Komolafe Deborah's Dissertation

KNOWLEDGE, PERCEPTION AND PRACTICE OF MEDICOLEGAL OBLIGATIONS
UNDER THE NATIONAL HEALTH ACT AMONG HEALTHCARE WORKERS IN

OSUN STATE
A DISSERTATION SUBMITTED TO
THE INSTITUTE OF ADVANCED CLINICAL SCIENCES EDUCATION UNIMED,
ONDO, ONDO STATE, NIGERIA.
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF A
MASTERS DEGREE IN HEALTH LAW AND POLICY
BY
Deborah, Jesutofunmi KOMOLAFE
MATRIC NO: HLP/22/3979
OCTONOVEMBER, 2023
AFFIRMATION
I, KOMOLFE, Deborah Jesutofunmi with Matriculation number HLP/22/3979 hereby affirm
that this work is original, and I have complied with the principles of academic honesty. The work
represents the culmination of countless hours of research, analysis, and dedication.
I dedicate this thesis to the pursuit of knowledge, the love of learning, and the relentless spirit of
inquiry.
ii
CERTIFICATION
I certify that this study was conducted by KOMOLAFE, Deborah Jesutofunmi (HLP/22/3979)
under my partial supervision and with the caveat that the candidate is solely responsible for any
errors and inconsistencies in the study.
…………………………… ………………….
Signature Date
Dr. Oluwadamilola Adejumo
(Project Supervisor)
KNOWLEDGE, PERCEPTION AND PRACTICE OF MEDICOLEGAL OBLIGATIONS

iii
UNDER THE NATIONAL HEALTH ACT AMONG HEALTHCARE WORKERS
IN OSUN STATE
KOMOLAFE, Deborah Jesutofunmi, Oluwadamilola Adejumo
ABSTRACT
There is growing concern within the medical profession and society about the increasing number
of complaints and lawsuits against physicians. There has been a growth in the number of legal
and ethical responsibilities that healthcare professionals, have to their patients, the medical
profession, and society as a whole. The ability to effectively guarantee citizens’ access to
comprehensive care is dependent on the presence of a well-regulated health care system that not
only recognizes the right to health but also charts a clear course as to how the right is to be
attained. The study assessed the knowledge, perception and practice of healthcare workers under
the National Health Act (NHA).
The study adopted a cross- sectional descriptive design. The sample size for the study was 255,
using Cochran sampling technique with 79.2% prevalence of perception and 95% confidence
interval. The instrument for data collection was questionnaire. The validity of the questionnaire
was established through face and content validity. The reliability was established, reliability
coefficients were 0.75, 0.77 and 0.83 for scales measuring knowledge, perception and practice of
healthcare workers respectively. Data collected were coded and entered into Stata 14. Both
descriptive and inferential statistics were done with level of significance (p=value) at 0.05.
Results were presented in tables, figures and text.
A total of 234 questionnaire completely filled questionnaires were retrieved (response rate
91.8%). The findings show that mean age of the respondents was 35.61±10.03 with highest
proportion in the age range of ≤ 30 years. The findings show that 54.5% were nurses and 42.1%
had 1-5years of practice. Many (59.2%) of the respondents hadn’t read National Health Act and
89.3% do not have a copy of the National Health Act. Less than half (41.6%) of the respondents
had good knowledge of NHA, 48.1% had positive perception of NHA, and 47.6% of the
respondents had good practice of NHA. The result of bivariate analysis shows there was a
significant association between knowledge of NHA and reading of NHA (χ2= 6.53, p=0.01) and
possession of NHA (χ2= 3.89, p=0.04). There was also a significant association between
perception of NHA and possession of NHA (χ2= 4.46, p=0.04). Also, there was a significant
association between practice of NHA and reading of NHA (χ2= 13.46, p=<0.01). The study also
shows that only job category was significantly associated with practice of NHA among the health
workers (p=0.012). At multivariate level, reading the NHA was a predictor of practice of NHA.
The study concluded that the knowledge and practice of NHA among healthcare workers was
poor, and their perception of NHA was negative. There is need for healthcare professionals to be
educated during pre-service and professional training about the nature and implications of
medico-legal matters which will help to improve the quality of care and service delivery.
Key words: Knowledge, Perception, Practice, National Health Act and Healthcare workers
iv
TABLE OF CONTENTS
Title Page i
AFFIRMATION ii
CERTIFICATION iii
ABSTRACT iv
TABLE OF CONTENT v
ACKNOWLEDGEMENTS viii
DEDICATION ix
CHAPTER ONE- INTRODUCTION
1.1 Background to the Study-------------------------------------------------------------------1
1.2 Statement of the Problem------------------------------------------------------------------3
1.3 Research Questions-------------------------------------------------------------------------5
1.4 Research Objectives------------------------------------------------------------------------5
1.5 Significance of the Study -----------------------------------------------------------------5
1.6 Scope of the Study--------------------------------------------------------------------------9
1.7 Structure of the Study----------------------------------------------------------------------9
CHAPTER TWO- LITERATURE REVIEW------------------------------------------------11
2.1 The Conceptual review----------------------------------------------------------------------11
2.1.1 Concept of Medico-legal Obligations of Healthcare Workers ------------------------11
2.1.2 Knowledge and Perception of Medico-Legal Obligations of Healthcare Workers--17
2.1.3 Knowledge, Awareness and Practice of Medicolegal Obligations --------------------20
2.1.4 Medicolegal Obligations of Healthcare Workers in Nigeria ---------------------------22

v
2.1.5 Laws Regulating the medical profession in Nigeria-------------------------------------26
2.1.6 NHA And Medico-Legal Obligations Under The NHA---------------------------------29
2.1.7 Factors Affecting the Knowledge, Perception and Practice of
Medicolegal Obligations Under NHA Among Healthcare Workers---------------------33
2.2 Conceptual Framework------------------------------------------------------------------------36
2.3 Empirical Literature Review------------------------------------------------------------------37
2.4 Theoretical Review-----------------------------------------------------------------------------39
2.4.1 Socio-Ecological Model Theory---------------------------------------------------------------39
2.4.2 Theory of Planned Behaviour (TPB)--------------------------------------------------------40
2.5 Research Hypotheses--------------------------------------------------------------------------41
CHAPTER THREE- METHODOLOGY--------------------------------------------------------43
3.1 Research Design--------------------------------------------------------------------------------43
3.2 Study Setting------------------------------------------------------------------------------------43
3.3 Study Population-------------------------------------------------------------------------------43
3.4 Sample Size and Sampling Technique------------------------------------------------------43
3.5 Research Instrument---------------------------------------------------------------------------44
3.6 Validity and Reliability of Instrument------------------------------------------------------45
3.7 Procedure for Data Collection---------------------------------------------------------------45
3.8 Method of Data Analysis----------------------------------------------------------------------45
3.9 Estimation Technique-------------------------------------------------------------------------46
3.10 Ethical Considerations------------------------------------------------------------------------47
CHAPTER FOUR- PRESENTATION OF RESULT AND DISCUSSION----------------48
4.1 Socio-demographic Characteristics of Respondents--------------------------------------49
vi
4.2 Knowledge of National Health Acts of Respondents ------------------------------------51
4.3 Perception of National Health Acts of Respondents-------------------------------------54
4.4 Practice of National Health Acts of Respondents---------------------------------------57
4.5 Hypotheses Testing and Inferential Statistics--------------------------------------------60
4.6 Discussion of Findings---------------------------------------------------------------------66
CHAPTER FIVE- SUMMARY, CONCLUSION, POLICY RECOMMENDATION
5.1 Summary and Conclusion-----------------------------------------------------------------70
5.2 Policy Recommendation-------------------------------------------------------------------71
5.3 Limitation of the Study---------------------------------------------------------------------71
5.4 Suggestion for Further Studies------------------------------------------------------------72
5.5 Contribution to Knowledge----------------------------------------------------------------72
BIBLIOGRAPHYREFERENCES----
--------------------------------------------------------------------------73
APPENDIX-----------------------------------------------------------------------------------80
vii
ACKNOWLEDGEMENTS
I am grateful to God almighty for his mercy and favour that is always available for me and for
his strength and grace throughout the period of this program.
Special thanks to my supervisor, Dr. Adejumo for giving useful guidance, insightful comments
and considerable encouragement to complete this project successfully. Words cannot express
how privileged I am to work with you.
To all my lecturers, I thank you for the knowledge impacted in me. God bless you Sirs and Mas.
My utmost esteem goes to my Pastor; Pastor Philip Odewole for his support, prayers and words
of encouragement. God bless you sir.
I remember my parents, Dr A.O. and Dr (Mrs) A.O. Komolafe who placed me on strong spiritual,
moral and academic foundation in the success of my M.Sc. program. Dad and Mum, without
your prayers, love, patience, and perseverance, I wouldn’t have made it thus far and with every
sense of gratitude, I say ‘thank you sir and ma’. You are wonderful parents, I appreciate you.
Last but certainly far from being the least, my gratitude goes to everyone who in one way or the
other contributed to the successful completion of this project. May God bless you all.
viii
DEDICATION
This research is dedicated to God Almighty, the Omnipotent, Omnipresent, and Omniscient God.
To Him alone be the glory and honour and majesty, Amen.
ix
LIST OF TABLES
Table 4.1 Respondents’ Socio-demographic Characteristics ---------------------------49

