Understanding Legal and Ethical Responsibilities: A Study on Nurses’ Knowledge in Pediatric and Neonatal Care Units in Duhok City, Kurdistan Region of Iraq

Introduction

Legal and ethical norms are the cornerstones of governing human actions and conduct and are critical to numerous realms of social activities. (Moosavi et al., 2017) Nursing is one of the stress-induced professions(Baral et al., 2018; Chegini et al., 2019). Their function is vital in the nursing profession,  where the ultimate goal is to maintain or restore human health. In Brazil, nurses must show themselves to be responsible and accountable in their obligations based on the laws and ethics of the profession (Jahanpour et al., 2013). Mistakes due to deviations in the areas not only pose personal struggles for nursing professionals but also threaten the integrity and public confidence of the profession(Sadoughi et al., 2011). A significant percentage of medical errors can be attributed to insufficient knowledge of how treatments should be given. The inadequacies of such an approach can have physical, emotional, and financial repercussions for the patient and may also undermine the patient's trust in the healthcare team (Azimi et al., 2013; Ghodousi et al., 2013).

Medical ethics is about the professional conduct and obligations of health care professionals. Knowing clinical ethics helps to foresee, manage, and solve ethical problems one faces in daily work. The nursing staff have many ethical duties towards patients in clinical practice. Ethical guidelines represent a means for offering quality care, acknowledging patients' rights, promoting patient safety, respecting human dignity, and establishing the requested behaviors within the professional environment. All of the reasons stated above make it very important that nurses have a good knowledge, attitude, and practice of clinical ethics (Hakko et al., 2018; Ranasinghe et al., 2020; Shrestha et al., 2021; Tafesse et al., 2022; Khoury et al., 2023).

Studies have shown a positive relationship between nurses’ knowledge of professional guidelines and their practice behavior. Such a correlation supports the notion that the use of evidence-based and safety-oriented guidelines that are rooted in such knowledge may reduce the risk of legal action considerably (Jahanpour et al., 2013). Therefore, the significance of the nurses' familiarity with legal regulations and professional standards is demonstrated in the reduction of medical errors (Jolaee et al., 2010).

It is essential In order to detect risk variables across a wide range of age groups. The objective of the present study was to assess nurses' knowledge concerning ethical & legal responsibilities in Duhok City, situated in the Kurdistan region of Iraq.

Materials and Methods

Study Design

This descriptive cross-sectional study aims to examine the legal and ethical responsibilities of nurses regarding their knowledge in pediatric and neonatal care units in Duhok City, Kurdistan Region of Iraq, from August 1^st, 2024, to April 30^th, 2025.

Setting of Study

The current study was conducted in the Maternity Hospital and Hivee Pediatric Hospital (pediatric and neonatal care units). These units were selected because they focus on susceptible patient populations, which entails a high level of legal and ethical consciousness among nurses.

Sample and Sampling

A non-probability purposive sampling method was employed to recruit 70 nurses working in pediatric and neonatal units within public hospitals in Duhok City, Kurdistan Region, Iraq.

Inclusion Criteria:

• Having at least one year of experience in pediatric or neonatal care.
• Willingness to participate in the study.

Instrument and Data Collection Tools

The data were collected through the adaptation of a structured questionnaire. The first section focused on obtaining demographic information about the nurses, including their age, gender, educational background, marital status, family status, work area, clinical experience, and training history. The second section discussed legal and ethical concerns in pediatric nursing and was split into three parts. The first portion of the test assessed nurses' knowledge of general pediatric nursing through 14 multiple-choice questions, each with three response options. The second portion included 10 multiple-choice questions on the legal aspects of pediatric nursing, and the final portion contained 10 multiple-choice questions that examined the ethical issues. The questionnaire was originally written in three different languages: Kurdish, Arabic, and English. Data were attained using two different approaches in order to accommodate the nurses' hectic schedule and the limited number of staff members available to take care of pediatric patients.

To ensure the legitimacy of the questionnaire, it was discussed with experts with extensive experience in pediatric nursing. Their feedback was incorporated into the final version of the questionnaire. Additionally, a pilot study was conducted to assess the instrument's validity. A random sample of 10 nurses was later excluded from the main study; these participants participated in the pilot. The reliability analysis yielded a Cronbach's alpha coefficient of r=0.8, which is considered suitable for the questionnaire.

