Work ethics among health workers in malawi

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
Table of Contents........................................................................................................................................2
INTRODUCTION ...........................................................................................................................................3
POSSIBLE CAUSES OF LACK OF ADHERENCE TO WORK ETHICS BY HEALTH WORKERS IN MALAWI.............4
WHAT CAN BE DONE IN MALAWIAN CONTEXT TO IMPROVE ADHERENCE OF WORK ETHICS BY HEALTH
WORKERS ....................................................................................................................................................6
Establishing and strengthening ethics committees ....................................................................................6
Managing moral distress and burnout among health workers....................................................................8
Strengthening implementation of performance appraisal and supervision by management. ..................10
SUMMARY.................................................................................................................................................12
REFERENCE ...............................................................................................................................................13

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 MALAWI
In 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 workers
Addressing 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.
SUMMARY
Adherence 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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