Studies in recent times have shown that health trainees across the world usually report that they felt not properly positioned to deal with ethical issues or dilemmas they came across during clinical work. Medical code of ethics, etiquette and conduct of professionals are guidelines that have been stipulated to protect the patient. The main aim of this research was to assess the knowledge ophthalmic trainees had in ethics and also assess their observations made while under tutelage. A descriptive study with a cross-sectional design was used in this research. Fifty (50) final year ophthalmic trainees were sampled conveniently from the Kwame Nkrumah University of Science and Technology, University of Cape Coast and Korle-Bu Ophthalmic Nursing School. Questionnaires were administered to 80 respondents. About 53% of trainees recalled and could recite the principal elements of the ethical codes and 60% reported that the Patients’ Charter was easy to implement. Fifty percent (50%) of the trainees reported that practitioners sometimes informed patients on their conditions with the same percentage reporting that practitioners sometimes involved patients in decision making on their ocular health condition. It is recommended that the Ghana Health Service and the Ministry of Health should be more involved in the training of ophthalmic trainees and must include in their curriculum, a combination of lecture room work, community service and experiential learning. This would position the trainees in terms of confidence and know-how in handling issue regarding ethics.

Keywords: Ophthalmic trainees, patient charter, code of ethics, practitioner, patients

Studies in recent times have shown that health trainees across the world usually report that they felt not properly positioned to deal with ethical issues or dilemmas they came across during clinical work.^1–4 The training guidelines of health work, stress on the development of certain competencies with regards to medical ethics prior to main fieldwork. As such, there is a disconnect between what was learned “indoors” and what faces them “outdoor”. It has been made known through evidence that teaching certain skills in health which include, ethical and cultural competencies, is most effective through service learning; a combination of community service with experiential learning.¹ Furthermore, better ethics training in health science schools have been associated with higher confidence but not higher knowledge.⁵ Medical trainees have also been shown to demonstrate unwillingness to seek aid unless in extreme cases where it is absolutely paramount, a situation that brings the safety of the patient into question.⁶

During medical training, trainees come under the tutelage of medical practitioners who are not only expected to have the skills and knowledge pertinent to their field of practice but also with the ethical and legal expectations that arise out of the standard practices.⁷ Their ability to carry out these expectations are key to the clinical development of trainees who observe and learn from them as well.⁸ Medical code of ethics, etiquette and conduct of professionals are guidelines that have been stipulated to protect the patient, to that end, the employment of the four major ethical principles in health care: Beneficence, Nonmaleficence as well as Respect for Autonomy and Justice is very paramount at all levels of training.⁹ This research sought to assess the knowledge ophthalmic trainees had in ethics and also assess their observations made while under tutelage.

This is a descriptive cross sectional study consisting of 50 final year trainees consisting of ophthalmic nursing students and final year optometry students. The Ophthalmic Nurses Training School at Korle Bu in Accra, Department of Optometry and Visual Science at Kwame Nkrumah University of Science and Technology in Kumasi and Department of Optometry at the University of Cape Coast in Cape Coast were selected for the survey. The research took place between January 2016 and March 2016. Subjects were required to complete a simple questionnaire at the start of the study, which were tailored to ensure that the various ethical concerns were duly captured. Permission was sought from final year trainees. All participants were informed of the purpose and design of the study and also the voluntary nature of their participation. Statistical Package for Social Scientists software version 20 was used to analyze the data obtained by computing frequencies and correlations.

Fifty (50) final year trainees participated in the study. Thirty were ophthalmic nursing trainees and 20 were optometry students.

Results from final year trainees

The Table 1 below shows trainees responses to the ease of application of medical ethics

The principal elements of the code of ethics and the trainees

The sampled population of fifty trainees were interviewed on the issue of the recall of the principal elements of the code of ethics; twenty-six (52.0%) trainees remembered these elements and recited them correctly, while 24 (48.0%) trainees could not recall the principal elements of the code of ethics they had been taught in school. Figure 1 depicts the results.

Figure 1The principal elements of the code of ethics and the trainees.

The ease of implementation of patient charter by trainee

Thirty (60.0%) trainees reported that the Patient Charter was easy to implement whiles 20 (40.0%) trainees claimed the Patient Charter was not easy to implement at the clinical level.

Practitioners informing patients on their conditions as observed by trainee

The trainees were questioned as to whether from their observation, practitioners informed patients about their conditions. Twenty-four (48.0%) trainees reported that practitioners sometimes informed the patients about their ocular health conditions and thirteen (26.0%) trainees claimed they saw practitioners very often informing patients on their ocular health conditions. Nine (18.0%) of the trainee respondents told the researcher that some practitioners often informed patients about their ocular health conditions while 4 (8%) trainees revealed that practitioners never informed patient about their condition during ocular health assessment. The Figure 2 below outlines their responses

Figure 2 Practitioners informing patients on their conditions as observed by trainees.