Table 4.2 Respondents’ Knowledge of National Health Acts---------------------------51
Table 4.3 Respondents’ Perception of National Health Acts ---------------------------54
Table 4.4 Respondents’ Practice of National Health Acts-------------------------------57
Table 4.5.1 Association between Practice of NHA and
Socio-demographic Characteristics---------------------------------------------60
Table 4.5.2 Association between Knowledge of NHA and reading
and possession of NHA-----------------------------------------------------------62
Table 4.5.3 Association between Perception of NHA and reading
and possession of NHA-----------------------------------------------------------63
Table 4.5.4 Association between Practice of NHA and reading
and possession of NHA----------------------------------------------------------64
Table 4.5.5 Multivariate regression of Reading the NHA and
possessing a copy of the NHA---------------------------------------------------65
x
LIST OF FIGURES
Fig 1 Summary of Respondents’ level of knowledge of NHA ---------------------------53
Fig 2 Summary of Respondents’ overall perception of NHA ----------------------------56
Fig 3 Summary of Respondents’ level of NHA practice-----------------------------------59
xi
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Medicolegal obligations have been included in the training curriculum of health professionals in
many countries and there has been a growth in the number of legal and ethical responsibilities
that healthcare professionals, have to their patients, the medical profession, and society as a
whole.1
It is important to have a good knowledge of all the branches of medical and ancillary science
taught to a medical student during the course of studies. Good medical practice requires that
medical graduates can demonstrate in practice knowledge and understanding of the law
regulating the profession.2 The ability to effectively ensure citizens' access to comprehensive
health care depends on the existence of a well-regulated health system that not only recognizes
the right to health but also provides a clear path for achieving this right.3
The National Health Act (NHA) was enacted in 2014 as Nigeria's first comprehensive law to
regulate the health system, with the aim of strengthening the right to health and building a strong
health system.4 Despite numerous policy documents, the NHA aimed to establish a clear
government commitment to its citizens. The National Health Act (NHA) in Nigeria provides a
legal basis for the regulation, development and management of the country's healthcare system.
It recognizes, protects, promotes and fulfils citizens' right to access health services. 5 However,
1
Fatma Kandeel, Hala Marawan and Situhom Elagamy, ‘Factors Affecting Knowledge, Attitude and Practice of
Physicians towards Medico-Legal Aspects in Clinical Practice in Menoufia Governorate Hospitals’ (2022) 22 The
Egyptian Journal of Forensic Sciences and Applied Toxicology 53.
2
Bose and others, ‘Assessment of Knowledge and Awareness about Medico Legal Issues among Interns and Post
Graduate Students in Rajahmundry, Andhra Pradesh’ (2021) Vol. 15, No. 4 October-December 2021, 2428.
3
Adejumo OA and others, ‘Knowledge of the National Health Act among Physicians in Two Tertiary Hospitals in
Southern Nigeria’ (2022) J.2022 5(2) 31st December 2022 85.
4
ibid.
5
ibid.
1
the success of the NHA depends on the knowledge of major stakeholders, such as physicians.
Despite high awareness among healthcare professionals, knowledge of the NHA is poor. A
comprehensive assessment is needed to identify knowledge gaps and ensure effective
implementation.6 The 1999 Constitution provides for the right to life and the duty of the State to
provide adequate health care and facilities in Section 33 and Section 17(3)(d). The NHA contains
several rights of health care providers and responsibilities of health care providers in Part 3.7 In
addition to the NHA, the Medical and Dental Practitioners’ Act sets out the requirements for
registration, membership and discipline of practitioners by the Medical and Dental Council of
Nigeria.8 Also, the Code of Medical Ethics codified by The Medical and Dental Council of
Nigeria (MDCN) in furtherance of its statutory functions as provided for in Section 1 (2) (c)
of the Medical and Dental Practitioners Act, laid down the standards of acceptable medical
and dental practice in Nigeria especially under Rules 26 to 70. 9
Health professionals form a significant component of health-care systems and are important in
the delivery of smooth, efficient, effective and quality health care services. 10 Since the goal of the
NHA is the regulation, development, management, and advancement of Nigeria's National
Health System, the role of health professionals in the actualization of this goal cannot be over-
emphasized.11 Their knowledge, perception and practice of the NHA will therefore likely
6
ibid.
7
National Health Act (2014).
8
‘Medico-Legal Practice in Nigeria: Balancing the Rights and Liabilities of Patients and Medical Practitioners. **’
(Kevin Martin Ogwemoh Legal, 25 September 2020) <Https://Www.Kmo.Legal/2020/09/26/Medico-Legal-Practice-
In-Nigeria-Balancing-The-Rights-And-Liabilities-Of-Patients-And-Medical-Practitioners/> Accessed 11 August
2023.
9
ibid.
10
Kandeel, Marawan and Elagamy (n 1).
11
Osahon Enabulele and Joan Emien Enabulele, ‘Nigeria’s National Health Act: An Assessment of Health
Professionals’ Knowledge and Perception’ (2016) 57 Nigerian Medical Journal: Journal of the Nigeria Medical
Association 260.
2
influence the degree of success in the implementation of the Act and the realization of its
ultimate benefits of improved health coverage, quality, and health outcomes.12
The foregoing notwithstanding, a casual interaction with some health professionals may seem to
suggest that since the NHA 2014 came into existence, not much may have been done to inform
and educate health professionals on its provisions.13 This study was therefore aimed at
scientifically assessing health professionals' knowledge, perception and practice of medicolegal
obligations under NHA among healthcare workers in Osun State.
1.2 Statement of the Research problem
Medical practice is guided by law, ethics, community morals, and professional standards to save
patients from malpractice and protect medical practitioners against lawsuits. 14 Physicians are
subjected to many legal, ethical, and moral obligations. It is an established law that physicians
owe a medical duty of care to their patients. This duty is sacrosanct and must be discharged with
such degree of skill and competence the average practitioner of the profession under similar
circumstances would use. Medical negligence arises where this degree of care is not observed. 15
The practice of medicine is capable of rendering noble service to humanity provided due care,
sincerity, efficiency, and professional skill is observed by the doctors. However, today, the
patient–doctor relationship has almost diminished its fiduciary character and has become more
formal and structured.16

