Knowledge, Attitude, And Practice of Medical Ethics Among Intern Doctors in a Medical College in Western Nepal

Int. Jr. of Contemp. Res. in Multi. PEER-REVIEWED JOURNAL Volume 4 Issue 3 [MayJun] Year 2025 628 © 2025 Abhishek Karn, Sanjay Kumar Sah, Shivendra Jha.This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY NC ND).https://creativecommons.org/licenses/by/4.0/ Research Article Knowledge, Attitude, And Practice of Medical Ethics Among Intern Doctors in a Medical College in Western Nepal Abhishek Karn 1*, Sanjay Kumar Sah 2, Shivendra Jha 3 1Additional Professor, Department of Forensic Medicine & Toxicology, BPKIHS, Dharan, Nepal 2 Associate Professor, Department of Forensic Medicine, Janaki Medical College, Ramdaiya, Nepal 3 Professor, Department of Forensic Medicine & Toxicology, BPKIHS, Dharan, Nepal Corresponding Author: Abhishek Karn * DOI: https://doi.org/10.5281/zenodo.17598073 Abstract Manuscript Information Ethics plays a vital role in the practice of medicine. It is the foundation for proper clinical practice, but its implementation into daily practices by interns has not been much studied in Nepal. The study aims to review the knowledge, attitude and practice of medical ethics among medical and dental interns and to identify gaps and recommend reforms. A cross-sectional study was conducted among 176 intern students of Universal College of Medical Sciences, Bhairahawa. A Self-administered structured questionnaires were developed, and it was pretested before the survey. The Questionnaires were divided into 4 sections: each for demographic information, knowledge, attitude and practice, respectively. The majority (72.8%) of the interns had moderate to good knowledge of medical ethics. Only 22.2% achieved a high (good) knowledge score (8–10 out of 10). High levels of agreement (Agree or Strongly Agree) were seen across all items regarding attitude. A strong practical orientation toward medical ethics among interns was observed. The findings emphasise sound ethical practices in clinical scenarios by medical interns. The study guides recommendations for Curriculum reforms and case-based training. ▪ ISSN No: 2583-7397 ▪ Received: 15-05-2025 ▪ Accepted: 19-06-2025 ▪ Published: 30-06-2025 ▪ IJCRM:4(3); 2025: 628-632 ▪ ©2025, All Rights Reserved ▪ Plagiarism Checked: Yes ▪ Peer Review Process: Yes How to Cite this Article Karn A, Sah SK, Jha S. Knowledge, attitude, and practice of medical ethics among intern doctors in a medical college in Western Nepal. Int J Contemp Res Multidiscip. 2025;4(3):628-632. Access this Article Online www.multiarticlesjournal.com KEYWORDS: Medical ethics, Interns, Nepal, KAP study Int. Jr. of Contemp. Res. in Multi. PEER-REVIEWED JOURNAL Volume 4 Issue 3 [MayJun] Year 2025 629 © 2025 Abhishek Karn, Sanjay Kumar Sah, Shivendra Jha.This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY NC ND).https://creativecommons.org/licenses/by/4.0/ 1. INTRODUCTION Medical ethics is based on four basic principles of autonomy, beneficence, non-maleficence, and justice, which guide the health professionals to deal with patients, the state and their colleagues regarding clinical practice. Nepal is a country where the society is multifaceted and ethical perplexity is high, even though the education as well as practice regarding ethics is substandard.1 When intern doctors jump from academic to clinical practice, they face difficulties while dealing with ethical judgment in real-world settings. Medical ethics provides welfare, confidence and protection of the patient, but its implementation among early-career doctors in low-resource settings like Nepal is not well registered. As Interns are at the forefront of providing healthcare, they encounter ethical dilemmas in consent, confidentiality, and end-of-life care; still, only a few studies assess their preparedness. 