Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana.

BACKGROUND: Nursing is a profession that care for personal and private aspects of people's lives. Therefore, nurses need to know the basic ethical aspects of nursing which is integral in nursing practices. The purpose of the study was to describe the ethical knowledge, attitude and practice of nurses in the Cape Coast Metropolis of Ghana.
METHOD: A cross-section design was used to collect data from 264 nurses in three selected healthcare facilities in the Metropolis. A structured questionnaire was administered to all the categories of these nurses in the selected facilities. Frequency counts and multiple regression statistics were used to analyze the data.
RESULTS: The results show 78% of nurses possess good ethical knowledge, 84% had a positive attitude, while 98% had good ethical practices. The results further show that nurses' professional rank [F (1, 259), 2.35, p = .02] and academic qualification [F (1, 259), 2.67, p = .008] were significant predictors of their ethical knowledge and attitude, respectively.
CONCLUSION: Inadequate resources, poor set up of working areas and understaffing are the major barriers limiting the practice of good ethical standards among the nurses. The Regional Health Directorate, the Ministry of Health and the Managers in charge of the health facilities need to work together to eliminate these barriers as they have the potential to negatively impact quality healthcare delivery in the Metropolis.

Introduction

Ethical issues in healthcare and nursing practice are becoming more complex with medical advances, and the increased dynamics of the healthcare system [1]. Ethics in healthcare is the standards or principles of moral judgment or actions which provide a methodical system in differentiating right from wrong based on certain beliefs [2]. And because nurses spend a lot time with patients and patient families, the practices of nurses in relation to their clients become paramount (Kieft et al., 2014). Thus, the first step for a nurse to make ethical decisions is to identify and understand the ethical issues surrounding patient care. Ethical nursing practice involves core ethical responsibilities that nurses are expected to uphold, which date back since 1953 [3]. Ethical codes in nursing, serve not only to define nursing “profession” but also outline primary duties, responsibilities and obligations towards their clients [4]. In that case, professional code of ethics for nurses serves as a guide for carrying out nursing responsibilities in a manner consistent with quality care, ethical obligations of the profession, acceptance of the rights of individuals, and for patients’ safety [5]. Moreover, individual dignity needs to be respected regardless of who is receiving the care, poor, rich, black, white, Christian, Muslim, male or female, a child or an adult [6], or a person of any gender.

It is important that nurses acquire and practice with the necessary knowledge of ethics to impact positively on the lives of their patients, patient family, and the society [7]. However, various studies have shown nurses’ weaknesses in the knowledge of ethics and its application in practice towards patients and their families [8, 9]. For instance, it has been reported that nurses’ approaches to ethical problems in Ghana do not always meet expectations of the international code of practice [7]. Accordingly, nurses’ ethical practices are being informed by local ethical practices which are related to the institutional setting and cultural environment in the country, Ghana [8]. Unfortunately, while some cultural values are complementing to the international best code of ethics and principles, many others were conflicting [7].

In Ghana, the Nursing and Midwifery Council (NMC), a statutory body responsible for nursing and midwifery professions, has a code of ethics. The code of ethics is meant to inform nurses and midwives of the best standard required in the exercise of their professional accountability, to inform the public, other professionals, and employers of the standard of professional conduct expected of registered nurses and midwives in the discharge of their duties at the various healthcare facilities [6]. Thus, demonstration of any unethical conduct by nurses on duty of care would mostly come as a result of their level of knowledge, attitude and many other factors such as institutional and social settings [10]. For instance, unethical behaviors of nurses are believed to be related to insufficient personnel, poor working conditions, excessive workload, lack of supervision, and minimal level of in-service training [10]. Evidence further suggests that majority of nurses do not acknowledge ethical issues at work, for which they exhibit unethical behaviors in their practice [11]. Furthermore, personal variable such as age, gender, level of education, professional qualification, marital status, years of experience, rank, ward setting, training, and institution could have significant influence on nurses’ level of knowledge, attitude, and practice of ethics in their professional duties [11-13]. These practices do not only negatively affect the health outcomes of patients under care, they equally reduce the professional image of nurses, their facilities, and the nursing profession [10, 13].

The aim of nursing profession is to provide the highest possible standard of care to patients, which requires that a high standard of professional behavior is exhibited [14]. Studies have shown that nurses lack ethical knowledge, portray negative ethical attitudes, and failed to apply their ethical codes in caring for their patients [9]. For example, media report revealed that in Ghana, nurses in the Cape Coast Metropolis have fallen short of applying ethical knowledge in their duties [6]. Moreover, it has been observed that at-duty-nurses insult their patients for expression of labor pain during delivery [7, 15]. For example, women who attended antenatal clinics complained about how nurses embarrassed them because of the women’s failure to attend antenatal appointments on schedule and their inability to afford some of the items required for delivery [16]. Beyond these, nurses are often described as unfriendly, stubborn, disrespectful, saucy, cruel, callous, and inhuman to their clients [17, 18]. Despite these growing concerns and incidences of unethical practices of nurses in health facilities in the Cape Coast Metropolis, there is a paucity of literature on the extent of such behavior and factors that might be influencing such practices. Hence, this study aimed to explore knowledge, attitude, and practices of ethics in nursing care among nurses in the Cape Coast Metropolis.

Methods

This was a cross-sectional survey involving 264 nurses from three healthcare facilities within the Cape Coast Metropolis (i.e. Cape Coast Teaching Hospital [CCTH], Municipal Hospital [MH] and University of Cape Coast Hospital [UCCH]. The data were collected between September and December 2016, in the three major healthcare facilities within the Cape Coast Municipality. This study applied a census, targeting all nurses, but those nurses on annual leave, study leave, sick leave, or on special assignment out of the facilities could not take part in the study. Thus, we are of the view that these group of nurses represent the general nursing population in the Cape Coast Municipality, because the three healthcare facilities have all the categories of nurses. Moreover, we recorded a return rate of approximately 81% (264 out of a total of 326). Thus, all the 326 nurses working in the municipality hospitals were included in the study.