12
‘Nigeria’s National Health Act: An Assessment of Health Professionals’ Knowledge and Perception - PMC’
<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036296/> accessed 10 August 2023.
13
ibid.
14
Alyahya, AI.; Elserafy, OS.; Alzoubaidi, and FM., and Moursi, OA., ‘Experience, Education, and Training Impact
on Medicolegal Knowledge, Attitude, and Practice. The Saudi Journal of Forensic Medicine and Sciences’ [2018]
January-April, 1(1).
15
Daud Momodu and Tijani Oseni, ‘Medical Duty of Care: A Medico-Legal Analysis of Medical Negligence in
Nigeria’ (2019) 9 56.
16
Bevinahalli N Raveesh, RagavendraB Nayak and ShivakumarF Kumbar, ‘Preventing Medico-Legal Issues in
Clinical Practice’ (2016) 19 Annals of Indian Academy of Neurology 15.
3
There are several factors that impact physicians' medicolegal obligations: lack of informed
consent, failure to obtain confidentiality, lack of documentation, poor standard of care, and
failure to prevent negligence.
Barnie and others study found that majority (73.6%) of the health workers had fairly adequate
knowledge about ethics, confidentiality and medico-legal issues. Two-thirds (64%) of the
respondents were aware of the necessity, requirement, demand for confidentiality of patient
information while 36% had no knowledge about these issues.17
Another study revealed that 87.5% of respondents were unaware of contract terms, 75.6% didn't
know the main medical laws body, and 92.2% felt unprepared for medicolegal issues, with only
34.4% attempting to do more experience.18
Knowledge of medicolegal obligations are crucial for physicians to ensure they are providing the
highest standard of care while also adhering to legal and ethical standards. It's important for
physicians to familiarize themselves with the specific regulations and guidelines set forth by the
NHA. Clinical practice or governance is a system through which healthcare provider is
providing qualitative services and safeguarding high standard of care by creating
enabling environment for excellence in clinical care. 19 The balance between excellence in
patient care and medico-legal requirements establishes a successful clinical practice. 20
1.3 Research Questions:
i. What is the level of knowledge of medico-legal obligations among healthcare workers in
Osun State?
17
Bernard Asamoah Barnie and others, ‘Knowledge and Perceptions of Health Workers’ Training on Ethics,
Confidentiality and Medico-Legal Issues’ (2015) 6 Journal of clinical research & bioethics 205.
18
Ismail Zaed and others, ‘Medicolegal Issues: Perception, Awareness, and Behavioral Changes Among Italian
Neurosurgical Community: Survey-Based Analysis’ (2021) 154 World Neurosurgery e774.
19
Tukur B and Celestine Nkanta, ‘Medico -Legal Issues in Clinical Practice: An Overview’ (2017) 1 89-98.
20
4
ii. What is the perception of medico-legal obligations among healthcare workers in Osun
State?
iii. What is the practice of medico-legal obligations among healthcare workers in Osun
State?
1.4 Objectives of the study
The aim of the study is to assess the knowledge and evaluate perception and practice of
medicolegal obligations under NHA among healthcare workers in Osun State. The specific
objectives are:
i. To assess the knowledge of medicolegal obligations among healthcare workers in Osun
State;
ii. To assess the perception of medicolegal obligations among healthcare workers in Osun
State; and
iii. To assess the practice of medicolegal obligations among healthcare workers in Osun State.
[iv.]
1.5 Significance of the Study
In the healthcare sector, the delivery of safe and high-quality care is of paramount importance.
Healthcare workers, including doctors, nurses, and other allied healthcare professionals, play a
vital role in ensuring patient safety and upholding ethical standards. 21 Medico-legal obligations,
which encompass legal and ethical responsibilities, are fundamental to the practice of healthcare
21
Rebecca CH Brown and Julian Savulescu, ‘Responsibility in Healthcare across Time and Agents’ (2019) 45
Journal of Medical Ethics 636.
5
professionals.22 These obligations are designed to protect the rights and well-being of patients,
maintain professional standards, and mitigate legal risks.
The National Health Act (NHA) is a comprehensive law that establishes the legal framework for
healthcare in [country/region].23 It describes the rights and responsibilities of both healthcare
providers and patients and emphasizes the importance of quality care, patient safety and ethical
considerations.24 Compliance with the medico-legal obligations outlined in the NHA is critical
for healthcare workers to provide effective and safe care while maintaining professional integrity.
Examining healthcare professionals' knowledge and practice of medico-legal obligations can
help identify areas where patient rights and safety may be at risk. This can lead to the
development of targeted interventions to improve health quality and patient outcomes.
Healthcare practitioners need inclusive and culturally relevant training based on practical
situations to deepen their knowledge of ethics, confidentiality, and medico-legal issues. 25
Lawsuits for medical negligence can be minimized or avoided by taking steps to keep patients
satisfied, adhering to policies and procedures, developing patient-centered care, and knowing
ways of defending against malpractice judgments.26
Respecting patients' confidentiality is an ethical and legal responsibility for health professionals
and the cornerstone of care excellence. Health professionals have a limited attitude towards
patient confidentiality but have relatively good knowledge. Providing a continuing medical
22
Maliheh Kadivar and others, ‘Ethical and Legal Aspects of Patient’s Safety: A Clinical Case Report’ (2017) 10
Journal of Medical Ethics and History of Medicine 15.
23
Association 260.
24
bnsartain, ‘Patient Rights & Responsibilities’ (24 August 2021) <https://uthealtheasttexas.com/patient-rights-
responsibilities> accessed 31 October 2023.
25
26
Bevinahalli N Raveesh, Ragavendra B Nayak and Shivakumar F Kumbar, ‘Preventing Medico-Legal Issues in
Clinical Practice’ (2016) 19 Annals of Indian Academy of Neurology S15.
6
ethics training package for health workers before joining the hospital and in between the working
time could be recommended to enhance health professionals' knowledge and attitude towards
patient confidentiality.27 Knowledge and attitude are essential for the proper handling of medico-
legal records. A healthcare professional with a good understanding of medico-legal aspects can
provide better care to patients and avoid legal issues. 28 Knowledge and a positive attitude are
crucial when dealing with medical-legal documents. Healthcare professionals who have
extensive knowledge of medico-legal matters can provide their patients with top-notch care and
prevent legal problems.
It is important for healthcare workers to have a good understanding of the legal obligations
associated with medical care. This knowledge is critical to protecting patient rights and safety.
Specific measures can be taken to achieve this, such as providing comprehensive and culturally
appropriate training.
Healthcare workers have both ethical and legal responsibilities to protect the patients they care
for.29 Healthcare workers have certain duties and obligations to ensure the well-being and safety
of the patients they treat. Understanding healthcare workers' perception of medico-legal
obligations can shed light on their awareness of legal responsibilities and the consequences of
non-compliance. This knowledge can assist in enforcing accountability within the healthcare
system and reduce the likelihood of medical malpractice. 30 Nurses, for example, have a Bill of
Rights that supports them in a range of workplace situations, including unsafe staffing,
27
Masresha Derese Tegegne and others, ‘Health Professionals’ Knowledge and Attitude towards Patient
Confidentiality and Associated Factors in a Resource-Limited Setting: A Cross-Sectional Study’ (2022) 23 BMC
Medical Ethics 26.
28
Saraswathi D and Edwin Jose, ‘Knowledge and Attitude towards Handling Medical-Legal Records among Nurses’
(2023) 6 IP Journal of Paediatrics and Nursing Science 69.
29
‘Ethical & Legal Responsibilities of Healthcare Workers - Video & Lesson Transcript’ ( study.com)
<https://study.com/WEB-INF/views/jsp/redesign/academy/lesson/seoLessonPage.jsp> accessed 31 October 2023.
30
Hemant Kumar and others, ‘Legal Awareness and Responsibilities of Nursing Staff in Administration of Patient
Care in A Trust Hospital’ (2013) 7 Journal of Clinical and Diagnostic Research: JCDR 2814.
7
mandatory overtime, and health and safety issues such as needle stick injuries, workplace
violence, and latex allergies.31 Nurses are required by law to inform authorities about any unsafe
or inappropriate actions or behaviours they witness from other healthcare workers. Lack of legal
awareness is considered one of the most important reasons for legal problems for nurses.
Therefore, it is necessary to teach legal terms to nurses to avoid lawsuits against them, nurses
should be familiar with regulations to avoid lawsuits against them.32
Healthcare workers have a moral and legal duty to ensure the safety and well-being of the
patients they care for. Understanding their obligations to medical and legal standards will make it
easier to hold them accountable for any wrongdoing and prevent medical errors. Nurses in
particular have a number of rights that protect them in various work situations, and they have a
legal obligation to report unsafe or inappropriate practices among their colleagues. To prevent
lawsuits against caregivers, it is important to educate them about legal terms and concepts.
The significance of this research rests in its ability to close gaps in healthcare workers'
understanding, perception, and performance of their medico-legal obligations. Patients and
healthcare professionals alike stand to gain from this research's potential to advance patient
rights, strengthen legal compliance, and, in the end, improve the standard of healthcare services.
There are however few studies done in Nigeria to assess the knowledge, perception and practice
of medico-legal obligations. This study will therefore assess the knowledge, perception and
practice of medico-legal obligations among healthcare workers in Osun State. It also sets out to
identify and explore the factors affecting knowledge, perception and practice of medicolegal
obligations under NHA among the healthcare workers in a bid to contribute to knowledge and
31
‘Nurses Bill of Rights | American Nurses Association | ANA’
<https://www.nursingworld.org/practice-policy/work-environment/health-safety/bill-of-rights/> accessed 31
October 2023.
32
Fatemeh Ghofrani-Kelishami and others, ‘The Necessity of Legal Awareness of the Nurses in Health System’.
8
provide evidence for advocacy for the sensitization and training of the health workers on medico-
legal issues.
1.6 Scope of the Study
This study focused on the assessment of knowledge, perception and practice of healthcare
workers on medico-legal issues and obligations. It also seeks to identify factors influencing
knowledge, perception and practice of medicolegal obligations under NHA among healthcare
workers in Osun State. Medicolegal obligation is the dependent variable in the research and
healthcare workers is the independent variable in the research. Therefore, this study focuses on
the knowledge, perception and practice of medicolegal obligations under NHA among healthcare
workers in Osun State.
1.7 Structure of the Study
This study covered chapters one to five and began with the introduction to the literature review,
the methodology, the analysis of the results, the empirical analysis/policy recommendations. This
study is divided into five chapters. In addition to this introduction chapter, Chapter two presents
the literature review which provides the conceptual, theoretical and legal review underpinning of
the study. In Chapter three research methodology and method guiding the study is explained.
This chapter explains what data to gather, why the data, where to gather them, and how to
analyse and interpret the findings. Chapter four presents analysis of the primary data used in the
study as well as its findings, further analysis of the data as well as discussions on the results of
the research findings relative to the reviewed literature. Finally, in Chapter five, the study
concludes by providing the summary of findings, contributions to knowledge and practice;
conclusions, policy recommendations and limitations for further study.
9
CHAPTER TWO
LITERATURE REVIEW
Understanding healthcare workers' knowledge, perception, and practice of these medicolegal
obligations is crucial for maintaining high standards of patient care and safeguarding the rights of
patients. This chapter focuses on the conceptual framework, theoretical framework, empirical
literature review, summary and gaps in literature. This chapter reviews the literature on
Knowledge, Perception, and Practice of medicolegal obligations under the National Health Act
(NHA) among Healthcare Workers. This review aims to establish a foundation for the current
10
study by examining prior studies, theories, and findings. It aims to identify research gaps to
justify the need for this study.
2.1 Conceptual Review
2.1.1 Concept of Medicolegal Obligations of Healthcare Workers.
Medical-legal obligations are the legal and ethical responsibilities that healthcare professionals,
such as doctors, nurses and other medical professionals, have when carrying out their work.
These obligations are based on both the principles of medical ethics and the laws that govern
health care practices. In other words, health care professionals are bound not only by ethical
guidelines that dictate how they should conduct themselves professionally, but also by laws that
determine what they can and cannot do in their practice. These obligations ensure that healthcare
professionals provide both legal and ethical care, promoting the well-being and safety of
patients.33
Medical ethics deals with medical law, the rights and responsibilities of doctors and patients in
law.34 Medical knowledge and legal mastery are applied in circumstances known as medicolegal
issues, which are at the convergence of medication and law. These issues regularly come up in
different settings, like the overall set of laws, forensic medication, and the medical industry.
Obligation rehearses control relational cooperation, maintain law and order, reward productive
work, and prevent reserved conduct. The construction of social associations and human
psychology makes liability designation unavoidable.35 However, Medicolegal obligations of
healthcare workers refer to the legal and ethical responsibilities that healthcare professionals
33
Linda Sheahan and Scott Lamont, ‘Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of
“Duty” for Health Practitioners’ (2020) 17 Journal of Bioethical Inquiry 697.
34
‘What Is Medicolegal?’ (Talking Healthtech) <https://www.talkinghealthtech.com/glossary/medicolegal>
accessed 12 October 2023.
35
Rebecca CH Brown and Julian Savulescu, ‘Responsibility in Healthcare across Time and Agents’ (2019) 45
Journal of Medical Ethics 636.
11
have in the course of their practice. These obligations are essential to ensure the delivery of safe,
high-quality healthcare and to protect the rights and well-being of patients. The concept
encompasses a range of legal and ethical duties that healthcare workers are expected to fulfill.
Thus, healthcare professionals have a legal and ethical duty to obtain informed consent from
patients before performing medical procedures or treatments. Informed consent means that
patients are adequately informed about the nature of the procedure, its potential risks and
benefits, and any available alternatives. Patients must voluntarily and willingly consent to the
proposed treatment or procedure.36 One of the main parts of healthcare is the possibility of
obligation in clinical practice, particularly with respect to medico-legal issues. It incorporates a
medical service proficient obligation to treat patients in a protected, viable, and sympathetic way
while maintaining the standards and regulations that control the clinical business.
The healthcare professional's responsibility is to guarantee that patients give informed consent
before any operation or therapy. This implies patients should be furnished with all applicable
data about the treatment, including potential dangers and choices, so they can make informed
conclusions about their consideration.37 Healthcare professionals have a duty of care to their
patients. This means they are responsible for providing care that meets accepted medical
standards and is in the best interest of the patient. 38 Precise and ideal documentation is vital in
medical practice. This incorporates medical records, consent structures, and other documentation
that provides a record of patient consideration and choices made. In ability to keep up with
legitimate records can have legal implications.
36
Allen TC. Medicolegal issues in pathology. Arch Pathol Lab Med 2008; 132:186-91.
37
Parthapratim Gupta, ‘Avoiding Litigation in Clinical Practice’ (2019) 24 Journal of Indian Association of
Pediatric Surgeons 158.
38
Momodu and Oseni (n 15) 2.
12
Proper and accurate documentation of patient care is a medico legal obligation. Accurate medical
records are crucial for patient care continuity, legal purposes, and maintaining the quality and
safety of healthcare. Healthcare workers owe a duty of care to their patients. This duty includes
acting in a manner consistent with the standards of their profession, prioritizing patient welfare,
and avoiding actions or omissions that could harm patients. 39 Healthcare professionals are
responsible for maintaining patient confidentiality. Disclosing patient information without their
consent can result in legal consequences, such as a breach of patient confidentiality. 40
Medical responsibility and medico-legal issues are intricate, necessitating healthcare
professionals to adhere to ethical standards and provide necessary training to minimize risks and
maintain high care standards. Perception plays a crucial role in shaping people's attitudes and
behaviors towards laws and obligations. How individuals perceive these legal and societal
constructs can have significant implications for their compliance, engagement, and support. 41
The perception of healthcare workers regarding laws and obligations is crucial because it plays a
significant role in shaping the delivery of healthcare services. Staying up-to-date with advances
in medical knowledge and practices through continuing education and professional development
is a medicolegal obligation. Healthcare workers are expected to maintain and improve their skills
and knowledge throughout their careers. Health institutions must comply with laws, regulations,
and standards related to healthcare delivery. This includes following professional licensing
39
Joseph Thomas, ‘Medical Records and Issues in Negligence’ (2009) 25 Indian Journal of Urology: IJU: Journal of
the Urological Society of India 384.
40
Cristina M Beltran-Aroca and others, ‘Confidentiality Breaches in Clinical Practice: What Happens in Hospitals?’
(2016) 17 BMC Medical Ethics 52.
41
Devon Johnson, Edward R Maguire and Joseph B Kuhns, ‘Public Perceptions of the Legitimacy of the Law and
Legal Authorities: Evidence from the Caribbean’ (2014) 48 Law & Society Review 947.
13
requirements, maintaining healthcare facilities to code, and adhering to relevant healthcare
legislation.42
Healthcare workers who have a positive perception of healthcare laws and obligations are more
likely to comply with them. This ensures that patients receive the care they need and deserve
while minimizing the risk of legal violations.43 Healthcare workers and organizations decrease
legitimate and financial risks by fathoming and maintaining medical care regulations and
commitments. Compliance brings down the chance of misbehavior claims, fines from the
government, and other legal issues. Healthcare experts are bound to treat their commitments as
experts in a serious way in the event that they grasp the meaning of regulations and
commitments. To keep the public confident about the medical care framework, this responsibility
is significant.
The public's trust in the healthcare system is influenced by how healthcare professionals are seen
in relation to laws and duties. The public is more likely to trust the system when healthcare
workers are seen as knowledgeable about and respectful of legal and ethical principles.44 The
perception of healthcare workers regarding laws and obligations is essential for maintaining the
integrity of healthcare systems, ensuring patient safety, and promoting ethical behavior. 45
Positive perceptions can lead to better compliance, adherence to ethical standards, and the
42
Nanandkar SD, Chavan GS. Assessment of medico-legal awareness of practicing obstetricians and gynaecologists
JIndian Acad Forensic Med 2008; 30:136-40.
43
Beena Jimmy and Jimmy Jose, ‘Patient Medication Adherence: Measures in Daily Practice’ (2011) 26 Oman
Medical Journal 155.
44
‘Ethics in Health Care: Improving Patient Outcomes’ (19 January 2023)
<https://publichealth.tulane.edu/blog/ethics-in-healthcare/> accessed 13 October 2023.
45
Maliheh Kadivar and others, ‘Ethical and Legal Aspects of Patient’s Safety: A Clinical Case Report’ (2017) 10
Journal of Medical Ethics and History of Medicine 15.
14
delivery of high-quality care, ultimately benefiting both healthcare professionals and the patients
they serve.46
Knowledge about medical ethics is as fundamental to the practice of medicine as clinical skills to
assess the knowledge of health care professionals regarding medico-legal issues. 47 It is generally
accepted in the healthcare system that a doctor is expected to carry out his duties with the utmost
care in the exercise of his skills and competences. Medical law covers a wide range of issues,
including errors in the administration of medications, errors in therapy, errors in the diagnostic
phase, neglect of warning signs, premature discharge of patients, complications of the health
situation due to errors in treatment procedures and other problems due to disorders of the health
care environment (e.g. infections), errors in referral or referral without appropriate care or first
aid, among others. However, these errors can arise from facility management, simple accidents
and other incidents are in recent errors not disclosed to patients, their relatives for fear of being
sued.
Medical errors do not necessarily comprise exploitative way of behaving, yet inability to reveal
mistakes can make it harder to decide the genuine reasons for Medical errors.48 Improving the
quality of patient care, patient trust in the healthcare system and ultimately health outcomes, it is
critical to understand healthcare professionals' attitudes toward their obligations to their patient.
The awareness of patient’s rights and healthcare worker’s obligations within the Nigeria setting
also appears to be really low. According to Nash, educating healthcare professionals during pre-
46
‘Ethical & Legal Responsibilities of Healthcare Workers - Video & Lesson Transcript’ (study.com)
<https://study.com/WEB-INF/views/jsp/redesign/academy/lesson/seoLessonPage.jsp> accessed 12 October 2023.
47
Mayuresh J Baheti, ‘Medico Legal Awareness: Where Are We? Â€ “A Survey among Health Professionals in
Maharashtra and Haryana’ (2015) 5 International Journal of Public Health Research 525.
48
Similoluwa Awe Dip.Law, Dip.HR, and LLB, ‘Medical Law and the Nigeria Healthcare - Simply Law’ (26 July
2022) <https://simplylaw.com.ng/medical-law-and-the-nigeria-healthcare/> accessed 26 August 2023.
15
service and professional training about the nature and implications of medico-legal matters is
important to improve the quality of care and thereby increase patient confidence in them. 49
While the knowledge of health workers on ethics and confidentiality issues may be considered
high and their perception somewhat positive, knowledge of crucial medico-legal issues outside
the core of ethics appears to be low. Healthcare professionals need inclusive and culturally
relevant training based on practical situations to deepen their knowledge and ensure patients
have trust in the healthcare system.
As with doctors, nurses' legal responsibility begins with their professional practice. With their
license they certify that they are legally competent and qualified to practice their profession. It is
a testament that as a professional nurse they are now able to provide holistic and high-quality
care to their clients.50 The same applies for other allied health professionals, there are certain
standards and codes of practice that is expected of them while they are at work. Their ignorance,
just as much as that of physicians or nurses’ may have serious implication on the health and
well-being of the patient. Hence, apart from the physicians, the nurses and allied health
professionals should also be liable and accountable for their actions. There is growing concern
within both the medical profession and society about the increasing number of complaints and
lawsuits against physicians.51 It is necessary that healthcare workers be aware of the legal aspects
linked or associated to their profession and take the needful measures to protect themselves from
legal traps.52
49
Barnie and others (n 18).
50
Tabitha Elizabeth Thomas1 and, Magendran.J2, ‘Awareness of Medico-Legal Issues among Medical College
Health Professionals’ (2020) Vol.20, No. 1 January-March 2020 506.
51
Tabitha Elizabeth Thomas1 and, Magendran.J2, ‘Awareness of Medico-Legal Issues among Medical College
Health Professionals’ (2020) Vol.20, No. 1 January-March 2020 506.
52
ibid.
16
It is essential to be aware of these medico-legal issues. Thus, it is necessary to assess how well-
informed the community of health professionals is regarding medico-legal matters and related
issues. Understanding and fulfilling these medicolegal obligations is crucial for healthcare
professionals to provide ethical, safe, and high-quality care while also protecting their legal
interests. Non-compliance with these obligations can have legal and professional consequences.
It is essential for healthcare professionals to be aware of and adhere to the specific obligations
outlined by their respective professional bodies and relevant healthcare laws and regulations.
2.1.2 Knowledge and Perception of Medico-Legal Obligations of Healthcare Workers.
Adequate knowledge of medical documentation practices is important to maintain accurate and
comprehensive patient records, which are essential for legal and clinical purposes. Healthcare
workers, including doctors, nurses, and other professionals, must possess a deep and up-to-date
understanding of medical science. This knowledge includes anatomy, physiology, pharmacology,
and the latest medical research. To improve the quality of patient care, patient trust in the
healthcare system, and ultimately health outcomes, it is critical to understand healthcare
professionals' attitudes toward patient confidentiality issuesand other ethical and medico-legal
issues.53
Healthcare workers need practical clinical skills to diagnose, treat, and care for patients
effectively. These skills often require ongoing training and development. Good doctors and
health experts apply clinical knowledge in a way that is legally and ethically correct. Clinical
practice or governance is a system through which healthcare provider is providing qualitative
services and safeguarding high standard of care by generating enabling environment in clinical
practice. Healthcare professionals also need to have a firm grasp of the rules and legislation that
53
ibid.
17
apply to their line of work. Health care providers are at high risk for litigations. Being aware of
the medico-legal aspects and the importance of documentation and carrying out one's duties
ethically can protect oneself from the risk of litigation.54
Knowledge of evidence-based practices and standards of care is essential. Healthcare workers
should be aware of guidelines and protocols relevant to their field to ensure the provision of
high-quality care. Understanding the legal and ethical obligations related to patient
confidentiality is crucial. Healthcare workers should know when and how patient information
can be shared and the potential legal consequences of unauthorized disclosure. 55
Health care experts have a moral and legal need to approach patients with respect. This suggests
that they should act in a manner that is reliable with perceived medical principles. Patients
reserve a privilege to the data relating in regards to their medical condition, accessible
treatments, and any risks. Healthcare professionals may be required by law to notify the
appropriate authorities of specific situations or incidents, such as communicable diseases or
possible child abuse. Medical care experts are expected to maintain proficient standards and
orders, a significant number of which have lawful repercussions. Legal repercussions might
happen from rebelliousness.
The safe and efficient provision of healthcare depends on the knowledge and understanding of
medico-legal requirements held by healthcare employees. Healthcare providers constantly
struggle to strike a balance between giving patients the best treatment possible and carrying out
their legal obligations. This complex relationship requires ethical decision-making, ongoing
education, and training.
54
Mika Fukada, ‘Nursing Competency: Definition, Structure and Development’ (2018) 61 Yonago Acta Medica 1.
55
Nash L, Walton M, Daly M, Johnson M, Walter G, van Ekert E, et al. GPs' concerns about medicolegal issues -
How it affects their practice. Aust Fam Physicians 2009;38:66-70.
18
Healthcare professionals' understanding of their medico-legal responsibilities is an important
component of their professional practice. When discussing these obligations, it is important to
note that they relate to the moral and legal duties that medical professionals have to patients.
79.2% of respondents viewed the NHA positively, with 78.5% believing it is relevant to Nigeria's
healthcare system and 61.5% believing it will reduce outward medical tourism. 56 The majority of
respondents in Nigeria, despite having good awareness of the NHA 2014, have a poor
understanding of the Act of Medico-Legal obligations under the Act, with only 17.7% having
read it, indicating a lack of comprehensive knowledge.57
Perception of medico-legal obligations is influenced by healthcare workers' attitudes and values.
A positive attitude toward adhering to legal and ethical standards is critical for ensuring
compliance. Healthcare workers' perception of the ethical considerations surrounding their
practice is important. Understanding the ethical principles, such as beneficence, non-
maleficence, autonomy, and justice, is essential to navigate complex ethical dilemmas. 58
Effective training, education, and ongoing professional development are essential to enhance
healthcare workers' knowledge and perception of medico-legal obligations. Furthermore,
creating a culture within healthcare organizations that emphasizes the importance of ethical and
legal compliance can positively influence healthcare workers' perceptions and attitudes toward
their medico-legal responsibilities. Additionally, providing access to resources and support for
addressing ethical and legal dilemmas can help healthcare workers navigate complex situations
while upholding their obligations to patients and the law.59
56
Soja R, Vivek V, Harshakumar K, Ravichandran R. Interocclusal recording materials and techniques: A literature
review. Int J Appl Dent Sci 2020;6(4):397-400. DOI: https://doi.org/10.22271/oral.2020.v6.i4f.1095
57
Barnie and others (n 18).
58
Parakh SC. Medicolegal article. Indian J Anaesth 2010; 54:39
59
Patel AM, Still TE, Vaughan W. Medicolegal issues in endoscopic sinus surgery. Otolaryngology Clin North Am
2010; 43:905-14.
19
2.1.3 Knowledge, Awareness and Practice of Medicolegal Obligations
Knowledge, awareness, and practice (KAP) of medico-legal obligations are interconnected
aspects of healthcare professionals' ethical and legal responsibilities. Knowledge of the
requirements for obtaining informed consent is essential. This includes understanding what
information to provide to patients, the legal and ethical significance of informed consent, and the
process for obtaining it. The practice of medico-legal obligations involves applying the
knowledge of legal and ethical standards to everyday clinical and professional situations.60
Rishipathak et al evaluated the emergency physicians' knowledge of Medico's legal implications.
A descriptive cross-sectional study was conducted in May 2022 with 300 Emergency Medical
Technicians (EMPs) from different parts of India. Respondents had to answer in binary format
(agree/disagree). The study was an attempt to determine the awareness and attitudes of
emergency physicians regarding the medico-legal issues they face. Much greater clarity was
noted among respondents on issues related to record keeping and informed consent. The study
confirms a high level of awareness of medico-legal concepts and issues, but issues related to
confidentiality require greater awareness of patient care and there was also, but issues related to
confidentiality require greater awareness of patient care and there was also ambiguity on several
concepts.61
Practicing informed consent means effectively communicating with patients to ensure they
understand their treatment options, associated risks, and benefits, and obtaining their consent. I
Hence, it also involves taking practical steps to protect patient confidentiality, such as
maintaining secure medical records and following protocols for information sharing.62
60
Radhika T, Nadeem J, Arthi R, Nithya S. Awareness about medico legal aspects and consumer protection act
among dentists. J Forensic Odontostomatol. 2017; 35: 1–8
61
Dr Parag Rishipathak, Dr Shrimathy Vijayaraghavan and Dr Anand Hinduja, ‘Awareness Regarding Medico Legal
Aspect Amongst the Emergency Medical Professionals: A Survey’ (2022) 10 Journal of Coastal Life Medicine 119.
62
Thomas J. Medical records and issues in negligence. Indian J URL 2009; 25:383-88
20
Ejeh et al assessed the KAP knowledge, attitude and practice of HCWs towards COVID-19 in
Nigeria. A cross-sectional survey of HCWs during the COVID-19 outbreak in Nigeria. The study
assessed 346 HCWs KAPon knowledge, attitude and practice using a self-administered online
questionnaire (Google Form) based on a convenience sampling technique. Data were retrieved
and analysed using descriptive statistics. Chi-square and one-way ANOVA were used to measure
the association and difference between demographic variables. The relationship between
knowledge, attitude and practice KAP was measured using Spearman's rho correlation test. The
results showed that HCWs in Nigeria had excellent knowledge and positive attitudes and good
practices towards COVID-19. However; There were areas where lack of knowledge, negative
attitudes and unacceptable practices were observed.63
Practicing the duty of care involves making clinical decisions and taking actions in the best
interests of the patient, minimizing harm, and acting in accordance with professional standards
and ethical principles. However, Continuous education, training, and ethical reflection can help
healthcare workers maintain and enhance their knowledge, awareness, and practice KAP of
medico-legal obligations.64
Other studies have examined the factors that influence the knowledge, attitude and practice
(KAP) of doctors in hospitals in Menoufia with regard to various medico-legal issue aspects. A
cross-sectional survey study was conducted in hospitals in Menoufia (both secondary and tertiary
care hospitals). The result shows that the average age of the 387 doctors examined was 38,979.58
years. 58.66% were male physicians. 58.40% were specialists. Most of them (67.44%) worked in
secondary care hospitals and 51.94% were surgeons. 24.29% had both primary and postgraduate
63
Francis Enenche Ejeh and others, ‘Knowledge, Attitude, and Practice among Healthcare Workers towards
COVID-19 Outbreak in Nigeria’ (2020) 6 Heliyon e05557.
64
Torres A, Konda S, Nino T, de Golian E. Medicolegal issues. Clin Dermatol 2016; 34:106-10
21
medical-legal training. Linear regression analysis showed that the significant independent
predictors of high awareness were years of employment, work in tertiary care hospitals, and
previous undergraduate and postgraduate medicalo-legal education and training. Significant
differences in doctors' knowledge, attitudes and practices KAP regarding medico-legal
aspectissues were found in hospitals in Menoufia.65
2.1.4 Medicolegal Obligations of Healthcare Workers in Nigeria
In the medical field, the job of health personnel is to offer proficient consideration to debilitated
people. End-of-life issues, consent, capability, truth telling, secrecy and security are key parts of
medical practice and these are viewpoints that lead to commitments and liabilities. In Nigeria,
explicit subjects emerging comparable to nursing, students, indigenous issues, children, the
elderly and psychological sickness are conveniently tended to, and there are broad arrangements
on the moral issues.66
Universal access to a qualified, skilled, motivated and equitably distributed health workforce is
pertinent for the delivery of quality health services needed to achieve national health sector goals
and sustainable development goals.67 Nigeria's government healthcare system ranked 197th out
of 200 by the World Health Organization in 2014, with a medical personnel-to-patient ratio
below WHO's recommendations of 1:600 for doctors and 1:700 for nurses.68 There are various
laws that govern medical practice in Nigeria. One of these laws is the Medical and Dental
Practitioners Act (CAP M8), which is intended to govern and regulate medical ethics in Nigeria
65
66
Nicholas Idoko, ‘Nursing Ethics and Practices in the Nigerian Context’ (Professions in Nigeria, 1 August 2023)
<https://professions.ng/nursing-ethics-and-practices/> accessed 31 October 2023.
67
‘(PDF) Understanding the Factors Influencing Health Workers’ Choice of Workplace Locations: A Qualitative
Description of Primary Healthcare Workers’ Perspectives in Nigeria’.
68
Momodu and Oseni (n 15).
22
and professional conduct for doctors and dentists. Another example is the professional rules for
doctors and dentists.69
Medicolegal obligations are the arrangement of responsibilities that health care experts should
maintain to guarantee the lawful and moral conveyance of medical care administrations while
defending the freedoms and prosperity of their patients .70 These obligations help maintain the
trust and integrity of the healthcare system and protect both patients and healthcare providers.
Medicolegal obligations of healthcare workers in Nigeria, as in numerous different nations, spin
around a bunch of legitimate and moral obligations that they should stick to in the course of their
training.71 These obligations are designed to ensure patient safety, protect the rights of patients,
and maintain the integrity of the healthcare system.
Healthcare professionals have a legal and ethical obligation to obtain informed consent from
patients before performing medical procedures or treatments. This entails providing patients with
comprehensive information about the nature of the procedure, potential risks and benefits, and
any available alternatives. Healthcare workers are legally bound to protect the confidentiality of
patient health information. This obligation requires safeguarding patient records and ensuring
that patient information is not disclosed without proper authorization, except in situations where
disclosure is mandated by law.72
In the medical field, the job of health personnel is to offer proficient consideration to debilitated
people. End-of-life issues, consent, capability, truth telling, secrecy and security are key parts of
medical practice and these are viewpoints that lead to commitments and liabilities. In Nigeria,
69
‘Medical Negligence in Nigeria: Addressing the Public on Its Scope and The Resultant Legal Implications -
Healthcare - Nigeria’
70
‘Ethical & Legal Responsibilities of Healthcare Workers - Video & Lesson Transcript’ (n 40).
71
72
Agarwal SS, Agarwal SS. Medical Negligence. Hospital’s Responsibility. J Indian Acad Forensic Med. 2009;
31:164–170s.
23
explicit subjects emerging comparable to nursing, students, indigenous issues, children, the
elderly and psychological sickness are conveniently tended to, and there are broad arrangements
on the moral issues.73
Proper and accurate documentation of patient care is a medicolegal obligation. This involves
maintaining complete and accurate medical records, which are essential for patient care
continuity, legal purposes, and maintaining the quality and safety of healthcare. Healthcare
workers owe a duty of care to their patients. Healthcare workers must respect and protect the
rights of patients. These rights include the right to dignity, privacy, and information. Patients
have the right to participate in decisions about their care and to receive care free from
discrimination.74
Universal access to a qualified, skilled, motivated and equitably distributed health workforce is
pertinent for the delivery of quality health services needed to achieve national health sector goals
and sustainable development goals.75 Nigeria's government healthcare system ranked 197th out
of 200 by the World Health Organization in 2014, with a medical personnel-to-patient ratio
below WHO's recommendations of 1:600 for doctors and 1:700 for nurses.76 There are various
laws that govern medical practice in Nigeria. One of these laws is the Medical and Dental
Practitioners Act (CAP M8), which is intended to govern and regulate medical ethics in Nigeria
and professional conduct for doctors and dentists. Another example is the professional rules for
doctors and dentists.77