 Measurement

To determine the nurses' knowledge level, the second Part of the questionnaire is segmented into three components: the first contains fourteen multiple-choice questions (MCQs) related to the General Pediatric Nursing Knowledge section. On the second one, ten multiple-choice questions (MCQs) pertain to the legal aspects of pediatric nursing. Ethical Issues in Pediatric Nursing 10 Multiple-Choice Questions is the last one covering fundamentals. Each question in the sections mentioned above has three responses.

Each accurate response received one point, whilst incorrect or unanswered items were assigned a score of zero. The maximum attainable score for the knowledge component was 34 points.

To enhance the understanding of knowledge levels among nurses, scores were classified as follows:

Low Knowledge: less than 50% correct responses (0–16 points)

Fair Knowledge: 50% to 75% correct responses (17–25 points)

High Knowledge: more than 75% correct responses (26–34 points)

Data analysis

The collected data were analyzed using descriptive and inferential statistics using SPSS version 27. A one-way ANOVA, independent samples t–test, and correlation were applied to determine the association between Nurses' socio-demographics and their knowledge.

Ethical consideration

Ethical considerations were taken into account by obtaining approval from the Scientific Committee at the College of Nursing, Duhok University, the Kurdistan Region of Iraq, followed by the Ethical Committee of the Directorate of Health in Duhok (No: 31072024-6-25 in 31th , July ,2024), and the respective hospital managers before engaging with the staff. In addition, informed consent was obtained from each nurse.

Results

The analysis of demographic data indicated that the age range of the nurses was 21-50 years, with 51.4% in the 27-32 age group, 18.6% in the 21-26 group, 12.9% in the 33-38 group, and 8.6% in both the 39-44 and 45-50 groups. Concerning gender distribution, 50.4% were female and 49.6% were male. In terms of their educational level, most of them hold an institute diploma certificate (58.6%), and 32.9% have a Bachelor's degree. The Marital status analysis revealed that most participants were married (61.54%), followed by unmarried individuals (36.92%). In comparison, a small fraction were separated (1.54%). Additionally, most of the respondents came from nuclear families (61.4%), with joint (37.1%) and extended families (1.4%) being less represented. About working area nurses were most commonly employed in the Neonatal Intensive Care Unit (NICU) (25.7%), followed by those in premature infant care units (20%), and Pediatric Intensive Care Units (PICU) (15.7%). The remaining participants worked in emergency, surgical, and medical settings.  Concerning Clinical experience, nearly half of the participants had 6–10 years of Clinical experience (45.7%), followed by 1–5 years (25.7%). More than half of the participants receive training regarding ethical and legal responsibility. However, this positive perception was limited to a minority of the sample, as nearly half of the respondents (48.6%) reported having no prior training in this area. Additionally, among those trained, seminars (25.7 %) and formal education (15.7 %) were the most common types, and a total of 36.92% of the participating nurses perceived the training on legal and ethical issues as adequate or excellent. (See Table 1).

The table presents the distribution of nurses’ knowledge levels on legal and ethical responsibilities in pediatric and neonatal care units. Most nurses (n=50) demonstrated a fair level of knowledge, and a notable portion (n=11) showed low knowledge. Finally, only a small fraction (n=9) of the participants demonstrated high knowledge. (See Table 2).

Table 2. Nurses' Knowledge of legal and ethical responsibility

This finding reflects the relationship between age and knowledge among the 70 participants. No statistically significant relationship was found between age and nurses' knowledge, with a p-value of 0.852 (See table 3).

Table 3. Correlation between Nurses' Knowledge and their Age

The table implies the relationship between nurses' knowledge and their gender. Despite a slightly higher average among male participants, there is no significant gender-based difference in nurses' knowledge regarding legal and ethical responsibilities in pediatrics and neonatal care settings (See table 4).

Table 4. Comparison of Nurses' Knowledge Scores Based on Gender

The findings show a statistically significant relationship between educational level and nurses’ knowledge of legal and ethical responsibilities in pediatrics and neonatal care settings. The F (3, 66) = 7.296, and Significance at p < 0.001 (See table 5).

Table 5. Nurses’ Knowledge by Educational Level

The present study shows the significant associations between nurses’ knowledge and their working area, illustrating that there were significant associations between the area of working and their knowledge of legal and ethical responsibilities in pediatric and neonatal care units. P-value is ≤ 0.001 (See Table 6)

Table 6. Nurses’ Knowledge by Working Area

According to the results of the present study, the results for nurses’ knowledge based on years of experience indicate that experience level significantly influences their knowledge of legal and ethical responsibilities in pediatric and neonatal care units. Sig is a p-value of 0.015 (See Table 7)

Table 7. Nurses’ Knowledge by Years of Experience

The result also reveals a statistically significant difference in knowledge scores between nurses who received training and those who did not, a p-value ≤0.001 (See Table 8).