Dependent measure

We used a 32-items questionnaire, developed by the researchers, to collect data. The instrument was developed from previous empirical literature on ethics and the code of ethics of Nurses and Midwives Council (NMC) of Ghana. The questionnaire solicited information on knowledge, attitude, and practice of ethics, and was in two sections, A and B. Section A was made up of six multiple choice items which solicited nurses’ background characteristics such as sex, age, professional qualification and rank, academic qualification, and years of working experience. With 24 items, the section B measured knowledge, attitude, and practice of ethics in nursing practice. This section also collected information on the nurses’ sources of knowledge (Q29) and barriers (Q30) to their ethical practice. The section was subcategorized into I, II and III, with I measuring knowledge about ethical practices (Q7-Q16), which the participants responded to as yes = 3; no = 2; do not know = 1. Subsection II contained two items (Q17-Q22) that solicited information about nurses’ ethical attitudes, where participants responded to as strongly disagree = 1; disagree = 2; agree = 3 and strongly agree = 4. Furthermore, subsection III (Q23-Q28) measured the extent of ethical practice among nurses, with the response categories of never = 1, seldom = 2, occasionally = 3 and always = 4. Section B yielded separate scores for knowledge, attitude, and practice of ethics by nurses. The high scores or arithmetic means reflect maximum performance on that particular construct (i.e. knowledge, attitude and practice).

Copies of the developed questionnaire were initially given to five university level and four diploma level nursing students to assess. The reviewed questionnaire was then given to two nursing tutors and two lecturers for their expert inputs. To pilot test the questionnaire, we further administered it to 79 conveniently sampled nurses from Asankrangwa Catholic Hospital and Samartex Hospital at Samreboi both in the Wasa Amenfi West District in the Western Region of Ghana. This group of nurses did not take part in the main study. Instrument yielded an internal consistency reliability value of 0.73, based on the pilot test and 0.78 from the main study.

The study protocols were approved by the Institutional Review Board (IRB) of the University of Cape Coast, Ghana (ID: UCCIRB/CES/2015/1), and permission was granted by the heads of administration and unit heads of the three healthcare facilities. To increase anonymity and confidentiality of the information provided by the nurses, copies of the instrument were put in unsealed envelopes and deposited with the ward in-charges who did the onward distribution to the nurses. Using the instruction on the introductory page of the questionnaire, we directed the nurses to seal the envelope containing the filled questionnaire before returning it to their in-charges. We utilized the ward in-charges in the data collection because they work daily with the nurses. The nurses were given three days to complete the instrument and returned same to their in-charges for the researchers to retrieve. We also attached an informed consent form to the instrument which every participant was supposed to sign.

Data analysis

Frequency and percentage counts were used to determine nurses’ level of knowledge, attitude and practice, and barriers to professional ethical conduct at work. Knowledge was measured initially as yes (3), no (2) and I don’t know (1) and was later categorized into two, yes and no because no and I don’t know were put together. Thus, from the 10 items measuring knowledge, the scores range from lowest of 10 to highest of 30, and participant must score 21 or higher to be categorized as knowledgeable, between 11-and 20 was considered moderate level of knowledge, and between 1 and 10 as low in ethical knowledge. Moreover, nurses’ attitude towards ethical issues at work was recategorized as positive or negative, from the initial four-point scale. Attitude was measured with six items (Strongly Disagree = 1 to Strongly Agree = 4), and the higher the score, the more positive the attitude of the participant is towards nursing ethical issues. And that, a nurse must have scored a composite score of 13 to be deemed to have positive attitude.

Furthermore, the extent of ethical practice was classified as never, seldom, occasionally and always (1 to 4), and the higher the composite score, the better the practices. In that case, a score between 13 and 24 is classified as adequate practice and that between 1 and 12 inadequate. Moreover, barriers to the practice of ethics among nurses were analysed and reported with the various items listed on the instrument using frequency and percentage analysis.

We further applied multiple regression analyses to determine the extent to which background characteristics of the nurses influence their knowledge, attitudes, and the extent of ethical practice at their various units of work. The constructs- knowledge (measured with 10 items), attitude (six items) and practice (six items) were aggregated to for composite numeric or continuous scores that satisfied regression analysis. Thus, we did run separate regression analysis for each of these variables against the demographic variables which have different levels of measurements. Statistical significance levels were determined at p value<0.05 [19, 20]. SPSS version 20.0 software was used to run all the statistical analyses.

Results

The majority of the participants (n = 194; 74%), were females, with only 26% (n = 70) being males. Sixty seven percent (n = 178) of the nurses were between ages 21 and 30, 24% (n = 62) were between 31 and 40 years, and nine percent (n = 24) were 41 years or above (See Table 1 for the rest).

Table 1

Demographic characteristics, ethical knowledge, attitudes, practices and barriers to ethical practice by nurses.