73
Nicholas Idoko, ‘Nursing Ethics and Practices in the Nigerian Context’ (Professions in Nigeria, 1 August 2023)
<https://professions.ng/nursing-ethics-and-practices/> accessed 31 October 2023.
74
Aliyu ZY. Discharge against medical advice: Sociodemographic, clinical and financial perspectives. Int J Clin
Pract. 2002;56(5):325–327.
75
‘(PDF) Understanding the Factors Influencing Health Workers’ Choice of Workplace Locations: A Qualitative
Description of Primary Healthcare Workers’ Perspectives in Nigeria’.
76
Momodu and Oseni (n 15).
77
‘Medical Negligence in Nigeria: Addressing the Public on Its Scope and The Resultant Legal Implications -
Healthcare - Nigeria’
24
Staying up-to-date with advances in medical knowledge and practices through continuing
education and professional development is a medicolegal obligation. Healthcare professionals
are expected to maintain and improve their skills and knowledge throughout their careers.
Healthcare professionals have a duty to prioritize patient safety and minimize harm. This
involves adhering to safety protocols, infection control measures, and responding promptly to
patient safety concerns.78
Medicolegal obligations of healthcare workers in Nigeria, as in numerous different nations, spin
around a bunch of legitimate and moral obligations that they should stick to in the course of their
training.79 These obligations are designed to ensure patient safety, protect the rights of patients,
and maintain the integrity of the healthcare system. Healthcare workers have a duty to obtain
informed consent from patients or their legal representatives before conducting medical
procedures, surgeries, or administering treatments. This involves providing patients with relevant
information about the risks, benefits, and alternatives to a particular treatment, allowing them to
make an informed decision about their care. Healthcare workers are legally bound to maintain
patient confidentiality. They must not disclose any patient's medical information to third parties
without the patient's consent, except when required by law or when it's necessary for patient care.
Healthcare experts are legally necessary to safeguard patient classification. This involves
keeping patient data hidden and not imparting it to any person or thing without the patient's
consent. According to Nigeria's National Health Act, this obligation is required. 80 It is likewise
legally expected that patient records be appropriately archived. As well as being fundamental for
78
Bryden D, Ian Storey. Duty of Care and Medical Negligence (Continuing Education in Anaesthesia Critical Care
and Pain) BJA Education. 2011;11(4):124–127.
79
80
‘Physicians’ Handling of Patients’ Health Information: Ethics and Law of Confidentiality |’
<https://lawexplores.com/physicians-handling-of-patients-health-information-ethics-and-law-of-confidentiality/>
25
patient consideration, complete and precise medical records safeguard healthcare suppliers
legitimately in case of a conflict. The local and federal regulations administering medical
services practice should be trailed by healthcare work force. This covers regulations overseeing
the utilization of physician recommended drugs, healthcare equipment, and contamination
counteraction. Healthcare workers are committed to provide a reasonable standard of care. This
implies conveying care that is in accordance with acknowledged medical practices and rules.
Inability to satisfy this guideline can prompt lawful risk.81
The essential idea is to guarantee that patients and healthcare clients have the opportunity to
impart all data about their wellbeing to a specialist to guarantee that appropriate treatment is
provided. Therefore, any information a doctor receives in the course of his or her work is
confidential and generally may not be disclosed to third parties. This is a moral obligation as
epitomized in the Hippocratic OathVow to which all doctors are sworn, as well as a lawful
obligation as has since been systematized in different public and worldwide instruments
regarding the matter. Nonetheless, the obligation isn't outright. In specific conditions, a doctor
might be allowed to unveil data that ought to in any case be private. Notwithstanding, meagre
endeavours have been made in Nigeria towards adjusting the privileges of patients versus that of
the clinical professionals.82
Understanding and fulfilling these medicolegal obligations is crucial for healthcare professionals
to provide ethical, safe, and high-quality care while also protecting their legal interests. Non-
compliance with these obligations can have legal and professional consequences. It is essential
81
Donna Vanderpool, ‘The Standard of Care’ (2021) 18 Innovations in Clinical Neuroscience 50.
82
Obi Okonkwo, ‘Topical Medico-Legal Challenges in Nigeria’ [2015] SSRN Electronic Journal
<https://www.ssrn.com/abstract=3983983> accessed 2 September 2023.
26
for healthcare professionals in Nigeria to be aware of and adhere to the specific obligations
outlined by their respective professional bodies and relevant healthcare laws and regulations. 83
2.1.5 Laws Regulating the Mmedical pProfession in Nigeria
Nigeria's medical profession is regulated by various laws and bodies to ensure the quality and
ethical practice of medicine.
The Medical and Dental Council of Nigeria (MDCN) is the main regulatory body in Nigeria for
the medical and dental professions. It was created by the 2004 Medical and Dental Practitioners
Act, Cap. M8, Laws of the Federation of Nigeria. In addition to accrediting medical and dental
schools, the MDCN is in charge of the registration, licensing, and regulation of medical and
dental professionals.84 The National Health Act of 2014 offers a framework for
the creation and administration of healthcare services in Nigeria. The regulation of
healthcare facilities and providers is one of the many facets of healthcare delivery covered.85
The MDCN has established a code of medical ethics that outlines the values and expectations
for professional behaviour for medical professionals in Nigeria. It describes the moral
obligations that doctors have in their work.86 However, tThe primary responsibility for regulating
the Nigerian healthcare system lies with the Medical and Dental Council of Nigeria (MDCN),
the professional healthcare regulator for the professions of medicine, dentistry and alternative
medicine in Nigeria, which include others; Criminal Code Act Cap C38 LFN 2004, Treatment of
Gunshot Victims Act 2017, National Health Acts 2014 etc.87

