventions would be to avoid burn-out and moral

distress though provision of enough resources to health facilities to allow the health workers be

able to provide services in their optimal capacity and not to over-work resulting in burn out.

Implementation of performance appraisal and supervision by managers is another intervention

that would help to reduce unethical practice by health workers as routine supervision would help

the health workers to be on their best behavior. Therefore, these interventions if properly used,

would help to reduce the cases of unethical practice in the country as they have proven to be

effective by others.

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