Table 8. Comparison of Nurses' Knowledge Scores Based on receiving a training course

Discussion

Nursing is a medical science whose objective is to contribute to maintaining the health and well-being of the individual, the family, and the community. Nurses confront particular ethical concerns in the provision of nursing care, and thus, one of the most prominent issues in nursing education is the acquisition of ethical principles. Nursing knowledge has been relatively well grounded and is based on technical skills (Hussein Abdelhammed et al., 2022).

The current study investigates the nurses' understanding of their legal and ethical responsibilities in the Kurdistan region of Iraq. It concentrated on nurses aged between 21 and 50 years. More than half of the participants fell within the 27–32 age range, highlighting a predominance of younger professionals in the nursing workforce. Similar age demographics have been noted in other research, for instance, a study conducted in Egypt by Ibrahim et al. (2019) reported that over 43.8% of nurses were between 25 to less than 35 years old while the minority (11.1%) was more than 45 years old (Ibrahim et al., 2019). On the other hand, the current findings are inconsistent with those of a study conducted in Turkey by Şahiner, P. (2024), which found that there is an equal distribution of younger nurses (aged 23–33) and older nurses (aged 34–50)(Şahiner, 2024).

A near-equal gender split is noteworthy and contrasts with global trends, where females comprise more than 80–90% of the nursing workforce (WHO, 2020). A total of seventy Nurses were working at the Hivee Hospital and Premature unit at the Maternity Hospital, over half of the nurses were females, and nearly half were males. This finding refutes the results of a study from Turkey, Şahiner, P. (2024), which found that the majority (n=145; 70%) of nurses were Female, emphasizing the unique balance seen in this dataset (Şahiner, 2024). The current research also contradicts another study conducted in Egypt, which discovered that over seventy percent of the nurses in the sample were female (Ibrahim et al., 2019).

Also, the results demonstrated that more than half of the Nurses had a Diploma degree, and more than a quarter of them held a BSc Degree, with 58.6 % and 32.9 %, respectively. This finding is inconsistent with another study carried out in Iran by Mojarad et al. (2022), which showed that over eighty percent of nurses held a bachelor’s level qualification (81.9%) (Mojarad et al., 2022).

Regarding their marital status, nearly two-thirds of them (61.54%) were married, and more than half (61.4%) of them lived in nuclear families this result is line with study that was done In Iran, Mojarad et al. (2022) noted that nearly three- quarters of the nurses were married, and often experienced higher levels of occupational stress due to dual responsibilities at work and home (Mojarad et al., 2022).

Furthermore, the findings revealed that almost half of the nurses worked in the NICU and preterm unit (25.7% and 20%, respectively). And have 6–10 years of clinical experience.  Approximately half (51.4 %) of the nurses had received some training, while the rest (48.6 %) had not. Among those trained, seminars (23.08%) and formal education (15.38%) were the most common types. This suggests limited access to structured continuing professional development (CPD), essential for ensuring clinical competency, especially in high-risk settings like the NICU or PICU. A total of 35.7 % of the participating nurses perceived the training on legal and ethical issues as adequate or extremely adequate. However, this positive perception was limited to a minority of the sample, as more than half of the respondents (48.6 %) reported having no prior training in this area. This discrepancy reveals a critical gap between training availability, participation, and perceived quality among nursing professionals. Previous studies have consistently highlighted the need for targeted and ongoing educational interventions to address this shortfall. For example, Sabra and Hossny (2020) also found that around 45.5% of participants possessed 5 to 10 years of experience. In contrast to the current study, a greater proportion—approximately 70.9%—had participated in training courses (Sabra et al., 2020). Similarly, Aliyu et al. (2015) revealed that just thirty-six percent of the individuals who participated in the study had relied on training workshops and seminars as their major source of knowledge (Aliyu et al., 2015).

This study's results revealed that most nurses (71.4%) have a moderate level of knowledge regarding legal and ethical responsibilities. In comparison, 12.9% show high knowledge, and 15.7% show low knowledge. This spread indicates a relatively good general awareness among nurses but also shows a need to achieve higher levels of competence in these crucial areas. These results are in line with those of previous research studies in similar healthcare settings. For example, Shrestha & Jose (2014) reported that about 45% of the Nurses had adequate knowledge of ethics, and the rest had inadequate knowledge of nursing ethics (Shrestha et al., 2021). Similarly, Koshy (2016) found that most of the nurses in pediatric wards at hospitals in Madhya Pradesh, India, understood both the ethical standards of professional behavior and practice (Koshy, 2016). Also, the result of the current study is in line with the study's findings in Saudi Arabia (Faraz et al., 2024).  The results of the research in India contradict all of these studies. In that study, nurses' awareness of legal concerns was found to be low in 76% of surveyed rural hospitals in India (Thirunavukarasu et al., 2018).