83
Chukwuneke FN. Medical Incidents in Developing Countries: A few case studies from Nigeria. Niger J Clin
Pract. 2015;18(7):20–24.
84
‘MEDICAL AND DENTAL COUNCIL OF NIGERIA’ <https://www.mdcn.gov.ng/page/about-us/mdcn-act-
other-regulation> accessed 14 October 2023.
85
National Health Act (n 7).
86
Richard X Davey, ‘Codes of Ethics for Laboratory Medicine: Definition, Structure and Procedures – A Narrative
Review Based on Existing National Codes’ (2020) 31 EJIFCC 262.
87
ibid.
27
a. The Acts Establishing Teaching Hospitals across Nigeria: This is a piece of legislation
in Nigeria that establishes the framework for the management and operation of teaching
hospitals in the country. Teaching hospitals are an integral part of the healthcare system,
as they serve as center for medical education, research, and the provision of specialized
healthcare services.88
Teaching hospitals in Nigeria are regulated by the Teaching Hospital Act. This legislation
establishes and provides guidelines for the management and operation of teaching
hospitals, which are integral to medical education and healthcare delivery in the country.
The Act outlines the management structure of teaching hospitals. This structure often
includes a board of management, a chief medical director (CMD) or chief executive
officer (CEO), and various administrative and medical departments. Teaching hospitals
have a range of functions and responsibilities, which are defined in the Act. These
functions include providing medical and healthcare services, conducting medical
research, and offering clinical training to medical students and resident doctors.89
b. National Health Act (NHA): The National Health Act of 2014 provides a legal
framework for the organization and administration of the national healthcare
system in Nigeria. It outlines the rights and responsibilities of healthcare
professionals, as well as the structure and funding of healthcare services. Section 26
(1) of the NHA provides that “all information concerning a user, including
information relating to his or her health status, treatment or stay in a health
establishment is confidential”.90
88
Chukwuneke FN. Medical incidents in developing countries: A few case studies from Nigeria. Niger J Clin Pract.
Medknow Publications and Media Pvt. Ltd.; 2015;18 Suppl (7): S20-4.
89
Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R
Soc Med. Royal Society of Medicine Press; 2001 Jul;94(7):322–30.
90
Zhang J, Patel VL, Johnson TR. Medical error: is the solution medical or cognitive? J Am Med Inform Assoc.
American Medical Informatics Association; 2002;9(6 Suppl): S75-7.
28
The NHA focuses on the revitalization of primary healthcare services in Nigeria. It emphasizes
the development of a functional primary healthcare system to improve healthcare access at the
grassroots level. The National Health Act represents a significant step toward improving
healthcare in Nigeria by addressing issues of accessibility, quality, and financing. It promotes the
principles of universal health coverage and strives to make essential healthcare services available
and affordable to all Nigerians. Hence, it is a crucial piece of legislation for the Nigerian
healthcare system and is aimed at improving the health and well-being of the population.91
Teaching Hospital Act: The Teaching Hospital Act is a piece of legislation in Nigeria that
establishes the framework for the management and operation of teaching hospitals in the country.
Teaching hospitals are an integral part of the healthcare system, as they serve as center for
medical education, research, and the provision of specialized healthcare services. 92
Teaching hospitals in Nigeria are regulated by the Teaching Hospital Act. This legislation
establishes and provides guidelines for the management and operation of teaching hospitals,
which are integral to medical education and healthcare delivery in the country. The Act outlines
the management structure of teaching hospitals. This structure often includes a board of
management, a chief medical director (CMD) or chief executive officer (CEO), and various
administrative and medical departments. Teaching hospitals have a range of functions and
responsibilities, which are defined in the Act. These functions include providing medical and
healthcare services, conducting medical research, and offering clinical training to medical
students and resident doctors.93
2.1.6 NHA And Medico-Legal Obligations Under tThe NHA.