	No.	%
Gender
Male	70	26
Female	194	74
Age
21–30	178	67
31–40	62	24
41+	24	09
Education
Diploma	138	52
Certificate	71	27
Bachelor or higher	55	21
Categories
Registered General Nurse	138	52
Health Assistant Clinical	55	21
CHN/RCN/RMN	41	16
Registered Midwives	30	11
Working Experience
5 Yrs or Less	177	67
More Than 5 Yrs	87	33
Knowledge
Good	205	77.7
Moderate	44	16.6
Poor	15	5.7
Attitude
Positive	221	83.7
Negative	43	16.3
Practice
Adequate	258	97.7
Inadequate	6	2.3
Barriers
Inadequate resources	187	70.8
Poor set up of working area	165	62.5
Understaffing	159	60.2
Inadequate education about the code of ethics	136	51.5
Conflicts between nurses and doctors	111	42.0
Working with unethical colleagues	111	42.0
Overcrowding	108	40.9
Lack of space	106	40.2
Working with incompetent colleagues	99	37.5
Conflict with superiors	92	34.8
Total	264	100

Note: CHN = Community Health Nurse; RCN = Registered Community Nurse; RMN = Registered Mental Nurse.

The results show that 77.7% (n = 205) of the nurses recorded good knowledge, 66.6% (n = 44) moderate, whereas 5.7% (n = 15) low. Again, majority, 83.7% (n = 221), of the nurses showed positive attitude, while 16.3% (n = 43) reported negative attitude towards ethics of their profession. Furthermore, the results reveal that 98% (n = 258) of the nurses recorded high practice of ethical standards at work, while 2.3% (n = 6) did not (see Table 1). The results on barriers to ethical practices reveal that more than half (71%, 63%, and 60%) of the nurses indicated that inadequate resources, poor set up of working areas and understaffing (among many others) prevent them from practicing good ethics (see Table 1).

Multiple regression analysis was calculated to predict nurses’ ethical knowledge using sex, age, rank and academic qualification as predictors. The model revealed a significant prediction, F (4, 259), 17.41, p = .001, accounting for 9% of the variance in nurses’ knowledge on ethics. Specifically, participants’ professional rank was the only independent variable significantly predicting nurses’ ethical knowledge F (1, 259), 2.35, p = .02, and accounted for 48% of their knowledge on ethics (see Table 2).

Table 2

Influence of sex, age, academic qualification and rank of nurses on the level of their ethical knowledge.

	B	R	R 2	β	t	p-value
Constant	6.69	.30	.09		17.41	.001
Sex	.00			.00	.02	.985
Age	.00			.01	.16	.874
Academic qualification	.17			.12	1.57	.119
Rank	.48			.21	2.35	.020

df (4, 259); F (17.41)

The second multiple regression analysis also indicated that the model significantly predicted nurses’ attitude to ethics, F (5, 258), 18.02, p = .001, accounting for a 6% variation in nurses’ attitudes towards ethics. The age of the participants was not included in this analysis because of the high correlations between age and working experience (r = .91). The analysis further indicated that nurses’ academic qualification was the only independent variable predicting their attitude towards ethical practice, F (1, 259), 2.67, p = .008, accounting for about 27% of the change in their attitude towards ethical practice (see Table 3).

Table 3

Influence of sex, academic qualification, professional qualification, rank and working experience of nurses on their attitude towards ethical practice.

	B	R	R 2	β	t	p-value
Constant	17.41	.25	.06		18.02	.001
Sex	−.23			−.03	−. 55	.585
Academic qualification	1.12			.27	2.67	.008
Professional qualification	.01			.01	.11	.916
Rank	−.69			−.11	−1.19	.236
Working experience	.03			.06	.79	427

df (5, 258); F (18.02)

The third regression model also indicated a significant prediction of nurses’ ethical practice, F (5, 258), 24.23, p = .001, accounting for 2% variation in nurses’ ethical practice. However, we did not include nurses’ academic qualification in this analysis since academic qualification and professional qualification recorded high correlation coefficient (r = .70). However, none of these predictor variables was independently statistically significant in determining nurses’ ethical practice (see Table 4).

Table 4

Influence of sex, academic qualification, professional qualification, rank and working experience of nurses on the extent of their ethical practice.

	B	R	R 2	β	t	p-value
Constant	21.82	.15	.20		24.23	.001
Sex	.05			.15	1.80	.073
Age	−.13			−.02	−.37	.712
Academic qualification	.12			.11	1.22	.226
Rank	−.25			−.05	−.53	596

df (5, 258); F(24.23)

Discussion

The focus of this study was to describe the knowledge, attitude, and ethical practices among nurses in the Cape Coast Metropolis of Ghana, and determine the extent to which demographic factors of the nurses influence their knowledge, attitude and practice of ethics in the nursing profession. We observed a good level of ethical knowledge among the nurses. First, we are of the view that the nurses in this study recognize ethical problems in the course of their care practice because of seminars and workshops they attended during the period of practice, as has been reported in other studies [7, 21]. Further, ethics is emphasized across all levels of nursing education globally and in Ghana [6, 22]. Besides, every professional group has established a code of ethics and standards, normally drawn from the ICN, so, it does not matter where the nurse is trained, they are expected to adhere to those ethics [23], which agrees with previous studies in Turkey [10], Spain [21], Australia [24], Italy [25], Iran [26], and Hong Kong [27]. Conversely, other previous findings from Northern India [8], Ethiopia [13], Germany [28], and Nigeria [29] revealed a low to moderate level of ethical knowledge. The reason for these dissimilarities could be attributed to methodological limitations. For example, while the earlier studies [8, 13] used nurses and other healthcare workers at primary healthcare facility levels, and [28] from national population surveys, our participants are nurses from secondary and tertiary facilities who are not necessarily representative of all nurses in Ghana. Though, knowledge alone does lead to practice, having a sufficient ethical knowledge may positively influence the professional conduct of nurses, which has been a great public concern in Ghana in recent times [17, 18].

