Abstract
Clinical ethical practice involves applying moral reasoning and ethical principles to routine patient care decisions, ensuring that healthcare professionals act honorably, respectfully, and responsibly. This study aimed to assess clinical ethical practice and associated factors among health professionals in public hospitals in Addis Ababa, Ethiopia. An institution‑based cross‑sectional study was conducted from August 15 to September 15, 2025, among 372 health professionals selected through simple random sampling from four public hospitals. Data were collected using self‑administered questionnaires which were adapted from existing literature. Analyses were performed using STATA version 15.1. Descriptive and inferential statistics were applied. Variables with p < 0.25 in bivariable logistic regression were entered into multivariable logistic regression. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported, with statistical significance set at p < 0.05. A total of 372 health professionals participated, yielding a 100% response rate. The magnitude of favorable knowledge, attitude, and practice of clinical ethics among participants was 61.7% (95% CI: 56.7–66.7), 50.5% (95% CI: 45.4–55.6), and 50.5% (95% CI: 45.4–55.6), respectively. In multivariable logistic regression, higher monthly salary (AOR = 3.36, 95% CI: 1.49–7.58), ethics training (AOR = 2.04, 95% CI: 1.11–3.75), and favorable knowledge (AOR = 2.09, 95% CI: 1.15–3.80) were positively associated with ethical practice, whereas longer work experience was negatively associated (AOR = 0.45, 95% CI: 0.23–0.88). Clinical ethical practice among health professionals was moderate, with nearly half lacking favorable knowledge, attitudes, and practice. Work experience, salary, training, and knowledge were significant determinants. Strengthening ethics education, continuous professional development, and institutional support is essential to enhance ethical adherence.
Keywords: Clinical ethical practice, Ethics, Health ethics, Health professionals
Subject terms: Health care, Health occupations, Medical research
Introduction
Clinical ethical practice is a cornerstone of modern healthcare, ensuring that patient care decisions are guided not only by technical competence but also by moral responsibility1–4. It encompasses respecting patients’ rights and preferences, ensuring informed consent, maintaining confidentiality, and promoting fairness in the allocation of resources1,4,5. Beyond technical competence, clinical ethical practice bridges medical knowledge with moral responsibility to improve the quality and equity of healthcare delivery4,6,7.
Clinical ethical practice is increasingly recognized as a global priority in healthcare, as professionals across diverse settings frequently encounter dilemmas related to informed consent, confidentiality, end‑of‑life care, and equitable resource allocation1,2.
In low‑ and middle‑income countries, these challenges are amplified by constrained resources, cultural diversity, and limited institutional frameworks to support ethical decision‑making. Ethiopia is no exception, where health professionals in public hospitals often struggle to consistently apply ethical principles due to inadequate training, high patient loads, and weak organizational support8–10.
Clinical ethical practice is shaped by multiple contributing factors that influence how health professionals apply ethical principles in daily care. Factors such as professional satisfaction, availability of functional clinical ethics committees and supportive institutional frameworks, ethics education of pre and in-service training, compassionate and respectful leadership increase the practice of8,11–13. Conversely, high workload, poor infrastructure, and unfavorable attitudes can be barriers to ethical practice8,14. This study aimed to assess clinical ethical practice and associated factors among health professionals in public hospitals in Ethiopia.
Methods and materials
Study area and period
The study was conducted in four public hospitals of Addis Ababa (Yekatit 12, Zewditu, Ras Desta, and ALERT) between August 15 and September 15, 2025. Addis Ababa is the capital of Ethiopia administratively divided into 11 sub cities and 116 woreda. Maps were generated using ArcMap 10.7 (Esri, Redlands, CA, USA; https://www.esri.com) based on 2021 shapefile boundaries from the Ethiopian Statistical Agency (Fig. 1). There were 14 governmental and 25 private hospitals in the city .
Fig. 1.
Map of study area generated using ArcMap 10.7, based on 2021 shapefile boundaries from the Ethiopian Statistical Agency.
Study design
An institutional‑based cross‑sectional study was conducted.
Population
The source population of the study were all health professionals that are working at public hospitals of Addis Ababa, while the study population were randomly selected health professionals that are working at selected public hospitals of Addis Ababa.
Inclusion and exclusion criteria
Health professionals currently working in public hospitals during the study period were included. Health professionals on apprenticeship or internship, those with less than six months of work experience, and staff without direct patient contact (e.g., CEOs, medical directors, and administrative managers) were excluded from the study.
Sample size determination and sampling procedure
The sample size for the study was determined using single population proportion formula. The following assumptions will be used: magnitude of good ethical practice (p) 32.7% in Ethiopia8, the margin of error (d) 5%, confidence level of 95%, and 10% non- response rate (NR), the final sample size of the study was 372. From the total 14 public hospitals in the city four hospitals namely Yikatit 12 hospitals, Zewditu hospitals, Ras-Desta hospitals and ALERT hospitals was selected by simple random sampling methods. The sample size was proportionally allocated based on the number of health professionals currently working in those selected hospitals. Finally study participants were randomly selected.