91
Olaniyan H. Liability for medical negligence in Nigeria. Niger J Heal Biomed Sci. 2005 Apr 11;4(2):165–75.
92
Chukwuneke FN. Medical incidents in developing countries: A few case studies from Nigeria. Niger J Clin Pract.
Medknow Publications and Media Pvt. Ltd.; 2015;18 Suppl (7): S20-4.
93
Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R
Soc Med. Royal Society of Medicine Press; 2001 Jul;94(7):322–30.
29
The National Health Act is a piece of legislation or law enacted by a government to regulate and
oversee the healthcare system within a specific country. Its primary purpose is to establish a legal
framework for the organization, delivery, and governance of healthcare services. 94 The NHA
often serves as a foundational document that outlines the rights and responsibilities of both
healthcare providers and patients. It can cover a wide range of areas within the healthcare
system, including the provision of medical care, funding, health insurance, and public health
initiatives.95
The NHA often contains provisions regarding patient confidentiality and data protection.
Healthcare professionals are legally bound to maintain the privacy of patients' medical records
and personal information.96 The NHA describe general society and confidential protection
programs that are utilized to pay for medical services. Regarding health insurance, taxes, and
financing for healthcare services, it could spread out the obligations of individuals, managers,
and the public authority. The NHA might lay out guidelines??????????s for the nature of medical
care administrations, remembering guidelines for proficient authorizing, office authorization, and
consistent improvement in medical care conveyance. Medical care suppliers are lawfully
committed to fulfil these guidelines.97
Health experts structure a significant part of medical services frameworks and are important in
the conveyance of smooth, productive, viable and quality medical services administrations. Since
94
Association 260.
95
Association 260.
96
‘Confidentiality and Privacy in Healthcare - Better Health Channel’
<https://www.betterhealth.vic.gov.au/health/servicesandsupport/confidentiality-and-privacy-in-healthcare> accessed
13 October 2023.
97
Michael Young and Mark A Smith, ‘Standards and Evaluation of Healthcare Quality, Safety, and Person-Centered
Care’, StatPearls (StatPearls Publishing 2023) <http://www.ncbi.nlm.nih.gov/books/NBK576432/> accessed 13
October 2023.
30
the objective of the NHA is the regulation, improvement, management, and advancement of
Nigeria's National Health System, the role of health experts in the completion of this objective
can't be over-emphasized. Their awareness, information, and impression of the NHA will
accordingly logical impact the level of progress in the execution of the Demonstration and the
acknowledgment of its definitive advantages of further developed wellbeing inclusion, quality,
and wellbeing results.98 Their awareness, knowledge and perception of the NHA will therefore
likely influence the degree of success in the implementation of the Act and the realization of its
ultimate benefits of improved health coverage, quality and health outcomes.99
If a country permits medical research, the NHA may???????? establish guidelines and ethical
standards for conducting research on human subjects, with a focus on informed consent and
safeguards against exploitation. Ensuring the provision of safe, high-quality healthcare services
and the protection of patients' rights and well-being requires compliance with legal and medico-
legal obligations under the NHA. The NHA upholds the rights of patients to make informed
decisions about their healthcare. Healthcare workers have a medico-legal obligation to ensure
that patients are adequately informed about their medical conditions, treatment options, and
potential risks and benefits. Obtaining informed consent before medical procedures is a critical
aspect of these obligations. Hence, healthcare workers are bound by medico-legal obligations to
maintain patient confidentiality. They must protect patient health information from unauthorized
disclosure, in compliance with the NHA and other relevant data protection laws.100
98
Federal Ministry of Health. One Year Anniversary of the National Health Act, 2014. Press Statement of the
Permanent Secretary, Federal Ministry of Health. 2015. Oct 31.
99
Gupta, N. 2011. Human Resources for Maternal, New-born and Child Health from measurement and planning of
Performance for Improved Health Outcome. Accessed online by May 13, 2019
100
Jackson Healthcare, LLC. Survey: Physician Attitudes on the Affordable Care Act. Survey Conducted. 2012.
[Last accessed on 2015 Dec 31].
31
The NHA emphasizes the provision of high-quality healthcare services. Healthcare professionals
are legally obligated to provide care that meets acceptable standards of quality. Failure to do so
can lead to legal consequences. Healthcare workers are expected to adhere to professional and
ethical standards in their practice. The NHA reinforces these ethical obligations and holds
healthcare workers accountable for any breaches of ethical conduct. 101 The Act establishes a
Basic Health Care Provision Fund to be financed from Federal Government Annual Grant of not
less than one percent of its Consolidated Revenue Fund grants by international donor’s partners
and fund from other source.
Out of the fund, 50% shall be used for the provision of basic minimum packages of health
services to citizens, ineligible primary or secondary health care facilities through the National
Health Insurance Scheme (NHIS); 20% shall be used to provide essential drugs, vaccines and
consumables for eligible primary health care facilities, and 10% shall be used for Emergency
Medical Treatment to be administered by a committee appointed by the National Council on
Health.102
The NHA requires healthcare institutions to maintain accurate and comprehensive medical
records. Healthcare workers have a medico-legal obligation to document patient care and
information appropriately, as these records are essential for patient care continuity and legal
purposes. Healthcare workers owe a duty of care to their patients. This means that they must act
in a manner consistent with the standards of their profession, prioritize patient welfare, and avoid
actions or omissions that could harm patients. The NHA includes provisions for the registration
101
Ajuwon GA. Use of the Internet for health information by physicians for patient care in a teaching hospital in
Ibadan, Nigeria. Biomed Digit Libra. 2006; 3:12.
102
Federal Republic of Nigeria, FRN Official Gazette, National Health Act. 2014. Vol.101no.145, Lagos: October
27.
32
and regulation of healthcare professionals. Healthcare workers have a medico-legal obligation to
be appropriately licensed and registered to practice in their respective fields. 103
Healthcare workers and institutions must comply with the regulations and standards set by the
NHA, including those related to the establishment and operation of healthcare facilities. The
NHA provides mechanisms for patients to lodge complaints and seek redress for any violations
of their rights or lapses in healthcare delivery. Healthcare workers and institutions have a
medico-legal obligation to address patient complaints and grievances in accordance with the
law.104
Understanding and adhering to these medico-legal obligations under the NHA is essential for
healthcare workers to provide safe, ethical, and high-quality care while also protecting their legal
interests. Non-compliance with these obligations can have legal and professional consequences.
It's important for healthcare professionals in Nigeria to stay informed about the specific
provisions of the NHA and other relevant laws and regulations governing their practice.
2.1.7 Factors Affecting the Knowledge, Perception and Practice of Medicolegal
Obligations Under NHA Among Healthcare Workers
Numerous factors may have an impact on healthcare workers' understanding,
perceptions, and practices regarding their medicolegal responsibilities under the National Health
Act (NHA). Improving compliance and adherence to the legal and ethical standards in healthcare
requires an understanding of these factors. Healthcare workers' personal values and commitment
103
Ogunyade TO, Obajemu AS. Use of information resources in some selected health science libraries in Lagos,
Nigeria. Nig Q J Hosp Med. 2006; 16:122–7.
104
Telecommunications in Nigeria. [Last accessed on 2016 Feb 03]. Available from:
https://en.m.wikipedia.org/wiki/Telecommunications_in_Nigeria.
33
to professionalism can influence their perception and practice of medicolegal obligations. Ethical
healthcare providers are more likely to follow the law.105 Healthcare professionals can stay
current on changes in healthcare laws and regulations by participating in regular in-service
training and continuing education programs. Their knowledge and comprehension of
medicolegal obligations can be improved by these programs.
For healthcare professionals to successfully carry out their medicolegal obligations, there must
be sufficient infrastructure and staffing. The absence of resources may result in non-compliance.
The level of education and training of healthcare workers in relation to the NHA and medico-
legal obligations plays a crucial role. Healthcare workers who receive comprehensive training on
the legal aspects of healthcare are more likely to have a better understanding of their
responsibilities. Healthcare workers must be aware of the existence and specific provisions of the
NHA and its associated regulations. Lack of awareness can lead to non-compliance with legal
requirements.
A supportive ethical climate within the healthcare facility, along with available support systems
for ethical and legal dilemmas, can positively impact healthcare workers' practice. Knowing that
they have access to guidance and assistance can encourage adherence to medicolegal obligations.
The expectations and demands of patients and the broader community can shape healthcare
workers' perception and practice of medicolegal obligations. A healthcare facility that values
patient rights and public trust may encourage healthcare workers to prioritize medicolegal
compliance.106
105
Stewart Gabel, ‘Ethics and Values in Clinical Practice: Whom Do They Help?’ (2011) 86 Mayo Clinic
Proceedings 421.
106
Henneman E. Unreported errors in the intensive care unit: a case study of the way we work. | AHRQ Patient
Safety Network. Crit Care Nurse. 2007; 27:27–34.
34
The culture within healthcare facilities can have a significant impact on how healthcare workers
perceive and implement medical-legal responsibilities. Institutions that prioritize compliance
with laws and patient rights are more likely to have knowledgeable and compliant staff, adequate
resources, including personnel, equipment and facilities, may impact the ability of health care
professionals to meet their medico-legal obligations.107 Lack of resources can cause healthcare
workers to feel forced to compromise on legal requirements.
Colleagues and peers can influence healthcare workers' behavior. If healthcare workers observe
their peers adhering to medicolegal obligations and behaving ethically, they are more likely to do
the same. Socioeconomic factors, including financial incentives or penalties related to
medicolegal compliance, can influence healthcare workers' practice. Financial incentives for
compliance with ethical standards of behavior, for example, can encourage adherence to legal
and ethical standards.108
The level of oversight and accountability in healthcare can impact healthcare workers'
compliance with medico-legal obligations. Adequate oversight and clear accountability
mechanisms can promote compliance, regular communication and updates regarding changes in
healthcare laws and regulations are essential to keep healthcare workers informed and up-to-date
on their obligations.109
Patients trust that healthcare workers have the skills and expertise that can cure or improve their
health conditions. In most countries, doctors and nurses are registered with national regulatory
authorities, which confirms that health workers have sufficient skills and knowledge to
107
Mojtaba Vaismoradi and others, ‘Nurses’ Adherence to Patient Safety Principles: A Systematic Review’ (2020)
17 International Journal of Environmental Research and Public Health 2028.
108
Millenson M. The Silence. Health Aff. 2003;22(2):103–12.
109
Institute of Medicine (US) Committee on Quality of Health Care in America and others, Setting Performance
Standards and Expectations for Patient Safety (National Academies Press (US) 2000)
<https://www.ncbi.nlm.nih.gov/books/NBK225181/> accessed 13 October 2023.
35
competently treat patients. Regulators can remove health workers from the register if they are
deemed incompetent and pose a danger to the public. If a healthcare worker under the
supervision of a senior healthcare professional causes harm through a medical error, the
supervising doctor or nurse may be held responsible.110
Cultural and religious beliefs may shape healthcare workers' values and perceptions of
medicolegal obligations. Understanding and respecting these cultural and religious aspects can
impact how healthcare workers navigate ethical and legal challenges. The complexity and
diversity of patient cases can present unique ethical and legal challenges. Healthcare workers
dealing with diverse patient populations and complex cases may require additional training and
support to navigate these situations.111
Various factors may impact healthcare workers' comprehension, outlook, and behavior
concerning their legal responsibilities under the National Health Act (NHA). These include how
well-managed risks are in clinical settings, how competent and regulated healthcare personnel
are, how well-informed and capable patients are, how much education and training healthcare
workers receive, and how accountable hospitals are. Healthcare professionals should be
cognizant of these elements and take action to enhance their comprehension of and adherence to
their legal responsibilities.
2.2 Conceptual Framework
Based on this literature review, a conceptual framework for this exploration was laid out, as
displayed in the figure below. The primary objective of this study was to assess the knowledge
110
Vincent K Mutai, ‘Legal Risks in Medical Practice’ (2019) 32 Community Eye Health 31.
111
Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects
physicians from malpractice charges. Psychiatry Serv. 2000;51(7):899–902.
36
and evaluate perception and practice of medicolegal obligations under NHA among healthcare
workers in Osun State.
Figure 1 Conceptual Framework for knowledge, attitude, and practice as determinants of health
outcomes.
Adapted from Vivek Podder et al. (2020).
This conceptual framework provides a visual representation of the relationships between
knowledge, perception, and practice of medicolegal obligations among healthcare workers,
guided by theoretical frameworks and influenced by various factors. The level of knowledge,
perception, and practice, as measured by several factors leads to the outcome factor in this study.
2.3 Empirical Literature Review
37
Previous studies have examined healthcare professionals' knowledge and perceptions of their
training in ethics, confidentiality, and medico-legal issues. A cross-sectional survey was
conducted among some categories of health workers (doctors, nurses and health assistants) in the
Accident and Emergency Directorate of Komfo Anokye Teaching Hospital. Information on
ethics, confidentiality and medico-legal issues was collected in which the study review found
that 74% had knowledge of ethics, confidentiality and medico-legal concepts; and 35.4% of
respondents reported that health professionals' attitudes toward ethics, confidentiality and
medico-legal concepts were inadequate. About 28.3% said their attitudes was good, while 26.3%
said their attitudes was fair and only 2% said their attitudes was very good. Nearly 49% of
respondents also said training on medico-legal subjects should be provided both during formal
training and in the workplace.112
Enabulele and Enabulele examined the healthcare workers’ understanding of the NHA. Their
studies showed that although most (79.2%) of the respondents had a good understanding of the
NHA 2014, Just over half (53.1%) of respondents believed that the NHA 2014 will help reduce
strikes in the healthcare sector. Although health professionals in Nigeria are well aware and
aware of the NHA 2014, their knowledge of the law is poor.113
In the northern part of Nigeria, Abdullahi assessed the knowledge and perception of Nigerian
nurses on the theory-practice gap. The result of this study showed that 83.80% of the respondents
had good knowledge and 89.10% of the respondents had good perceptions.114
112
113
Association 260.
114
Kabir Ozigi Abdullahi, Shahrzad Ghiyasvandian and Marzieh Hasanpour, ‘Theory-Practice Gap: The Knowledge
and Perception of Nigerian Nurses’ (2022) 27 Iranian Journal of Nursing and Midwifery Research 30.
38
Other literatures have assessed the knowledge and attitudes of practicing physicians regarding
medical ethics and medical law in several countries, particularly in Asia. Most findings found
that practicing physicians lacked knowledge of ethical and forensic issues.115
Mishra et al in their study conducted in India examined the knowledge of informed consent
policies and attitudes toward obtaining informed consent, including from individuals with mental
illness, as well as knowledge of confidentiality policies and attitudes relevant to their
interpretation and implementation. Just over half (n=62) responded and were contacted by
telephone. Participants' knowledge of ethical guidelines and informed consent averaged 8.16,
1.29 and 8.55 1.46, respectively. For these participants, there was no association between length
of work experience and knowledge of informed consent policies.116
Another study by Rajah et al assessed Malaysian doctors, pharmacists and nurses, their
knowledge, attitudes and perceived barriers to health literacy and also identified the associated
factors. 34.2% had poor knowledge and more than half had a negative attitude (51.9%) towards
HL, with no significant differences between doctors, pharmacists and nurses. The majority of
those surveyed found time constraints and a lack of human resources to be major hurdles in the
HL area. Study results supported concerns about inadequate knowledge and significantly
negative attitudes toward HL among health care providers in the study, with the most commonly
cited barriers being lack of time and human resources.117
2.4 Theoretical Review