The finding again indicates a good attitude of nurses towards ethical practice. We reason here that participants are applying their ethical knowledge to practice, which may be influencing their attitude. Moreover, many of these nurses come in contact with various ethical issues in their practices, evidence which were reported in Oceania [11], Africa [12, 13], Asia [27], and Europe [30, 31]. Healthcare delivery in the Cape Coast Metropolis of Ghana may be improved through positive attitude of nurses because it is likely to enhance health outcome of patients since negative attitudes from nurses could compromise patient’s recovery [10, 13]. For instance, a study by Norbergh et al. [31] indicated that positive attitude of healthcare professionals is important for the wellbeing and quality of care they give their patients because such attitudes enhance patients’ satisfaction, health, and psychological wellbeing.

We further observed adequate ethical practice among our participants. The reason may be because participants do well understand the issues in ethics that they were taught during their training. Moreover, these nurses may have encountered ethical issues which could inform their adequate practice. Similarly, other studies conducted in Africa [12, 13] among nurse participants found nurses’ ethical practices to be adequate or good. Ethical practice is essential not only to nursing practice but also to patients [1, 4]. Moreover, practices deemed unethical can compromise the health of the client, and cause a lawsuit against the practitioner, resulting in the revocation of license and/or imprisonment. This is because flouting the NMC ethical code and causing harm to a client could be punishable by law in Ghana [6]. However, studies from Nigeria [32] and West Indies [33] found inadequate ethical practice among nurses. The disparities in the findings may be because of the vast time period between these studies and the current one. For example, the study from Nigeria [32] is 10 years earlier to the current study. This time interval is enough in an evolving industry like healthcare for some ethical transformations and improvement to take place among professionals including nurses.

There is also an indication that inadequate resources, poor set up of the working area and understaffing are major barriers to ethical practices among these nurses. Plausibly, most of these nurses do not get the necessary or basic resources (i.e. consumables, conducive working environment to ensure confidentiality and privacy of clients) which is demotivation to adherence to ethical practices. In low-middle-income countries such as Ghana, healthcare delivery is bedeviled with several barriers, including space, understaffing and lack of or inadequate provision of resources, to enhance caregiving to patients [18, 34]. For example, evidence [34, 35] indicates that understaffing may force nurses to abandon opportunities to provide good nursing care to their patients [18]. Understaffing may also increase workload, absenteeism, turnover, work stress, burnout, and job dissatisfaction of the care practitioner [32, 34]. In this case, quality healthcare delivery may fester unprofessional conduct and become counterproductive to health outcomes of patients.

We further observed that participants’ professional ranks influence their level of ethical knowledge. Perhaps, majority of the nurses in this study are at junior ranks and are likely to be young and may have completed school in not-too-distant time [21]. It is also sound to theorized that as these nurses move from one rank to another, they encounter different ethical dilemmas which may increase their knowledge of ethics, as found in Nigeria [12], New South Wales [36], and Kenya [37]. Moreover, we realized that academic qualification positively determined nurses’ attitude towards ethical practice at work. Deductively, majority of the study participants attained diploma degree, who also possess a good level of knowledge and a positive attitude towards ethical practices. This is similar to a study from Ethiopia [13] which found that level of education/academic qualification influences nurses’ attitude towards care of their clients. Though our study did not draw cause and effect linkage, it is sound to infer that, higher educational qualification has a propensity to positively transformed attitudes towards practice in healthcare.

This is a cross-section study, and we do not intend to infer cause and effect, generalize our findings and conclusions to the whole of Ghana or other healthcare professionals. This study further opens the discourse on nurses’ ethical knowledge, attitudes, and practices during the healthcare delivery process, in the Cape Coast Metropolis of Ghana. Also, because it was a survey, the nurses may not have given us the “true picture” of their practices as may be happening at their various wards.

Conclusions

The focus of this study was to describe the knowledge, attitude, and ethical practices among nurses in the Cape Coast Metropolis of Ghana, and determine the extent to which their demographic characteristics influence their knowledge, attitude and practices of ethics at work. Though these nurses in Cape Coast Metropolis recorded good ethical knowledge, have positive attitude towards ethical practice, and are ethically conscious in their practices, and they are faced with inadequate resources. Furthermore, professional rank and academic qualification determined the ethical knowledge and attitude of these nurses and their practices while they attempt to care for their clients.

Recommendations

Nurses need to continually update their knowledge through seminars/workshops so they can be well-informed of ethical issues arising in their practices. Nurse managers need to do more periodic monitoring to maintain the high image of the profession. The teaching of ethics at the training schools needs to be intensified since most of the nurses obtained such knowledge from school before entering into practice. Moreover, we recommend sanctions and penalties for nurses who are reported and confirmed to be involved in unethical practices. In addition, there is the need to provide the needed resources, increase the staff strength, and get better working space to help these nurses give the needed quality of care to their patients. Extending this study nationwide will be ideal, to get wider views and understanding of the issues studied. Also, longitudinal and or observational study or studying this phenomenon from the clients’ perspectives will be of benefit to the healthcare system.

28 Sep 2020

PONE-D-20-10854

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

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Reviewer #1: Review report 30th July, 2020

Summary of Review and overall impression

Ethical issues in nursing is an important area on nursing given that Nurses interact with patients at very delicate point in their lives when they are vulnerable to abuse of their rights.

However, there are important issues that need to be included.E.g the specific ethical principles, theories etc. that are of importance to nursing. The authors need to demonstrate how these principles are integrated in the International Council of Nurses guidelines and operationalized in National nurses’ regulatory body and curricular for nurses in Ghana.

There is also need to describe how the ethical guidelines for nurses relate to the specific areas of Ghana constitution

My general view is that assessment of knowledge, attitude and practice of nurses in the area of ethics is an important issue but the manuscript needs to be revised substantially before publication as follows:

Introduction: There is need for major revision to give description in the subject matter of ethics, magnitude of the problem, the negative effects and gaps in Knowledge, attitudes and practice that justify the study.