Study variables
Dependent variable: Clinical ethical practice.
Independent variables: Socio demographic factors (Age, sex, educational level, marital status, income), Knowledge towards health ethics, Attitude toward health ethics, Job related factors: profession, work experience, job satisfaction, ethics training.
Data collection tools and procedures
Data were collected using a standardized, pretested, self‑administered questionnaire adapted from prior Ethiopian and international studies8,9,11. The questionnaire contains socio-demographic characteristics, clinical ethical practice, knowledge and attitude of health ethics, professional satisfaction, availability of clinical ethical committees (CECs), and previous educational curriculum.
Operational definitions
Clinical Ethical Practice: assessed using 16 item a 4-Likert scale type response. Respondents who answered ≥ 75% of the items were classified as having favorable clinical ethical practice. while those who answered ≤ 75% had unfavorable CEP8,15.
Attitude towards clinical ethics: assessed using 14-item questions with a 5-Likert scale response. Respondent scored ≥ 75% of the questions had favorable attitudes towards clinical ethics, while those who answered ≤ 75% had unfavorable attitudes towards CEP8,9,15.
Clinical/health ethical Knowledge: assessed using nine yes/no questions about the application of the code of ethics. Respondents who replied ≥ 75% of the questions had favorable knowledge towards clinical ethics, while those who answered less than or equal to 75% had unfavorable knowledge towards CEP8,9,15.
Data quality management
The questionnaire was pretested among 20 health professionals at Menelik II hospital, and necessary modifications were made. The tool was locally validated, and internal reliability was assessed (Cronbach’s alpha = 0.81), indicating acceptable consistency. Training was given for four data collectors BSc in public health by profession and one master of public health supervisor about the purpose of the study, data collection tools and procedures.
Data processing and analysis
Data were collected using Kobo Toolbox and exported to STATA version 15.1. Descriptive statistics were used to summarize variables. Logistic regression was conducted to identify factors associated with clinical ethical practice, with variables significant at p < 0.25 in bivariable analysis entered into multivariable analysis to avoid excluding potentially important variables. Statistical significance was declared at p < 0.05.
Results
Socio-demographic characteristics
In this study, 368 health professionals participated, yielding a response rate of 98.9%. Among the study participants 168 (45.7%) were males. The mean age was 37.2 (SD ± 4.3) years. Majority 239 (64.9%) had BSc degree and 208(56.5%) of them were married (Table 1).
Table 1.
Socio-demographic characteristics of health care professionals working in public hospitals of Addis Ababa, Ethiopia, 2025.
| Independent variables | Category | N(%) |
|---|---|---|
| Age (years) | 21–30 years | 214(58.2) |
| 31–40 years | 154(41.8) | |
| Sex | Female | 200(54.3) |
| Male | 168(45.7) | |
| Educational level | Diploma | 12(3.3) |
| BSc | 239(64.9) | |
| General Practitioner | 53(14.4) | |
| MSc or MPH | 32(8.7) | |
| Specialist | 32 (8.7) | |
| Marital status | Single | 160(43.5) |
| Married | 208(56.5) | |
| Profession | Nurse | 158(42.9) |
| public health | 26(7.1) | |
| Physician | 73(19.8) | |
| Midwives | 31(8.4) | |
| Pharmacy | 33(9.0) | |
| Laboratory | 29(7.9) | |
| Others | 18(4.9) | |
| Work experience | Juniors | 133(36.1) |
| Seniors | 159(43.2) | |
| Experts | 53(14.4) | |
| Chief | 23(6.3) | |
| Monthly salary | < 8233.49 birr/months | 233(63.3) |
| >=8233.4 birr/month | 135(36.7) |
Knowledge, attitude, and practice of health professionals towards CEP
Regarding knowledge of CEP, 227(61.7%) of the respondents had good knowledge on component of CEP. also, 186(50.5%) had favorable attitude toward CEP, scoring above the mean score value for CEP (Fig. 2).
Fig. 2.
Knowledge, attitude, and practice of health professionals towards clinical ethical practice in public hospitals, addis ababa, Ethiopia, 2025.
Profession-related characteristics
Among the study participants, 226 (61.4%) were happy with their current profession, and 204 (55.4%) chose their current profession by when they joined the university. Most study participants219 (59.5%) were ready to recommend others to pursue their current professions. Almost half of the participants were unaware of an ethics committee, most learned ethics through training, some reported inadequate curriculum coverage, a portion had faced unethical practice accusations, improper discharge was the most common ethical dilemma, and more than half were dissatisfied with their jobs (Table 2).
