الفهرس 
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Abstract
Due to the extension of the role played by the nurse, the circle of professional responsibility which falls on the nurse has expanded. This creating a fertile environment unprecedented in history to the spread of law suits and claims against nurses in light of the tremendous societal development represented in the spread of media supporting the rights of patients and easy access to knowledge by members of the community and the emergence of movements supporting the individual’s rights in society and the patients’ rights in particular. Also, in order for the nurse to keep up with this tremendous development, he/she must be familiar with the legal framework of his/her practice as well as the legal aspects of his profession. In addition to, authors from around the world have agreed that nurses’ knowledge of legal liabilities as well as the legal framework governing clinical nursing practice is the best way to avoid falling under the jurisdiction of law.
The present study aimed to assess nurses’ knowledge and views about legal liability in the clinical nursing practice following a descriptive research design. It was conducted in all Critical Care Units, Intensive Care Units, and General Care Units at the following four hospitals: Alexandria Main University Hospital, Shark El Madina Hospital, Abo Qir General Hospital, and Al Salama New Hospital. These hospitals are affiliated to the University, the General Secretary of Specialized Medical Centers, Ministry of Health and Population, and Private sectors respectively. Each of the selected hospitals was selected as it was considered the largest capacitated one in terms of nurses’ number and bed capacity.
A sample of 650 nurses was recruited by using simple random sampling using power analysis technique. One tool was used in this study; it entitled Nurses’ Knowledge and Views about Legal Liability Questionnaire that was developed by the researcher based on review of related current literature. First an initial version of the tool was developed in English and then translated into Arabic. It was consisted from 77 questions that represent study variables. A pilot study was carried out on 10% of nurses (n=65) that weren’t included in the study subjects in order to check and ensure the clarity of tool, identify limitations of the study, problems that may be encountered during data collection. Many obstacles were raised during pilot study as the response rate was too low, more missed items, some questions were vague, tool was too long, time consuming and some study participants didn’t have knowledge to select any response from the available responses. A final version was developed by excluding some vague and redundant questions as an attempt to make the tool more concise, more applicable and easy to complete by study participants.
Final tool consists of two parts: Part (I) includes nurses’ personal and professional data in terms of their age, sex, years of experience since graduation, years of experience in the current unit, qualifications, hospital setting where nurses were recruited, unit type, attendance of any previous workshops or seminars regarding nursing legal liability, need for studying legal aspects of nursing practice and the reasons behind this need, previous study of legal liability of nursing practice, previous exposure to or involvement in illegal practice, liability suits /claims and possibility of awareness with anyone involved in illegal nursing practice. Part (II) includes 63 questions used to assess thirteen dimensions of legal liability as follows: negligence, malpractice, assault, battery, false imprisonment, defamation of character, fraud, invasion of privacy, informed consent, physician order and carrying out medical procedures by doctor order, staffing issues (nursing assignment, nursing shortage, abandonment, and improper delegation and supervision), dealing with suit prone patients, and employment of nursing students and non-nursing unlicensed personnel.
Questions are in the form of case studies (n=17), multiple choice questions (n=22), and true or false questions (n=24). Regarding case studies questions; each case study comprised of a scenario that was selected from actual clinical nursing practice and includes nursing acts followed by three questions: one question in the form of multiple choice that ask the nurse about his/her knowledge about the type of nursing liability in the case study, one question ask the nurse about his /her point of view regarding the nurse liability in the case study; responses in this question are in the form of Yes or No that represent nurse awareness or lack of awareness about nursing legal liabilities, and one question is an open ended question (why) that asks nurse to give rationalization regarding his /her previous point of view.
The tool was measured for its validity in terms of face, content, discriminant, and convergent validity. Concerning face and content validity, the initial version of the tool was tested for its content validity by a panel of nine experts from the academic departments at the Faculty of Nursing, Alexandria University. The final version of the tool was submitted to a panel of three experts from Faculty of Law who are specialized in Civil Law, Criminal Law and General Law in order to obtain their legal point of view regarding all acts involved in the tool with in the content of the Egyptian constitution and laws.
Initial and final versions of the tool were tested for its discriminant validity by measuring the ability of the tool discriminate between the mean score for the lowest quartile and the mean score for the highest quartile for each dimension. It was found that there is a statically significant difference between the mean score of the first quartile and third quartile for all dimensions of initial and final version of the tool which means it was discriminatory valid. Also, convergent validity was done through factor analysis which was done on 100 nurses. Two ways was used to determine the factorability of an inter-correlation matrix; The Kaiser-Meyer-Olkin (KMO) and Bartlett’s test of sphericity. Both tools were exposed to factor analysis based on component analysis with varimax rotation method and an Eigen value of more than one.
The reliability of the tool versions (initial and final version) was assessed using Kuder–Richardson Test - 20 (KR-20) for internal consistency and inter-item consistency. As the tool was multi-dimensional one, the overall score for tool reliability can’t be obtained but reliability for each dimension was obtained. Results of the reliability show that tool versions were reliable. The final version of the tool was selected to collect data for many reasons: more reliable than initial version of the tool, more valid than initial version, more concise and clear than initial version and more feasible and applicable than initial version.