The literature review does not demonstrate logical arguments that justify the study

Methodology: There are major methodological issues of concern indicated on the specific areas (see comments in the manuscripts for detailed suggestions).

Results and Discussion: Need to be revised as indicated in the comments within the document.

Generally-there is need to revise the manuscript for logical flow.

Declaration of competing interest-I declare that I do not have any conflicting interest

The specific questions and remarks

Items Remarks

1. The study presents the results of original research √

2. Results reported have not been published elsewhere. √

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail -Needs revision

4. Conclusions are presented in an appropriate fashion and are supported by the data. -Need revision

5. The article is presented in an intelligible fashion and is written in Standard English. -Needs Re organization to reflect logical flow

6. The research meets all applicable standards for the ethics of experimentation and research integrity.

-Ethical issues observed not clearly explained

7. The article adheres to appropriate reporting guidelines and community standards for data availability

-Yes but needs improvement

Reviewer #2: This is an interesting and informative paper on a geographically understudied area of nursing practice. As I am a qualitative researcher, I cannot comment on the regression analysis specifically. Outside of that, the study design and methodology seem sound and the results support the conclusions, with one caveat:

I would encourage the authors to consider and discuss the difference between 1) 'ethics' in a general social sense, 2) professional ethics as specific to nursing, and 3) the particular written national codes of ethics they discuss in the paper. They should make clear that when discussing 'nurse's knowledge of ethics', they mean the third sense, namely formal written codes of conduct. I'm saying this because it could be well possible that rather than having 'no ethics at all', as the authors seem to imply, the nurses in question simply operate on a different (maybe not formal/bureaucratic) understanding of ethics, which then conflicts with professional standards. For example, their treatment of women in antenatal clinics may not be in tune with formal ethical standards at the hospital - but is it possible that it conforms to a 'local' ethics which demands that women attend the clinic and pay for the items needed there? These distinctions might make for an interesting follow-up study, but as it stands, the data does not support the claim that nurses do not have any knowledge of any ethics at all - just that they do not have knowledge of the relevant formal codes applying to their jobs.

I would also recommend to have the article professionally edited if at all possible to eliminate potential misunderstandings due to language use (e.g. p 57 ln 59 - 'couples'?).

The authors state that the original data will be made available upon request, but it appears that PLOS ONE requires data to be deposited in a public depository for the paper to be accepted. Once these points are addressed, I warmly recommend the paper for publication.

Reviewer #3: 1. Page Number - PN (3) Line Number - LN (58): - Is this issue of unethical practice among nurses a global one or just

specific to some places? Or are there other forms in other places?

2. PN (3) LN (75-79): - Where were these studies conducted? Is this a global problem or localized? You need to be specific

here. There might be a need to present existing global studies especially from the western world in relation to the

unethical nursing practices.

LN 79 - Please change to ‘Midwifery’.

3. PN (4), LN (85-86): - This sentence is not clear. How does the attitude and the practice of nurses influence how they act

and conduct their duties? Or that the nurses’ knowledge of the ethics of their profession influenced their attitudes and

practices?

LN (95-97): - Is this referring to the nurses in Ghana?

4. PN (5), LN (116): - Change to ‘bachelor’s degree’

5. PN (6), LN (144-147): - This appears confusing. Can you please elaborate on this sentence especially regarding the

evaluation by the two senior research assistants? Was this part of the analysis?

LN (149-150): This is not clear. Which of the group of nurses did not take part in the main study? Why were they not

involved in the main study? Was there a pilot test?

6. PN (10), LN (273): - Change to ‘…and in Ghana’

LN (294): Please rewrite this.

7. PN (11), LN (305-307): - Yes, this is true. However, do the nurses in Ghana or any of the African countries face lawsuits

for unethical practices? Are the people aware of their rights regarding the unethical practices of the nurses

who take care of them? Have you also considered the issues of quackery in the nursing profession, whereby people

assumed that everyone working in health facilities wearing ‘white uniforms’ are nurses? In essence, what role does

quackery play in the unethical practices observed among the nurses in Ghana?

LN (314 - 320): From your finding, and with the high percentage of ethical practices among nurses in Ghana, what could

be the explanation for these inhibiting factors raised here and the high percentage of ethical practices among the

nurses interviewed in this study?

8. PN (12), LN (332-333): - You need to expatiate more on this issue. Are diplomate nurses found to be more involved in

unethical practices as a result of their low level of education? Or what?

From this study findings, nurses who have diploma in nursing also have high level of knowledge about the ethics of

nursing profession. This appears to contradict earlier studies in relation to this.

LN (349-350): How can the findings from this study be generalized to other health care professionals? Are they also

influenced by the same factors? Are there studies that suggest that they also practice unethically? Which of the health

care professionals do you want to generalize your findings to?

LN (350-353): Further study should be encouraged to identify specific nursing specialties where there are reports of

unethical practices. There is also a need to identify the specific aspects of the nursing ethics where unethical practices

have been identified among nurses. Studies should be done to identify if there are complaints about unethical practices

among other health care professionals.

9. PN (13), LN (357-358): There should be sanctions and penalties for nurses who are reported and confirmed to be

involved in unethical practices.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Dr Steph Grohmann

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: REVD PONE-D-20-10854 Reviewed 30th July 2020.pdf

Click here for additional data file.

21 Apr 2021

Dear Editor and Reviewers,

On behalf of all authors, I convey our gratitude to you for the critical and constructive review that has led to the improvement of our paper entitled “Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana”. We have revised the manuscript based on the comments raised by both the Editor and the Reviewers. We believe the manuscript has improved substantively and will be published in your reputable journal, PlosOne. All the changes have been marked yellow colour in the revised manuscript. Please address all correspondence to me via email at: francis.sambah@stu.ucc.edu.gh

Thank you

Editors Comments

1. Comment:

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Response: We have made the necessary corrections in conformity with the PLOS ONE’s style.