Table 2.
Profession-related characteristics of health care professionals working in public hospitals of Addis Ababa, Ethiopia, 2025.
| Independent variables | Category | N(%) |
|---|---|---|
| Happy with current profession | Yes | 226(61.4) |
| No | 142(38.6) | |
| First choice of your profession | Yes | 204(55.4) |
| No | 164(44.6) | |
| Advising of others to pursue your profession | Yes | 219(59.5) |
| No | 149(40.5) | |
| Source of information for code of ethics | University | 155(42.1) |
| Training | 195(53.0) | |
| Others | 18(4.9) | |
| Know the presence of ethical committee | Yes | 172(46.7) |
| No | 196(53.3) | |
| The function of the ethics committee | Correction measure | 140(38.0) |
| Punishment | 130(35.3) | |
| Advice | 73(19.8) | |
| Treatment | 25(6.8) | |
| Curriculum adequacy in the University or college | Yes | 206(56.0) |
| No | 102(27.7) | |
| I don’t remember | 60 (16.3) | |
| Facing ethical problems in his or her experience | Yes | 231(62.8) |
| No | 137(37.2) | |
| Perceived reason for unethical Practice | Workload | 272(73.9) |
| Negligence | 47(12.8) | |
| Lack of knowledge | 33(9.0) | |
| Insufficient salary | 16(4.3) | |
| Accused regarding an ethical issue | Yes | 62(16.8) |
| No | 306(83.2) | |
| Encountered ethical dilemma | Yes | 254(69.0) |
| No | 114(31.0) | |
| Common ethical dilemma | Religious issue | 161(43.8) |
| Improper discharge | 109(29.6) | |
| Truth telling | 72(19.6) | |
| End of life issue | 26(7.1) | |
| Satisfaction with your job | Satisfied | 178(48.4) |
| Unsatisfied | 190(51.6) |
Factors associated with clinical ethical practice
Sex, educational level, profession, work experience, monthly salary, choice profession, source of information, curriculum adequacy, ethical problem experience, satisfaction with job, knowledge and attitude were candidate variables entered into multivariable logistic regression analysis. Among these work experience AOR = 0.45,95%CI: (0.23,0.88), monthly salary (AOR = 3.36, 95% CI: 1.49–7.58), training (AOR = 2.04, 95% CI: 1.11–3.75), and knowledge (AOR = 2.09,95% CI: 1.15,3.8) were significantly associated with the CEP (Table 3).
Table 3.
Bivariable and multivariable analyses for factors associated with the CEP in public hospitals of Addis Ababa in 2025.
| Variables | Category | CEP | COR95%CI | AOR95%CI | |
|---|---|---|---|---|---|
| Favorable | Unfavorable | ||||
| Sex | Female | 114 | 86 | 1.77(1.17,2.68)* | 0.63(0.30,1.31) |
| Male | 72 | 96 | 1 | 1 | |
| Education | Degree & below | 168 | 136 | 3.16(1.75,5.70)* | 1.15(0.49,2.73) |
| Above degree | 18 | 46 | 1 | 1 | |
| Profession | Nurse | 87 | 71 | 1 | 1 |
| Public health | 12 | 14 | 0.70(0.30,1.61) | 0.46(0.16,1.30) | |
| Physician | 14 | 59 | 0.19(0.10,0.38)* | 0.09(0.03,2.57) | |
| Midwives | 20 | 11 | 1.48(0.67,3.30) | 2.59(0.85,7.89) | |
| Pharmacy | 22 | 11 | 1.63(0.74,3.59)* | 0.51(0.20,1.31) | |
| Laboratory | 31 | 16 | 1.58(0.80,3.12)* | 2.52(0.04,6.10) | |
| Work experience | Juniors | 90 | 43 | 1 | 1 |
| Seniors | 64 | 95 | 0.32(0.20,0.52)* | 0.45(0.23,0.88)** | |
| Expert & above | 32 | 44 | 0.35(0.19,0.62)* | 0.62(0.21,1.81) | |
| Monthly salary | < 8233.49 birr | 146 | 87 | 3.99(2.53,6.28)* | 3.36(1.49,7.58)** |
| >=8233.4 birr | 40 | 95 | 1 | 1 | |
| Choice profession | Yes | 115 | 89 | 1.69(1.12,2.56)* | 1.84(0.93,3.62) |
| No | 71 | 93 | 1 | 1 | |
| Source of information | University | 71 | 84 | 1 | 1 |
| Training | 115 | 98 | 1.39(092,2.10)* | 2.04(1.11,3.75)** | |
| Curriculum adequacy | Yes | 97 | 109 | 0.73(0.48,1.10)* | 0.49(0.27,1.91) |
| No | 89 | 73 | 1 | 1 | |
| Ethical problem | Yes | 128 | 103 | 1.69(1.11,2.59)* | 1.95(0.96,3.98) |
| No | 58 | 79 | 1 | 1 | |
| Satisfaction with job | Satisfied | 99 | 79 | 1.48(0.98,2.24)* | 0.62(0.32,1.21) |
| Unsatisfied | 87 | 103 | 1 | 1 | |
| Knowledge | Unfavorable | 55 | 86 | 2.13(1.39,3.28)* | 2.09(1.15,3.81)** |
| Favorable | 131 | 96 | 1 | 1 | |
| Attitude | Unfavorable | 100 | 82 | 1 | 1 |
| Favorable | 86 | 100 | 0.71(0.47,1.06)* | 0.81(0.44,1.47) | |
*P < 0.25, **P < 0.05.