115
Taufik Suryadi, Kulsum, ‘Knowledge and Attitude Among Resident Doctors Related to Ethical And Medicolegal
Issues in a Teaching Hospital’.
116
NN Mishra and others, ‘Knowledge & Attitudes of Mental Health Professionals Regarding Psychiatric Research’
(2014) 139 The Indian Journal of Medical Research 246.
117
Retha Rajah, Mohamed Azmi Hassali and Ching Jou Lim, ‘Health Literacy-Related Knowledge, Attitude, and
Perceived Barriers: A Cross-Sectional Study among Physicians, Pharmacists, and Nurses in Public Hospitals of
Penang, Malaysia’ (2017) 5 Frontiers in Public Health
<https://www.readcubea.com/articles/10.3389%2Ffpubh.2017.00281> accessed 12 August 2023.
39
2.4.1 Socio-Ecological Model Theory
In health professional education (HPE), it is important to recognize and understand the theories
behind the learning process in order to optimize learning environments, increase efficiency and
harmonize the education system. Therefore, it is argued that learning theories should inform the
curricula, planning, implementation and evaluation of interventions in health professions
education programs (HPEPs).118 However, learning theories are not regularly and consistently
implemented in educational practice, this is in fact due to a lack of specific contextual examples
that could help educators consider the theories' relevance to their teaching environments. 119 The
Socio-Ecological Model offers a thorough method for comprehending the various levels of
influence on human behaviour, in this case, the conduct of healthcare professionals with regard
to their medicolegal duties. These models encompass some interconnected levels which are;
a. The Individual level
This focuses on the individual traits of healthcare professionals, such as their
understanding of, attitudes toward, beliefs in, and values regarding medico-legal duties. It
takes into account how each person's background, training, and life experiences have
shaped their perception of these duties; and
b. The Interpersonal level
The emphasis here is on the interactions and connections that healthcare professionals
have with one another, their managers, their patients, and their families. Healthcare
118
Banan Mukhalalati and others, ‘Applications of Social Theories of Learning in Health Professions Education
Programs: A Scoping Review’ (2022) 9 Frontiers in Medicine 912751.
119
ibid.
40
professionals' perceptions and practices of medico-legal obligations may be impacted by
peer influence, role modelling, and communication.
Healthcare organizations have a big impact on how healthcare personnel behave. Healthcare
professionals' ability to prioritize and carry out their medico-legal obligations may be influenced
by organizational culture, rules, procedures, and leadership styles.
2.4.2 Theory of Planned Behaviour (TPB)
TPB posits that individuals' behavioural intentions are influenced by their attitudes, subjective
norms, and perceived behavioural control. Knowledge is a crucial component influencing
attitudes and perceived control. The Theory of Planned Behaviour (TPB) is a widely recognized
psychological theory that explains and predicts human behaviour. Developed by Icek Ajzen in
the late 1980s, the TPB is an extension of the earlier Theory of Reasoned Action (TRA). 120 It
posits that an individual's behavioral intention is the most immediate determinant of their
behavior. The theory suggests that people consciously evaluate their actions before deciding to
engage in them.121
This construct reflects an individual's positive or negative evaluation of performing a specific
behavior. It is determined by the perceived outcomes or consequences of the behavior. Subjective
norm reflects an individual's perception of the social pressure to perform or not perform a
behavior. It is influenced by the person's beliefs about what important others (e.g., family,
friends, colleagues) think they should do. A strong subjective norm results from a perception that
important others expect the behavior and a high motivation to comply with those expectations. 122
120
Ajzen, I. and Fishbein, M. (1980) Understanding Attitudes and Predicting Social Behavior. Prentice-Hall,
Englewood Cliffs
121
122
41
Perceived behavioral control reflects the individual's perception of their ability to perform the
behavior successfully. It is influenced by both internal and external factors, including self-
efficacy (confidence in one's ability to perform the behavior) and control factors (perceptions of
factors that might facilitate or hinder the behavior).123
The central premise of the TPB is that behavioral intention is influenced by the person's attitude,
subjective norm, and perceived behavioral control. This behavioral intention, in turn, is the
immediate predictor of the actual behavior. However, it's important to note that while the TPB
posits that intention leads to behavior, the actual behavior may also be influenced by external
factors, situational constraints, and other variables.
2.5 Research Hypotheses
The null hypotheses for this study are:
i There is no significant association between knowledge of NHA and reading and possession of
NHA among healthcare workers in Osun state.
ii There is no significant association between reading and possession of NHA, and perception
of NHA among healthcare workers in Osun state.
iii There is no significant association between reading and possession of NHA, and knowledge
of NHA among healthcare workers in Osun state.
123
42
43
CHAPTER THREE
RESEARCH METHODOLOGY
This chapter provides the sources of data and descriptions of methodology that was employed for
the study.
3.1 Research Design
This quantitative study used descriptive design and inferential statistics to assess Knowledge,
Perception and Practice of medicolegal obligations under NHA among healthcare workers in
Osun State.
3.2 Study Setting
Samples were selected from public healthcare workers in (Obafemi Awolowo University
Teaching Hospital Complex, Seventh day Adventist Hospital and Uniosun Teaching Hospital),
Osun State.
3.3 Study Population
The population of this study were the healthcare workers in (Obafemi Awolowo University
Teaching Hospital Complex, Seventh day Adventist Hospital and Uniosun Teaching Hospital),
Osun State.
3.4 Sample Size and Sampling Technique
The sample size was determined using the formula of Cochran (1977).
2
z p (1− p)
n=
e2
44
Where:
n = sample size
z = 5% type 1 error @ 95% confidence interval level.
p= prevalence from previous studies at 79.2%124
e = margin error
2
z p (1− p)
n=
e2
2
1.96 x 0.79 x 0.21
n= 2
(0.5)
2
1.96 x 0.79 x 0.21
n=
0.0025
3.8416 x 0.1659
n=
0.0025
n=255
A purposive sampling technique was used to select healthcare workers in selected hospitals in
Osun State where clinical activities were most prominent.
3.5 Research Instrument
This study employed questionnaire to collect data for the objectives of the study. The instrument
was divided in four sections – Section A, B, C & D. Section A addressed the Sociodemographic
Characteristics of the Respondents with 8 questions items, Section B assessed the Knowledge
with 17 question items, Section C assessed the Perception with 8 question items & Section D
assessed Practice with 10 question items. Section B was assessed based on Yes, No and I don’t
know Section C was assessed on a 5-point Likert scale of strongly disagree, disagree,
124
Association 260.
45
undecided, agree and strongly agree. Section D was assessed based on never, sometimes and
always.
3.6 Validity and Reliability of the Instrument
The data collection instrument was validated in terms of face and content by presenting it to the
researcher’s supervisor for review in order to remove any ambiguity and item construction
issues. Each item of the instrument was examined for clarity, appropriateness, scope and
relevance to the study. Appropriate correction was made to suit the study objectives. The validity
of the questionnaire is determined through face and content validity criteria. The constructive
criticism and /or suggestions was used to make the final draft of the questionnaire.
The data were analysed and the internal consistency of the research instrument was determined
with Cronbach Alpha statistical test. The questions that were ambiguous and lower the reliability
coefficient were removed from the main study. The reliability of the instruments was tested using
internal consistency. The reliability coefficients were 0.75, 0.77 and 0.83 for scales measuring
knowledge, perception and practice of healthcare workers respectively.
3.7 Procedure for Data Collection
The data was collected by visiting and sending google forms via emails to the healthcare workers
in Osun State. The voluntary participation of the respondents was sought, and they were assured
of confidentiality of information given to the study. Any participant that desire to withdraw their
participation in the study was obliged to, without any consequence. The administered
questionnaires were cross checked for any omission and proper response before it was cleared.
3.8 Method of Data Analysis
46
The data for knowledge, perception and practice were normally distributed and hence the mean
score was used to categorise the variables. The mean score for knowledge was 10.5±3.17 and
scores less than or equal to the mean were categorized as poor knowledge while scores greater
than the mean score were categorized as good knowledge. Also, the mean score for perception
was 27.4±3.43 and scores less than or equal to the mean score were categorized as negative
perception while scores greater than the mean score were categorized as positive perception. The
mean score for practice was 13.8±4.21 and scores less than or equal to the mean were
categorized as poor practice while scores greater than the mean score were categorized as good
practice.
3.9 Estimation Technique
Data collected were analysed using Stata 14 statistical package. Data collected were coded.
Sections A is a categorical variable while data collected on Sections B was a Yes or No question,
Section C was on 5-point Likert scale which were coded 1 to 5 with ‘1’ for strongly disagree, ‘2’
for disagree, ‘3’ for undecided, ‘4’ for agree and ‘5’ for strongly agree and Section D was based
on Never, Sometimes and Always. Both descriptive (frequency, percentage, median) and
inferential statistics (multivariate) were done and data were presented in tables and charts.
The Normality test (Shapiro-Wilk W test for normal distribution)125,
Variable | Obs W V z Prob>z