2. Comment:

In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a table of relevant demographic details, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place.

Response: We have made efforts to review the method section and included the dates for the study, inclusion and exclusion criteria. In addition, we put the demographics into a table (Table 1).

3. Comment:

Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response: We reworked on these, describing the questionnaire and how data was collected.

4. Comment:

We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Response: We have made the necessary efforts to edit the manuscript and also sought a help from a professional scientific editor.

Comment:

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services. If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following: The name of the colleague or the details of the professional service that edited your manuscript. A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file). A clean copy of the edited manuscript (uploaded as the new *manuscript* file).

Response: We have employed Dr. Jacob Owusu Sarfo and Mr. Frank Mensah for copy edition the manuscript.

5. Comment:

We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Response: The dataset supporting this manuscript has been uploaded into the Open Science Framework platform DOI 10.17605/OSF.IO/SXMGU

Comment:

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

Response: The data is freely available at Open Science Framework platform via DOI 10.17605/OSF.IO/SXMGU

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

Response: The dataset supporting this manuscript has been uploaded into the Open Science Framework platform DOI 10.17605/OSF.IO/SXMGU

We will update your Data Availability statement on your behalf to reflect the information you provide.

6. Comment:

PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Response: The corresponding author and one of the co-authors have added their ORCID iDs.

Reviewer #1:

Summary of Review and overall impression

Comment:

Ethical issues in nursing is an important area on nursing given that Nurses interact with patients at very delicate point in their lives when they are vulnerable to abuse of their rights. However, there are important issues that need to be included. E.g the specific ethical principles, theories etc. that are of importance to nursing. The authors need to demonstrate how these principles are integrated in the International Council of Nurses guidelines and operationalized in National nurses’ regulatory body and curricular for nurses in Ghana.

Response: We have attempted to address the issues raised here.

Comment:

There is also need to describe how the ethical guidelines for nurses relate to the specific areas of Ghana constitution.

Response: We made changes to the literature reflecting these issues.

Comment:

My general view is that assessment of knowledge, attitude and practice of nurses in the area of ethics is an important issue but the manuscript needs to be revised substantially before publication as follows:

Introduction: There is need for major revision to give description in the subject matter of ethics, magnitude of the problem, the negative effects and gaps in Knowledge, attitudes and practice that justify the study.

Response: We have made changes to improve the introductory part of the manuscript.

Comment:

The literature review does not demonstrate logical arguments that justify the study

Response: We have made changes to improve the literature.

Comment:

Methodology: There are major methodological issues of concern indicated on the specific areas (see comments in the manuscripts for detailed suggestions).

Response: We have made substantive revision to the method section to reflect the comments made by the reviewers.

Comment:

Results and Discussion: Need to be revised as indicated in the comments within the document.

Generally-there is need to revise the manuscript for logical flow.

Response: We have revised the results and discussion for logical flow in the manuscript.

Comment:

Declaration of competing interest-I declare that I do not have any conflicting interest

Response: We added that to the manuscript.

Reviewer #2:

Comment:

This is an interesting and informative paper on a geographically understudied area of nursing practice. As I am a qualitative researcher, I cannot comment on the regression analysis specifically. Outside of that, the study design and methodology seem sound and the results support the conclusions, with one caveat:

Response: We appreciate your comments.

Comment:

I would encourage the authors to consider and discuss the difference between 1) 'ethics' in a general social sense, 2) professional ethics as specific to nursing, and 3) the particular written national codes of ethics they discuss in the paper. They should make clear that when discussing 'nurse's knowledge of ethics', they mean the third sense, namely formal written codes of conduct. I'm saying this because it could be well possible that rather than having 'no ethics at all', as the authors seem to imply, the nurses in question simply operate on a different (maybe not formal/bureaucratic) understanding of ethics, which then conflicts with professional standards. For example, their treatment of women in antenatal clinics may not be in tune with formal ethical standards at the hospital - but is it possible that it conforms to a 'local' ethics which demands that women attend the clinic and pay for the items needed there? These distinctions might make for an interesting follow-up study, but as it stands, the data does not support the claim that nurses do not have any knowledge of any ethics at all - just that they do not have knowledge of the relevant formal codes applying to their jobs.

Response: We appreciate the comments. We made changes to reflect ethical practices of nurses in the Ghanaian context.

Comment:

I would also recommend to have the article professionally edited if at all possible, to eliminate potential misunderstandings due to language use (e.g. p 57 ln 59 - 'couples'?).

Response: We deleted the word “couples” to make the sentence readable.

Comment:

The authors state that the original data will be made available upon request, but it appears that PLOS ONE requires data to be deposited in a public depository for the paper to be accepted. Once these points are addressed, I warmly recommend the paper for publication.

Response: We are making the necessary efforts to upload the data.

Reviewer #3:

Comment:

1. Page Number - PN (3) Line Number - LN (58): - Is this issue of unethical practice among nurses a global one or just specific to some places? Or are there other forms in other places?

Response: We have attempted to rewrite the sentence for clarity.

Comment:

2. PN (3) LN (75-79): - Where were these studies conducted? Is this a global problem or localized? You need to be specific here. There might be a need to present existing global studies especially from the western world in relation to the unethical nursing practices. LN 79 - Please change to ‘Midwifery’.

Response: We have rewritten the sentences to make better understanding of the issues raised.

Comment:

3. PN (4), LN (85-86): - This sentence is not clear. How does the attitude and the practice of nurses influence how they act and conduct their duties? Or that the nurses’ knowledge of the ethics of their profession influenced their attitudes and practices? LN (95-97): - Is this referring to the nurses in Ghana?