2,3 Even the medical and dental curricula incorporate ethical studies, various studies conducted in South Asia revealed a significant gap in the practical implementation and internalisation of ethical principles among healthcare trainees.4,5 This is because they lack proper training, they have limited subjection to applied ethics and are exposed to deficient mentorship models.6 The concern is amplified in medical colleges of Nepal, where systemic constraints and hierarchical teaching practices may undermine ethical clarity and confidence among interns.7 This study aims to evaluate the current status of knowledge, attitudes, and practices related to medical ethics among medical and dental interns in a Nepali medical college. The findings are expected to inform curriculum developers, educators, and policymakers in improving ethics education and its real-life application. This study evaluates the knowledge, attitude and practice of medical ethics among medical and dental interns to identify gaps and recommend reforms. 2. METHODOLOGY A cross-sectional study was conducted among intern students of Universal College of Medical Sciences, Bhairahawa. A total of 176 subjects were recruited for the study; among them, 125 students were from an MBBS background and 41 students were from a BDS background. Census sampling was utilised to recruit the subjects. A Self-administered structured questionnaire was framed after reviewing various literature, and it was pretested before the survey. Approval to conduct the study has been obtained from the IRC of Universal College of Medical Sciences (UCMS/IRC/233/19). Informed consent was taken from each participant after explaining the procedure. The Questionnaires were divided into 4 sections. Section A contains a demographic profile, including age, gender and course. Section B of the questionnaire was regarding the assessment of knowledge having total score of 10 and categorised as poor, moderate and good. Attitude was measured by a questionnaire from section C, which included 10 items, and 5 5-point Likert scale was applied for evaluation. Section D contains a questionnaire of 10 items in yes/no format regarding practice assessment. The scoring system was as follows: - Knowledge: scores 0-4=poor, 5-7= Moderate, 8-10= Good; Attitude: response analysed as Agree (strongly agree + disagree), Neutral, disagree (strongly disagree); and practice: Reported as frequency and percentage of positive (yes) response. The collected data were analysed by SPSS version 23. Descriptive statistics were used for demographic and CAP variables. Knowledge, attitude and practice of different groups were analysed with the chi-square test. Strength of association was analysed by Cramer’s statistically significant. Effect size interpretation was made as Cramer’s V <0.1=small, 0.10.5=medium, and >0.5= large. 3. RESULTS Table 1: Demographic Characteristics Table Variable Category Number of Interns (n = 176) Age Mean Age 24.5 years Age Range 23–27 years Gender Male 94 (53.4%) Female 82 (46.6%) Course MBBS 125 (71.0%) BDS 51 (29.0%) Table 2: Knowledge Level Distribution Knowledge Level MBBS BDS No. of Interns (%) Good (8–10) 27 12 39 (22.2%) Moderate (5–7) 67 22 89 (50.6%) Poor (0–4) 31 17 48 (27.3%) Over 70% of the interns had at least moderate knowledge of medical ethics, but only ~1 in 5 achieved a high (good) score. • Chi-square (χ²) = 1.812 • p-value = 0.404 • Cramer’s V = 0.10 (this signifies a weak association). This means that while there may be some relationship between the variables, it is not very strong or significant enough to be meaningful in predictive contexts Interpretation: Majority (72.8%) of the interns had moderate to good knowledge of medical ethics. Only 22.2% achieved a high (good) knowledge score (8–10 out of 10). There is no statistically significant difference between MBBS and BDS interns in terms of knowledge level (p > 0.05). Effect size (Cramer’s V = 0.10) is considered small, implying limited practical significance of the course-wise variation. Int. Jr. of Contemp. Res. in Multi. PEER-REVIEWED JOURNAL Volume 4 Issue 3 [MayJun] Year 2025 630 © 2025 Abhishek Karn, Sanjay Kumar Sah, Shivendra Jha.This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY NC ND).https://creativecommons.org/licenses/by/4.0/ Table 3: Attitude Response Distribution Question Strongly Agree Agree Neutral Disagree Strongly Disagree Q1. Ethics should be taught formally 45 (25.6%) 73 (41.5%) 31 (17.6%) 16 (9.1%) 11 (6.2%) Q2. Ethics