Data collection was conducted by the researcher and the questionnaire was hand delivered to the study subjects at the study settings. Data collection took five months and response rate was 100 %. All data collected was coded and open end questions were categorized into different categories then data was entered into the computer using the Statistical Package for Social Sciences (SPSS) version 21. Frequency tables and cross tabulations with percentages were used to illustrate the results of categorical data and tested by the Fisher’s Exact Test using. Quantitative data were summarized by the minimum, maximum, median, arithmetic mean and standard deviation. Comparison of means was done by Student t-test and One-Way Analysis of Variance {A Monte Carlo probability (MCP)}.
The followings are the main results yielded by this study:
1- Demographic and professional properties of nurses
The highest percentage of nurses (43.8%) were between 25 to less than 35 years old while the minority of them (11.1%) was more than 45 years old.
More than half of nurses (55.8%) were working in General Care Unites. Also, about three- quarters of nurses (72.5%) were females
Concerning nurses’ qualification; 40.2% had technical nursing institute diploma compared with 1.4% of nurses who had post-graduate diploma in nursing and a similar percentage had master in Nursing Science Degree.
In relation to nurses’ years of experience since graduation, about 40% had from 1 to less than 5 years of experience, while 14.2% had less than 1 year of experience.
More than three -quarters of nurses (76%) did not study any courses or accessed to scientific materials concerning legal aspects of nursing.
The highest frequency of nurses (89.8%) were willing to study contents related to legal issues in nursing, 25.6% of them are willing to do to know the rights and responsibilities of nurses, whereas 15.2% were in need to improve their general knowledge and experiences by studying these aspects.
The majority of nurses (91.2%) did not attend any workshop regarding the legal liability of nursing.
At the same time, 12% of nurses were previously involved in illegal practice; more than one- half of them (56.4%) reported that they were not sued compared with 43.6% of them who reported that they were sued.
2- Knowledge and views of nurses about legal liability of nursing practice
The mean score percentage of nurses’ overall knowledge of legal liability of nursing practice was (46.66±25.79).
The highest mean score percentages of nurses’ knowledge about legal liability in descending order were related to fraud (51.57±35.88), followed by staffing issues (49.6±34.81), invasion of privacy (49.03±38.46), informed consent (43.66±31.14), negligence (41.63±29.23), and malpractice(35.81±22.53). On the other hand, the lowest mean score percentages of nurses’ knowledge about legal liability in ascending order were regarding to assault (23.31±22.17), followed by false imprisonment (28±25.12), battery (30.26±31.42), carrying out physician order (31.87±22.97), nursing student employment (33.72±27.33), dealing with suit prone patient (33.93±26.02), and defamation of character (35.75±29.29). Moreover, 62.3% of nurses had poor/ inadequate level of knowledge regarding the overall knowledge domains compared with 35.9% of them who had fair/ moderate level.
The mean score percentage of nurses’ overall points of views about legal liability of nursing practice was (55.00±15.4).
The highest mean score percentages of nurses’ point of view about legal liability in descending order were found related to fraud (64.46±47.9), followed by invasion of privacy (62.31±48.8), informed consent (61.85±48.6), staffing issues (56.54±42.1), malpractice (52.46 ±29.3), dealing with suit prone patients (51.85 ±50), and negligence (51.69 ±34.1). On the other hand, the lowest mean score percentages of nurses’ point of view about legal liability in ascending order were found related to battery (37.31±48), followed by carrying out physician order (38.38±48.6), assault (40±49), defamation of character (41.15±29.4), false imprisonment (47.69±50), and employment of nursing students (50.23±35.2).
3- Nurses’ overall knowledge and point of view about legal liability of nursing practice in relation to their demographic and professional characteristics
There are statistically significant differences between nurses’ overall knowledge about legal liability and all demographic data of nurses except their years of experience in the current work unit (p=0.091) whereas, there are no significant differences between nurses’ overall knowledge about legal aspects and all professional data of nurses except their previous study of courses or scientific materials about legal issues of nursing practice (p=0.001).
There are statistically significant differences between nurses’ overall point of view about legal liability and their years of experience since graduation, qualifications and the hospital setting where they were recruited whereas, there are no significant differences between nurses’ overall point of view about legal aspects and their professional characteristics.
Conclusion and Recommendation
The present study concluded that there is a greater potential risk on nurses working in Alexandria healthcare settings to be sued and fall under jurisdiction of law that will be exacerbated to nursing liability crisis with in the current rapidly changing Egyptian legal and healthcare system unless rapid effective remedial actions are taken. There is a need for continued and intensified efforts to ensure that nurses acquire the knowledge necessary about the legal aspects and issues of nursing practice and the effects of misuse of law.
This study has reached to the following main recommendations:
Design well- structured formal courses to nurses about legal aspects of nursing practice during undergraduate study and much attention should be paid to its implications.
Introduce formal orientation program to nurses at the beginning of their internship that must contains contents related to laws, regulations, and legal aspects governing nursing practice in order to provide nursing interns with the sound legal knowledge before graduation.
Nursing authorities in cooperation with Ministry of Health and Population must develop nursing practice law that regulate nursing profession and set clear guidelines in which nurses built their professional decisions.
A nursing educational center should be established in healthcare settings that focus continually on legal liability through different on- job training and workshops.