The correlation is negative and statistically insignificant (p > 0.05), which means there is no significant relationship between the nurse's age and gender and the level of knowledge about legal and ethical responsibilities. In other words, nurses’ age does not seem to predict or affect their knowledge scores in the current study. Moreover, Consistent with the recent findings, a survey undertaken at Udupi Hospital in Karnataka, India, which investigated critical care nurses' understanding of legal and ethical dimensions, similarly revealed no noteworthy correlation between demographic variables and the knowledge levels of the nurses (Verghese et al., 2016). This result is also consistent with the work of Kaur et al. (2014), who also confirmed that demographic determinants, including age and gender, do not always significantly influence providers’ legal or ethical knowledge levels (Kaur et al., 2014). Others, on the contrary, reveal antagonistic findings. For instance, Shafiei et al. (2013) discovered a direct correlation between participants' age and an increase in knowledge. They proposed that clinical experience could result in enhanced familiarity with legal and ethical guidelines, thereby facilitating deeper learning (Shafiei et al., 2013). Also, a study carried out in India conveys a distinct perspective, as it indicated a statistically significant correlation between the age of nurses and their knowledge level (Mojarad et al., 2022). A significant relationship was seen between the Nurses' Educational Level and their Knowledge (p= ≤ 0.001). Similar findings were reported in a study carried out in Egypt by Abdelhammed et al. (2022), who noted that older nurses, those with higher educational qualifications, and more experience tended to have better knowledge, p=0.001 (Hussein Abdelhammed et al., 2022). These findings are also in agreement with the study conducted by Kaur et al. (2014), who argued that professional qualification affects nurses’ capacity to deal with patient-related legal matters; the graduate nurses scored better than the diploma nurses (Kaur et al., 2014). Likewise, Zarzeka et al. (2016) found that Nurses possessing advanced education demonstrated a statistically significantly greater awareness of the independent aspect of their profession (p<0.002) (Zarzeka et al., 2016).

The results also indicated a statistically significant relationship between the Nurses' Knowledge and their workplaces (p-value = ≤ 0.001). The current finding is in line with a study done by Ibrahim et al. (2019), which revealed that Nurses in critical care units exhibited significantly greater knowledge than their counterparts in general care units (p = 0.008) (Ibrahim et al., 2019). The findings indicated a statistically significant correlation between nurses' knowledge of ethical and legal issues and their years of experience in various clinical wards (p = 0.015). Furthermore, previous involvement in training courses significantly influenced the statistical relationships identified in the present results (p <0.001). These results align with those of prior research studies in similar healthcare settings. For example, A study conducted by Khulpuwa Maring and Kala Barathi among nurses in obstetrics and gynecology wards in India revealed a noteworthy correlation between the nurses' work experience in these settings and their understanding of the professional, ethical, and criminal laws pertinent to the nursing field (Maring et al., 2019). In a similar vein, these findings align with those of a prior investigation carried out by Kaur et al. A consistent positive correlation was identified between nurses' legal awareness and their total nursing experience, in addition to the training institution (p < 0.05) (Kaur et al., 2014). These results are Contradictory to Verghese et al. (2016), who observed no correlation between the extent of legal and ethical knowledge in patient care and the duration of clinical experience (Verghese et al., 2016).

Conclusion

In summary, the research has highlighted a fair level of awareness about pediatric and neonatal nurses' legal and ethical accountabilities. Although most respondents were between 27 and 32 years old and had a diploma degree, mean scores did not significantly correlate with age and gender. Instead, determinant factors including education, workplace, work experience, and past training were significantly associated with nurses' knowledge about their legal and ethical responsibilities. These results highlight the need for focused educational interventions and ongoing professional development to improve nurses’ competence in this vital aspect of care, ultimately enhancing patient safety and ethical care.

Conflict of interest

I declare that there are NO conflicts of interest

Acknowledgment

I want to thank the Duhok Directorate of Health and the administrations of Hivee Pediatric and Maternity Hospitals for their cooperation during this research.

I express my gratitude to all the nurses who participated in this study. Their contribution was significant and highly valued.

Funding: This research was conducted without the support of external funding sources.