is harder in low-resource settings 50 (28.4%) 70 (39.8%) 24 (13.6%) 24 (13.6%) 8 (4.5%) Q3. Confidentiality always possible 71 (40.3%) 65 (36.9%) 18 (10.2%) 12 (6.8%) 10 (5.7%) Q4. Doctors should disclose errors 52 (29.5%) 75 (42.6%) 18 (10.2%) 16 (9.1%) 15 (8.5%) Q5. Patients should decide on treatment 57 (32.4%) 65 (36.9%) 31 (17.6%) 17 (9.7%) 6 (3.4%) Q6. Ethics affects satisfaction 47 (26.7%) 68 (38.6%) 35 (19.9%) 17 (9.7%) 9 (5.1%) Q7. Break confidentiality in outbreaks 46 (26.1%) 83 (47.2%) 22 (12.5%) 15 (8.5%) 10 (5.7%) Q8. Ethics are needed only in difficult cases 47 (26.7%) 79 (44.9%) 25 (14.2%) 17 (9.7%) 8 (4.5%) Q9. Reporting misconduct is ethical 52 (29.5%) 79 (44.9%) 21 (11.9%) 16 (9.1%) 8 (4.5%) Q10. Consent even in minor procedures 60 (34.1%) 64 (36.4%) 24 (13.6%) 16 (9.1%) 12 (6.8%) Interpretation • High levels of agreement (Agree or Strongly Agree) were seen across all items, especially: • Q3: Confidentiality always possible (77.2% agreement) • Q9: Reporting misconduct (74.4% agreement) • Q7: Break confidentiality in public threats (73.3% agreement) • Neutral responses ranged from 10% to 20%, indicating some uncertainty in ethical stance. Disagreement (Disagree + Strongly Disagree) was relatively low, staying below 18% across all items. Table 4: Attitude Statements vs. Course Statement Chi² p-value Cramer’s V Interpretation Q1. Ethics should be taught formally 2.39 0.122 0.12 Not significant Q2. Ethics is harder in low-resource settings 0.07 0.796 0.02 Not significant Q3. Confidentiality always possible 0.02 0.887 0.01 Not significant Q4. Doctors should disclose errors 0.87 0.350 0.07 Not significant Q5. Patients should decide on treatment 0.01 0.911 0.01 Not significant Q6. Ethics affects satisfaction 0.17 0.679 0.03 Not significant Q7. Break confidentiality in outbreaks 1.43 0.231 0.09 Not significant Q8. Ethics are needed only in difficult cases 0.00 1.000 0.00 No difference Q9. Reporting misconduct is ethical 0.23 0.631 0.04 Not significant Q10. Consent even in minor procedures 0.13 0.716 0.03 Not significant No significant differences in ethical attitudes between MBBS and BDS. Attitudes were largely similar, with only weak associations observed. Table 5: Practice of Medical Ethics – Response Distribution Practice Statement Yes (n) Yes (%) No (n) No (%) Q1. I always take informed consent before any procedure. 134 76.13% 42 23.86% Q2. I ensure privacy during the patient’s physical examination. 140 79.54% 36 20.45% Q3. I always keep a chaperone during a patient’s examination. 124 70.45% 52 29.54% Q4. I always follow the principle of non-maleficence. 109 61.93% 67 38.06% Q5. I maintain strict patient confidentiality. 133 75.56% 43 24.43% Q6. I avoid discussing patients’ information in public places. 134 76.13% 42 23.86% Q7. I have read the NMC Code of Medical Ethics. 129 73.29% 47 26.7% Q8. I feel comfortable making ethical decisions. 125 71.02% 51 28.97% Q9. I have consulted seniors about ethical dilemmas. 141 80.11% 35 19.88% Q10. I use ethical guidelines during patient care. 133 75.56% 43 24.43% Interpretation • High adherence was observed across all ethical practices. • The most followed practices were: o Q9. Consulting seniors for ethical dilemmas (80.11%) o Q2. Ensuring privacy (79.54%) • The least followed (but still majority) was: o Q3. Using chaperones during examination (70.45%) These results reflect a strong practical orientation toward medical ethics among interns. Int. Jr. of Contemp. Res. in Multi. PEER-REVIEWED JOURNAL Volume 4 Issue 3 [MayJun] Year 2025 631 © 2025 Abhishek Karn, Sanjay Kumar Sah, Shivendra Jha.This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY NC ND).https://creativecommons.org/licenses/by/4.0/ Table 6: Practice Statements vs. Course Statement Chi² p-value Cramer’s V Interpretation Q1. Take consent before procedures 0.81 0.369 0.07 Not significant Q2. Ensure privacy in physical examination 0.01 0.937 0.01 Not significant Q23. Use a chaperone during physical examination 0.73 0.394 0.06 Not significant Q4. Follow the principle of nonmaleficence 0.76 0.382 0.07 Not significant Q5. Maintain confidentiality 0.00 0.964 0.00 No difference Q6. Avoid public discussion of patients 0.48 0.488 0.05 Not significant Q7. Read NMC Ethics Code 0.00 0.988 0.00 No difference Q8. Comfortable making ethical decisions 0.00 0.964 0.00 No difference Q9. Consult seniors in dilemmas 1.88 0.170 0.10 Borderline small Q1.0. Follow ethical guidelines 0.00 1.000 0.00 No difference Insight: High levels of ethical practice were reported, especially around privacy, using chaperones, and avoiding unprofessional disclosures. Interpretation: Ethical practice behaviours were also consistent across MBBS and BDS interns. No statistically significant differences were observed. 