Perception of ethical issues by students of health professions

In recent years in education in health professions in Slovakia big changes have taken place. New insights regarding approximation to the European education system and contextual understanding of health professionals and patients encourage need of change in approaches. The transition from deep-rooted paternalism to individual responsibility of the patients created a gap which was needed to fulfil in education. In our research we analyzed using ANOVA statistics with p<0.01 a non-standardized questionnaire looking what impact had study of ethical issues on their approach to marginalization, labelling, empathy and holistic approach. Significant difference between both groups of students (125 students at the beginning of the study and 119 students at the end of the study) has been shown related to the study of professional ethics on one side and approach to marginalization, labelling, empathy and holistic approach at other side.


Introduction
In Slovakia, during recent years in education of health professions big changes have taken place. Qualifying studies in most fields have been transferred from secondary to higher education, and new insights regarding approximation to the European education system and contextual understanding of health professionals and patients encourage need of change in approaches. This requires above all a change in attitudes towards the patient in the course of medical practice. The transition from deep-rooted paternalism to individual responsibility of patients created a gap which is needed to be fulfilled in education.

Survey methods
The aim of this study was to assess the changes in perception of ethical issues by students of selected health professions in order to point out the importance of teaching Professional Ethics, Law and Legislation in Health Care as well as Psychology. We have set the following research tasks: -Determination of the hypotheses, -Evaluation of perception of ethical issues by students at the beginning of the study program, -Evaluation of perception of ethical issues by students at the at the end of the studyafter the completion of selected courses, -Comparison and assessment of research outcomes.
In our survey we used a non-standardized questionnaire which we analyzed by ANOVA statistics with p < 0.01. Questionnaire included 20 closed questions. At the beginning of the study (first year of the study) 125 questionnaires were distributed and 119 questionnaires at the end of the study (by completion of third year of study). Respondents consisted of 125 students of the first year (age 19.2 ± 2.6) and 119 students of the third year of BSc studies (age 22.4 ± 2.7) in Nursing, Paramedics, Public Health, and Physiotherapy at the Faculty of Health in Ruzomberok. Survey was conducted in 2015 and 2016. We established 4 hypotheses: H 1 We assume significant difference between both groups of students in approach to the issue of marginalization of patients.
H 2 We assume significant difference between both groups of students in approach to labelling of patients.
H 3 We assume significant difference between both groups of students in approach to empathy.
H 4 We assume significant difference between both groups of students in holistic approach.

Results
All results were analyzed in relation to the students after completing the courses: professional ethics, law and legislation in health and psychology. In all these study subjects they had opportunity to learn about the mentioned topics.
Multi cultural society gives more prominence to the fact of understanding other ethnicities and cultural groups. Students should be prepared to work with patients from different environment, cultural background, and religious group to eliminate the social, economic, health and other factors. They must focus on it comprehensively, because residents of poor communities are territorial, physically, educationally and culturally marginalized. The primary cause of marginalization is language and social barriers [1]. To decrease level of marginalization in nurses' work was introduced trans-cultural nursing into practice. Trans-cultural nursing helps overcome marginalization, because its aim is to provide cultural identical and differentiated care to healthy or sick persons and help them cope with the adverse conditions, disease, or dying culturally appropriate manner [2].
Regarding to marginalization in our study a significant difference between both groups of students has been shown related to the study of professional ethics as well as to law and legislation in health care on one side and approach to marginalization at other side. Significant difference between both groups was not confirmed in relation to psychology. Hypothesis H 1 was confirmed partially as is shown in Table 1.
The next issue in the work of medical professionals is labelingdescribing someone or something in a word or short but simplified phrase. Often it is a false attribution of behaviour or assignation to a group that bears certain characteristics (mostly negative) without a deep examination of the truth. It features in plotting of prompt consideration and opinion. We meet it in the context of generalization for example, in patientsseniors. It is claimed that they are grumpy, irritable, or they do not understand something because they are already old [3]. The cause of the simplification of their attitudes is often excessive stress at work. It is therefore essential that students are prepared for this work by building a mental state achieved by focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations, used as a therapeutic techniquemindfulness. Incorporating this coping strategy into the curriculum ensures that students will have the tools to deal with the stressors of the course, which in turn will enhance the student experience [4].
Results of our study confirmed significant difference before and after completion of all three study subjects -Professional Ethics, Law and Legislation in Health Care and also Psychology. Hypothesis H 2 has been fully confirmed as shown in Table 2. Need to help yourself and others as well as to solve complicated life situations on the advice of others is a certain way to achieve peace. Empathy manifests itself in every single person, whether we like to admit it or not. It is a kind of feature in a personal "I," but not everyone uses it in equal measure. Even if we have it, it is extremely important to develop and support it. In the nursing literature we met statements that the ability to respond empathically is among the factors that improve the relationship between nurse and patient. According to them, empathy is considered as one of the most important and also the most complex factors affecting communication between nurse and patient. Empathy is considered as an essential prerequisite for a nurse to effectively care for a patient and for a holistic understanding of a patient's perspective in a student population [5]. Authors of the study titled "The Effect of Empathy Training of the Empathic Skills of Nurses" stated that profound impact of empathy training on quality of nursing care has been recognized and relevant training will lead to an improvement in nurses' empathic skills, which in turn, will enable them to understand their patients better, establish positive interpersonal relationships with them, and boost their professional satisfaction, but when they held an experiment with training, after the training, no statistically significant difference was found (p = 0.886) [6]. In our experiment, which was similar we get results showing statistical significance at the level p = 0.01 after successful completion of the course of Professional Ethics (p = 0.008), Law and Legislation in Health Care (p = 0.003) and psychology (p = 0.007). Results are indicated in Table 3. Hypothesis H 3 in our study has been confirmed. Table 3. Approach of students to empathy.
Considering holistic approach, the relationship between nurse and patient requires particular attention not only to the patient's verbal expressions, but also non-verbal and creation of a professional attitude in communication, which can to affect the nursing process on both sitesthe nurse and the patient himself. In a similar intentions we can understand Plato's and Nightingale's holistic, scientific, and humanistic approach to living, and to care practice in all its dimensions, grounds the discipline of nursing in a liberal arts and critical thinking matrix, elevating nursing to higher ethical, safe, and professional levels of standards [7]. Hypothesis H 4 has been only partially confirmed, because of significant differences between both groups considering all two study subjects -Professional Ethics and Law and Legislation in Health Care. A result only underlines the importance of good preparation in behavioural subjects for health care students. See Table 4.