Practitioners involving patients in deciding treatment options as observed by trainees

The trainees were again assessed on their opinion as to how frequent practitioners involved patients in decision making concerning treatment options for their ocular health condition. All 50 trainees responded to this question; twenty-five (50.0%) trainees said practitioners sometimes involved patients in deciding treatment options; thirteen (26.0%) revealed that practitioners never involved patients in deciding treatment options, eight (16.0%) trainees claimed practitioners often involved patients in deciding treatment whiles 4 (8.0%) said practitioners very often involved patients in deciding treatment options (Figure 3).

Figure 3Shows the responses of the trainees.

Practitioners adherence to some of the code of ethics as observed by trainees

The trainees were asked to report whether from their observation practitioners were influenced by the religion, ethnicity or the socioeconomic status of their patients. Twenty-three (46.0%) trainee respondents claimed practitioners were never influenced by the religion, ethnicity or the socioeconomic status of their patients, thirteen (26.0%) trainees said practitioners were sometimes influenced by the religion, ethnicity or the socioeconomic status of their patients, eight (16.0%) trainee interviewees alleged that practitioner were very often influenced by the religion, ethnicity or the socioeconomic status of their patients whiles 5 (12.0%) trainees asserted practitioners were often influenced by the religion, ethnicity or socioeconomic status of the patient (Figure 4).

Figure 4 Influence of practitioner by patients' religion, ethnicity and socioeconomic status.

All the trainees reported that they had studied medical ethics in school with 66.0% of them reporting that it was easy to apply at the clinical level. Approximately 52% could remember and recite the principal elements of the code of ethics regulating the practice of eye health care. The teaching of medical ethics in health school has become very important. A study by Gondal,¹⁰ in assessing the role of teaching ethics in medical curriculum revealed that, there was a clarion call for revised medical ethics education during teaching in medical schools for undergraduates because the existing teachings were becoming redundant. He also suggested that a well-constructed course outline be employed across board and that more teachers should be trained properly in medical ethics, so as to equip the medical professionals being trained. This information was got after a thorough Internet search was done expansively on Pubmed, Google scholar and Medline on various papers with respect to teaching and the impact of teaching bioethics to medical students.^10,11 The trend toward revised medical ethics education with properly trained tutors to that effect, might have been the reason for all trainees reporting to have studied medical ethics in school with more than half reporting ease of application. About 60% of the trainees reported that the Patients’ Charter was also easy to implement. By and large, the ability to recall the code of ethics by trainees, showed a better awareness of the code of ethics of the ophthalmic practice; this would auger well for patients if the trainees should start practicing at the clinical level.

Eighteen percent of the trainees reported that practitioners very often informed patients on their ocular health conditions with eight percent reporting that practitioners very often involved patients in deciding treatment options about their ocular health conditions. Doctors in government hospitals are usually burdened with large number of patients waiting and so, do not have adequate time to address their patients in the right matter. This might have been the reason why trainees rarely observed adequate doctor-patient interaction. This presents an issue because doctor-patient interaction is pivotal to the patient and the hospital as a whole. A study by Zolnierek et al.¹² showed that communication in care for patient is highly correlated with patient adherence to medication and treatment protocols. In their study, there was a 19% higher risk of non-adherence among patients whose physician communicated poorly compared with those whose physician communicates well.^13,14

About 26% of the trainees had observed that practitioners were sometimes influenced by a patient’s religion, ethnicity or socioeconomic status. Ghana is seen to be a religious country made up of predominately Christians and Muslims. A staunch Christian who encounters a Muslim, especially a female one, is very cautious as to how to handle such a patient, lest he contravenes their law. Furthermore, individuals of high social status or opulence are given more attention and handled with much care, it is only “natural” that such things occur, explaining the trend observed by the trainees. A study done by Bradley,¹⁵ also reported such trends. Patient related factors that influenced decision making included, ethnicity, age, education, social class, doctor’s feeling towards the patient and the doctor’s wish to maintain good doctor-patient relationship.^16–18 These behaviors on the part of practitioners as reported by trainees might influence their perception of ethical principles as well.

The Ghana Health Service and the Ministry of Health should be more involved in the training of ophthalmic trainees and must include in their curriculum a combination of lecture room work, community service and experiential learning. This would position the trainees in terms of confidence and know-how in handling issues regarding ethics. Also ophthalmic practitioners should be admonished to become good examples to these trainees in the way they handle patients and ethical issues.

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