4. DISCUSSION A large number of studies have been conducted by various scholars regarding the assessment of KAP among the medical practitioners and students worldwide. A study from Pakistan reported that final-year medical students had a sound theoretical knowledge about medical ethics, but they were poor in applying it in clinical scenarios.8 A similar study conducted in India revealed that more than half of the total interns lack the training in bioethics, and about the same number of interns showed hesitation and dilemmas for ethical application in medical practice.9 A report from a study carried out in 2018 at B.P. Koirala Institute of Health Sciences revealed that while medical students could describe the ethical principles in theory, they did not have much confidence in implementing them during clinical practices. They usually feel an undefined protocol as a barrier to applying medical ethics in clinical settings.10 In another study at Kathmandu Medical College, it was found that dental interns had even lower awareness of the ethical codes, especially related to patient confidentiality and informed consent.11 Regionally, similar trends have been observed in Sri Lanka and Bangladesh, where subjective education regarding ethics is enough, but practical mentorship is lacking.12,13 A study from Sri Lanka highlighted the urgent need for interactive, casebased ethics teaching during internships rather than only classroom lectures.12 The recurring themes across these studies knowledge gaps, inconsistent attitudes and poor ethical practices, underline the necessity of structured and contextual ethics education, especially in transitional phases like internships. Nepal, with its unique cultural and systemic healthcare characteristics, demands localised assessments such as the present study to bridge these ethical gaps effectively. 5. CONCLUSION Most interns show moderate knowledge, a positive attitude, and ethically sound practices. The knowledge level showed no. Statistically significant difference between MBBS and BDS interns (p = 0.404), though most had moderate knowledge. Only 22% demonstrated high-level knowledge, highlighting a gap for curriculum strengthening. Attitudinal and practice behaviours were largely homogeneous across courses, with no meaningful variation. The results underscore the need to enhance ethical education depth (especially knowledge mastery) but reflect a positive attitude and high compliance with ethical practices in clinical environments. REFERENCES 1. Sherpa K, Bhandari G. Medical ethics in Nepal: Challenges and way forward. Nepal Med J. 2020;3(1):5– 10. 2. Adhikari S, et al. 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J Nepal Health Res Counc. 2018;16(1):20–5. 11. Paudel S, Koirala M. Ethics in dentistry: Knowledge and perception among interns. Kathmandu Univ Med J. 2021;19(74):157–61. Int. Jr. of Contemp. Res. in Multi. PEER-REVIEWED JOURNAL Volume 4 Issue 3 [MayJun] Year 2025 632 © 2025 Abhishek Karn, Sanjay Kumar Sah, Shivendra Jha.This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY NC ND).https://creativecommons.org/licenses/by/4.0/ 12. Silva A, Fernando G. Teaching ethics in Sri Lanka’s medical curriculum: Gaps and suggestions. Sri Lanka J Bioeth. 2020;9(2):44–51. 13. Rahman MM, Miah MT. Ethical practices among Bangladeshi interns: Current status. Bangladesh Med Res J. 2021;25(3):115–22. Creative Commons (CC) License This article is an open-access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY 4.0) license. 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