Response: We have improved the literature.

Comment:

4. PN (5), LN (116): - Change to ‘bachelor’s degree’

Response: We made the change accordingly.

Comment:

5. PN (6), LN (144-147): - This appears confusing. Can you please elaborate on this sentence especially regarding the evaluation by the two senior research assistants? Was this part of the analysis? LN (149-150): This is not clear. Which of the group of nurses did not take part in the main study? Why were they not involved in the main study? Was there a pilot test?

Response: We have rewritten this part for clarity. This was a pilot test of the questionnaire.

Comment:

6. PN (10), LN (273): - Change to ‘…and in Ghana’ LN (294): Please rewrite this.

Response: We made the change accordingly.

Comment:

7. PN (11), LN (305-307): - Yes, this is true. However, do the nurses in Ghana or any of the African countries face lawsuits for unethical practices? Are the people aware of their rights regarding the unethical practices of the nurses who take care of them? Have you also considered the issues of quackery in the nursing profession, whereby people assumed that everyone working in health facilities wearing ‘white uniforms’ are nurses? In essence, what role does quackery play in the unethical practices observed among the nurses in Ghana?

Response: We have made the necessary improvement to this part of the discission.

Comment:

LN (314 - 320): From your finding, and with the high percentage of ethical practices among nurses in Ghana, what could be the explanation for these inhibiting factors raised here and the high percentage of ethical practices among the nurses interviewed in this study?

Response: We have made modifications to this.

Comment:

8. PN (12), LN (332-333): - You need to expatiate more on this issue. Are diplomate nurses found to be more involved in unethical practices as a result of their low level of education? Or what?

From this study findings, nurses who have diploma in nursing also have high level of knowledge about the ethics of nursing profession. This appears to contradict earlier studies in relation to this.

Response: We have expatiated this appropriately.

Comment:

LN (349-350): How can the findings from this study be generalized to other health care professionals? Are they also influenced by the same factors? Are there studies that suggest that they also practice unethically? Which of the health care professionals do you want to generalize your findings to?

Response: We have restated this section appropriately to reflect that we refereeing to only nurses.

Comment:

LN (350-353): Further study should be encouraged to identify specific nursing specialties where there are reports of unethical practices. There is also a need to identify the specific aspects of the nursing ethics where unethical practices have been identified among nurses. Studies should be done to identify if there are complaints about unethical practices among other health care professionals.

Response: We have modified this appropriately.

Comment:

9. PN (13), LN (357-358): There should be sanctions and penalties for nurses who are reported and confirmed to be involved in unethical practices.

Response: We added a sentence that calls for sanctions and penalties for nurses with unethical practices.

Submitted filename: Review comments and our Responses.docx

Click here for additional data file.

17 Aug 2021

PONE-D-20-10854R1

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

PLOS ONE

Dear Dr. Sambah,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 01 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #4: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #4: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #4: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #4: • line 34: Method – survey design is not appropriate term. it is preferable to use cross-sectional design

• line 38: high ethical knowledge is not appropriate – it is better to state good knowledge

• line 39: 98% were ethical conscious in their practices – it is better to state 98% had good ethical practices

• line 44: nurses’ practice with high ethical standards – needs to be rephrased

• MeSh terms to be used for Keywords.

• lines 78-80: what is the reference /basis for these statements?

• lines 95-96: rephrase statement

• lines 90-115: sentences look repetitive. they may be condensed. syntax errors to be corrected. it seems that problems/concerns with nurse patient communication have been interchangeably used with ethical behaviour. This is not appropriate & needs to be corrected.

• line 119: how was sample size calculated?

• line 130: of the 42 items – only details of 30 items have been mentioned in section A & B

• lines 164-168: grammatical corrections needed

• lines 190-192: how were knowledge, attitude & practice scores aggregated as continuous scores? why were the variables not analysed as categorical variables?

• line 193: what is a latent variable?

• line 194: what is mixture of variables? – it is preferable to utilize appropriate statistical terms.

• line 195: p value<0.05

• what software was used for data analysis?

• line 200: high knowledge – to be corrected

• line 208-209: table title needs to be reworded. level of ethical knowledge is incorrect usage

• tables can be reframed to depict key variables rather than reproducing the data output tables

• line 225: CHN/RCN/RMN – the explanation for the abbreviated terms need to be provided as footnotes under the table

• lines 230-232: it is preferable to classify knowledge as good & poor

• line 311: high level of ethical knowledge to be replaced by good knowledge about ethics

• line 325: who could not be a presentation of the all nurses in Ghana. – needs to be rephrased as not representative of all nurses in Ghana

• lines 331-332: sentences to be rephrased

• lines 334-337: please substantiate your claim on attitudes & patient recovery

• lines 357-358: syntax error to be corrected

• lines 368-370: sentences need to be rephrased

• line 379: conclusion- should summarize key findings of the study in 3-4 sentences

• lines 380-383: may be removed from conclusions

• lines 384-388 avoid usage of term – high ethical standards

• lines 395-396: sentences need to be rephrased

• lines 391-393: are limitations of the study & not conclusions

• line 414: syntax error

• the tool/questionnaire used for the study may be enclosed for better clarity on the questions

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #4: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

14 Sep 2021

Response to Editor and Reviewers comments

“line 34: Method – survey design is not appropriate term. it is preferable to use cross-sectional design:

Response: We have made the correction as appropriate (line 34).

• “line 38: high ethical knowledge is not appropriate – it is better to state good knowledge”

Response: We changed it to the “good knowledge” (line 38)

• “line 39: 98% were ethical conscious in their practices – it is better to state 98% had good ethical practices”

Response: We corrected the sentence in (line 39)

• “line 44: nurses’ practice with high ethical standards – needs to be rephrased”

Response: We rephrased the sentence as appropriate (lines 44&45)

• “lines 78-80: What is the reference /basis for these statements?”