Discussion
Among health professionals participated in this study 38% of participants lacked favorable knowledge, and nearly half lacked favorable attitudes and practice towards CEP. Also, work experience, monthly salary, source of information, and knowledge were significantly associated with CEP.
In this study, 38% of the health professionals lack favorable knowledge regarding CEP. This is inline similar finding in Ethiopia and abroad8,16. Also, half of the participant lack favorable attitude towards CEP. Which is lower than finding from Ethiopia8.
Similarly, almost half of health professionals participated in this study lacks favorable CEP. This finding is consistent with the study conducted in Ethiopia and abroad17,18. However, this finding showed better proportion of health professional practicing favorable CEP than study finding in Ethiopia8,9,11. These differences may reflect curriculum variation, study period, cultural context, methodological differences, or infrastructural factors.
Senior professionals were significantly less likely to demonstrate favorable CEP compared with juniors. This may reflect burnout, moral fatigue, or reduced vigilance due to routine familiarity, whereas junior staff may apply recently acquired training more rigorously. The finding is in line with study conducted in Ethiopia18. This suggests that junior staff may be more inclined to apply recently acquired training and adhere closely to ethical standards. In contrast, senior professionals may experience burnout, moral fatigue, or reduced adherence due to routine familiarity, which can weaken ethical vigilance.
Interestingly, lower‑income professionals were more likely to demonstrate favorable ethical practice (AOR = 3.36). This paradox, also observed in Bale Zone, may be explained by Herzberg’s two‑factor theory: salary prevents dissatisfaction but does not necessarily motivate ethical commitment. Lower‑income professionals may rely more on intrinsic motivators such as responsibility and recognition18.
Moreover, ethics training increased the likelihood of favorable practice more than twofold. This finding aligns with Gondar Zone and Addis Ababa studies, which highlighted training as a determinant of ethical adherence8. Both pre‑service and in‑service training enhance knowledge, attitudes, and confidence in applying ethical standards, underscoring the need for structured ethics curricula19,20.
Professionals with favorable knowledge were 2.09 times more likely to demonstrate favorable ethical practice. This is in line Ethiopia9,11. Knowledge strengthens confidence in handling dilemmas and improves adherence to ethical principles21.
Limitation of the study
The limitation of this study is that data were collected through a self-administered questionnaire, which may have introduced response bias. Additionally, since this study relied on self‑reported data, responses may have been influenced by social desirability bias. The absence of vignette‑based questions (realistic clinical scenarios) is acknowledged as a limitation, as such approaches are considered more valid for ethical research.
Conclusion
In this study, nearly half of health professionals in Addis Ababa public hospitals lacked favorable KAP towards clinical ethical practice. Work experience, monthly salary, ethics training, and knowledge were identified as significant determinants of CEP. These findings highlight the need to strengthen ethics education, expand continuous professional development, and establish supportive institutional frameworks such as functional ethics committees. Addressing systemic factors including workload, job satisfaction, and organizational culture is also essential to sustain favorable CEP.
Acknowledgements
We would like to thank study participants for their participation and also the research assistant for their dedication during data collection and data entry.
Abbreviations
- AOR
Adjusted odds ratio
- BSc
Bachelor of science
- CEC
Clinical ethics committee
- CEP
Clinical ethical practice
- CI
Confidence interval
- FMOH
Federal ministry of health
- GP
General practitioner
- MPH
Master of public health
- MSc
Master of science
- NR
Non-response rate
- SD
Standard deviation
- WHO
World health organization
Author contributions
SM, SG, TT, DG, and AT involved in the study design, literature review, analysis and manuscript writing. All the authors read and approved the final draft of the manuscript.
Data availability
The data set is available and submitted with this manuscript.
Declarations
Competing interests
The authors declare no competing interests.
Ethics approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki. Ethical clearance was obtained from the Sante Research and Publication Office Ethics Committee. Written informed consent was obtained from each participant after assuring autonomy, confidentiality, and anonymity.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data set is available and submitted with this manuscript.