Response: We provided the references to these statements

• “lines 95-96: rephrase statement”

Response: We corrected the statement

• “lines 90-115: Sentences look repetitive. They may be condensed. syntax errors to be corrected. it seems that problems/concerns with nurse patient communication have been interchangeably used with ethical behaviour. This is not appropriate & needs to be corrected.”

Response: we restructured these sentences

• “line 119: How was sample size calculated?”

Response: We used all the nurses in the three facilities, which we described under the method section.

• “line 130: of the 42 items – only details of 30 items have been mentioned in section A & B”

Response: we actually used 32 items, which are accounted for in the descriptions

• “lines 164-168: grammatical corrections needed”

Response: we provided the corrections as needed

• “lines 190-192: how were knowledge, attitude & practice scores aggregated as continuous scores? why were the variables not analysed as categorical variables?”

Response: These explanations are provided under the data analysis (lines 168-185)

• “line 193: what is a latent variable?”

Response: We did provide a clear description for this.

• “line 194: what is mixture of variables? – it is preferable to utilize appropriate statistical terms.”

Response: We provided an appropriate description for that.

• “line 195: p value<0.05”

Response: We made the change as required.

• “what software was used for data analysis?”

Response: The correction has been made, as we used SPSS software, version 20.0.

• “line 200: high knowledge – to be corrected”

Response: We change it to good knowledge

• “line 208-209: table title needs to be reworded. level of ethical knowledge is incorrect usage. tables can be reframed to depict key variables rather than reproducing the data output tables”

Response: We change the table tittle as suggested

• “line 225: CHN/RCN/RMN – the explanation for the abbreviated terms need to be provided as footnotes under the table”

Response: We provided the full meaning of the abbreviations

• “lines 230-232: it is preferable to classify knowledge as good & poor”

Response: We change the phrases good and poor knowledge

• “line 311: high level of ethical knowledge to be replaced by good knowledge about ethics”

Response: We changed the sentence to reflect “goof knowledge”

• “line 325: who could not be a presentation of the all nurses in Ghana. – needs to be rephrased as not representative of all nurses in Ghana”

Response: This sentence has been corrected appropriately

• “lines 331-332: sentences to be rephrased”

Response: Sentences have been corrected

• “lines 334-337: please substantiate your claim on attitudes & patient recovery”

Response: We provide references and examples in support of the claims

• “lines 357-358: syntax error to be corrected”

Response: The correction was made

• “lines 368-370: sentences need to be rephrased”

Response: Sentences have been corrected

• “line 379: conclusion- should summarize key findings of the study in 3-4 sentences”

Response: We summarized the key findings appropriately

• “lines 380-383: may be removed from conclusions”

Response: We removed the sentences as suggested.

• “lines 384-388 avoid usage of term – high ethical standards”

Response: We change to good knowledge

• “lines 395-396: sentences need to be rephrased?”

Response: Sentences have been corrected

• “lines 391-393: are limitations of the study & not conclusions”

Response: These sentences have been removed

• “line 414: syntax error”

Response: We did correct this sentence

Submitted filename: Ethics paper_Review Comments_14_9_2021.docx

Click here for additional data file.

1 Nov 2021

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

PLOS ONE

Dear Dr. Sambah,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by December 16, 2021. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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A 'Response to Reviewers' letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

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21 Dec 2021

Respond to Comments from the Reviewer

We are very grateful to reviewers for the thorough review done so far on our paper. We provide the following responses to the comments. We indicated our corrections in Red Link in the main document (Revised Manuscript with Track Changes).

1. Updated references

Response:

2. Line 44: Good high ethical standards is not appropriate phrase. Please correct the statement.

Response: We corrected this, by deleting “high”.

3. Line 103: Improperly carried out ethical practices in their routine care like insulting patients. Please rephrase.

Response: we corrected this sentence, lines 102-103

4. Lines 125-126: It is preferable to state that all the 326 nurses working in the municipality hospitals were included in the study.

Response: This sentence is changed accordingly, line 124

5. Tables 2, 3, 4: Titles can be modified to improve understanding.

Response: Titles have been modified accordingly, lines 258-259, 276-277, 292-293

6. Line 330: The finding again indicates a high positive attitude- avoid usage of phrases like high positive attitude.

Response: We introduced “good” attitude in the sentence, line 324

7. Line 333: Oceanian – spell check for error.

Response: We correct, “Oceania”, line 327

8. Lines 369-372: Sentences are grammatically incorrect. Kindly rephrase.

Response: We attempted to correct the sentences for understanding, lines 362-364

Submitted filename: Response to Reviewers Comments.docx

Click here for additional data file.

24 Jan 2022

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

PONE-D-20-10854R3

Dear Dr. Sambah,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements including language corrections.

Within one week, you’ll receive an e-mail detailing the required amendments. You must seek independent editorial help to address language issues. Refer to the 5th criterion for publication listed by PLoS ONE (https://journals.plos.org/plosone/s/criteria-for-publication). When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

Additional Academic Editor Comments:

Not all grammatical mistakes are addressed by the authors despite providing 3 opportunities to revise the manuscript. PLoS ONE does not copy edit accepted manuscripts. Therefore, authors must address language issues preferably while addressing other technical requirements or at least at the time of proof corrections.

7 Feb 2022

PONE-D-20-10854R3

Ethics in Healthcare: Knowledge, Attitude and Practices of Nurses in the Cape Coast Metropolis of Ghana

Dear Dr. Sambah:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Prof. Dr. Ritesh G. Menezes

Academic Editor

PLOS ONE