-------------+------------------------------------------------------
know | 233 0.99758 0.412 -2.054 0.98001
practice | 233 0.99932 0.115 -5.012 1.00000
perception | 233 0.99940 0.103 -5.274 1.00000
125
Daniela Reisz and others, ‘Stress and Bio-Ethical Issues Perceived by Romanian Healthcare Practitioners in the
COVID-19 Era’ (2021) 18 International Journal of Environmental Research and Public Health 12749.
47
3.10 Ethical Considerations
The purpose of the study was explained to the healthcare workers in the language they
understood and no one was forced to participate in the research and all data collected were kept
confidential. Both verbal and written consent were taken from the participants.
48
CHAPTER FOUR
PRESENTATION OF RESULTS AND DISCUSSION
This chapter presents the results of the study. A total of 234 HCWs participated in the study, the
sample size for the study was 255. However, a total of 234 completed questionnaire were
retrieved and analysed. Hence, the response rate in this study was 91.8%. The results were
presented according to the objectives under four sections. The first section presents the socio-
demographic, section two presents results of respondents’ knowledge of National Health Act,
section three presents the results of respondents’ perception of National Health Act, section four
presents the respondents’ practice of National Health Act, section five presents the results of the
three null hypotheses for the study and inferential statistics of the Knowledge of National Health
Act, reading and possession of National Health Act and reading and possession of National
Health Act, and perception of National Health Act. The last section of this chapter presents the
discussion of findings.
The results were presented under the following subheadings:
4.1 Socio-demographic Characteristics of Respondents

4.2 Knowledge of NHA byof Respondents
4.3 Perception of NHA byof Respondents
4.4 Respondents’ Practice of obligations under the NHA of Respondents
4.5 Hypotheses Testing and Inferential Statistics
4.6 Discussion of Findings
49
4.1 Socio-demographic Characteristics of Respondents
Table 4.1 Respondents’ Socio-demographic Characteristics
Variable Frequency Percentage (%)
Age
≤ 30 years 90 38.6
31-40 years 82 35.2
41-50 years 36 15.5
51-60 years 25 10.7
Sex
Male 81 34.8
Female 152 65.2
Marital status
Single 89 38.2
Married 141 60.5
Widowed 2 0.9
Divorced 1 0.4
Ethnicity
Yoruba 192 82.4
Igbo 21 9.0
Hausa 1 0.4
Edo 6 2.6
Igala 2 0.9
Others 11 4.7
Years of Practice
1-5 98 42.1
6-10 48 20.6
11-15 39 16.7
16-20 16 6.9
Above 20 32 13.7
Job Category
Nursing 127 54.5
Medical Practice 44 18.9
Pharmacy 14 6.0
Medical Laboratory Science 27 11.6
Medical Rehabilitation 15 6.4
Others 6 2.6
50
Have you read National Health Act (NHA)?
Yes 95 40.8
No 138 59.2
Do you possess a copy of National Health Act (NHA)?
Yes 25 10.7
No 208 89.3
Source: Author’s Field Survey, 2023
Table 4.1 shows that the largest proportion (38.6%) of the respondents was less than or equal to
30, 65.2% were female and majority (60.5%) were married, majority (82.4%) were from Yoruba
tribe, 42.1% had years of practice of 1-5, 54.5% were Nursing, majority (59.2%) had not read the
National health act and (89.3) don’t have a copy of the National Health Act.
51
4.2 Knowledge of NHA by Respondents
Table 4.2 Respondents’ Knowledge of NHA
Items Yes No
Freq (%) Freq (%)
Do healthcare workers have a right to refuse persons emergency medical 55 (23.6) 178 (76.4)
treatment?
Can a healthcare worker refuse to treat user who is physically abusive? 129 (55.4) 104 (44.6)
Can a healthcare worker refuse to treat user who is verbally abusive? 117 (50.2) 116 (49.8)
Can a healthcare worker refuse to treat user who sexually harasses the 171 (73.4) 62 (26.6)
healthcare worker?
Do healthcare workers have an obligation to give a user relevant 207 (88.8) 26 (11.2)
information pertaining to the state of health and necessary treatment
relating to the health status?
Do healthcare workers have an obligation to give a user relevant 202 (86.7) 31 (13.3)
information pertaining to the user’s right to refuse health services?
Do healthcare workers have an obligation to explain the implications, 203 (87.1) 30 (12.9)
risks or obligations of such refusal to the user?
Do healthcare workers have an obligation to keep records 210 (90.1) 23 (9.87)
Do healthcare workers have an obligation to keep all information relating 217 (93.1) 16 (6.87)
to the user’s health status, and treatment confidential?
Do healthcare workers have an unhindered access to health records? 166 (71.2) 67 (28.8)
Do healthcare workers have an obligation to protect the health records? 211 (90.6) 22 (9.44)
Do healthcare workers have a right to take health records out of the 81 (34.8) 152 (65.2)
hospital if necessary?
Are there circumstances when a healthcare worker can remove such 32 (13.7) 201 (86.3)
tissue, blood or organ without the consent of the person?
Do healthcare workers have an obligation to use tissue removed or blood 143 (61.4) 90 (38.6)
or a blood product withdrawn from a living person for only medical and
dental purposes?
Does the NHA establish a National Health Insurance Scheme (NHIS)? 123 (52.8) 110 (47.2)
Does the NHA establish a Basic healthcare provision fund? 102 (43.8) 131 (56.2)
52
Does the NHA establish a Vulnerable group fund? 81 (34.8) 152 (65.2)
Source: Author’s Field Survey, 2023.
Table 4.2 shows that the knowledge of the healthcare workers. Majority of the respondents
(76.4%) were willing to refuse medical treatment, 55.4% agreed to treat user who is physically
abusive, 50.2% of the healthcare workers agree to treat user who is verbally abusive, More than
half (73.4%) agree to treat a user who sexually harasses the healthcare worker, 88.8% of the
respondents agree to providing the user with information pertaining to their health status, 86.7%
agree to providing the user with information pertaining to refuse health services, Majority
(87.1%) do explain the risks and implications of refusal of treatment to the user, 90.1% agree to
keeping records of the users, 93.1% agree to keeping user’s relevant information about their
health status and treatment confidential, Majority (71.3%) of the healthcare workers have access
to health records, 90.6% agree to having the right to protect the health records, the healthcare
workers agree (65.2%) that they are not allowed to take health records out of the hospital, 86.3%
of the respondents agree to non-removal of tissue, blood or organ without consent, 61.4% agree
to removal of tissue, blood or a blood product withdrawn from a living person, 52.8% agree to
NHA establishing a National Health Insurance Scheme, 56.2% of the respondents says that NHA
did not establish a Basic healthcare provision fund, 65.2% of the respondents says that NHA did
not establish a Vulnerable group fund.
53
Knowledge of NHA
100.0%
90.0%
80.0%
70.0%
58.4%
60.0%
50.0%
41.6%
40.0%
30.0%
20.0%
10.0%
0.0%
Poor Knowledge Good Knowledge
Figure 4.1: Respondents’ level of knowledge of NHA
Figure 4.1 shows that 58.4% of the respondents had poor knowledge of NHA while 41.6% had
good knowledge of NHA
54
4.3 Perception of NHA by Respondents
Table 4.3 Respondents’ Perception of NHA
Items Strongly Disagree Undecid Agree Strongly
Disagree Freq (%) ed Freq (%) Agree
Freq (%) Freq (%) Freq (%)
There is need for seminar to guide the 20 (8.6) 9 (3.9) 7 (3.0) 82 (35.2) 115
health workers on NHA (49.4)
Healthcare workers obligations under 18 (7.7) 65 (27.9) 63(27.0) 64(27.5) 23 (9.9)

the NHA lay a burden on the healthcare
workers
Healthcare worker’s rights under the 40 (17.2) 68 (29.2) 69(29.6) 41(17.6) 15 (6.4)
NHA favour healthcare workers at the
expense of healthcare users
NHA provisions are necessary for 19 (8.2) 16 (6.9) 19 (8.2) 121(51.9) 58 (24.9)
quality healthcare provision
NHA does not effectively address legal 20 (8.6) 57(24.5) 75(32.2) 56 (24.0) 25(10.7)
aspects of healthcare delivery
It is difficult to comply with medico- 28 (12.0) 78 (33.5) 71(30.5) 43 (18.5) 13(5.6)

legal requirements outlined in the NHA
NHA need amendments of the medico- 16 (6.9) 20 (8.6) 85(36.5) 84 (36.1) 28 (12.0)
legal provisions
Adequate support and resources are not 14 (6.0) 23 (9.9) 67(28.8) 74 (31.8) 55 (23.6)
provided to healthcare practitioners to
meet their medico-legal responsibilities
55
under NHA
Table 4.3 shows that the 49.4% and 35.2% of the respondents strongly agree and agree that there
is need for seminar to guide the health workers on NHA, less than half (27.9%) of the
respondents disagreed that the NHA lay a burden on the healthcare workers, 29.6% had no idea
about NHA favouring healthcare workers at the expense of healthcare users, More than half
(51.9%) of the respondents agreed that NHA provisions are necessary for quality healthcare
provision, Majority (32.2%) do not know about the legal aspects that NHA addresses in respect
to healthcare delivery, 33.5% of the respondents disagree to inability to comply with medico-
legal requirements in the NHA, 36.5% are not sure about the need for amendments of the
medico-legal provisions and 31.8% of the respondents agreed to the unavailability of adequate
support and resources of healthcare practitioners to meet their medico-legal responsibilities
under NHA.
56
Perception of NHA
100.0%
90.0%
80.0%
70.0%
60.0%
51.9%
50.0% 48.1%
40.0%
30.0%
20.0%
10.0%
0.0%
Negative perception Positive perception
Figure 4.2: Respondents’ overall perception of NHA
Figure 4.2 shows that 51.9% of the respondents had negative perception of NHA while 48.1%
had positive perception of NHA
57
4.4 Practice of obligations under the NHA by Respondents
Table 4.4 Respondents’ Practice of obligations under the NHA
Items Never Sometimes Always

Freq (%) Freq (%) Freq (%)
Check NHA before you carry out a medical task that 96 (41.2) 75 (32.2) 62 (26.6)
you don’t do frequently
Review the NHA to ensure compliance with its medico- 78 (33.5) 78 (33.5) 77 (33.1)
legal obligations in your medical practice
Access resources or support that you think would be 57 (24.5) 98 (42.1) 78 (33.5)
helpful in fulfilling your medico-legal responsibilities
under the NHA
Obtain informed consent from patients before 13 (5.6) 30 (12.9) 190 (81.6)
performing medical procedures or treatments
Ensure accurate and up -to-date medical records for 8 (3.4) 26 (11.2) 199 (85.4)
patients
Seek legal advice or consulted with medico-legal 54 (23.2) 76 (32.6) 103 (44.2)
experts regarding your obligations under NHA
Provide healthcare users information on the risks, 15 (6.4) 61 (26.2) 157 (67.4)
benefits and alternatives to treatments
Refer patients to appropriate specialists or collaborate 10 (4.3) 41 (17.6) 182 (78.1)

with other healthcare providers for comprehensive
patient care when necessary
58
Confronted with decisions related medico-legal issues 50 (21.5) 108 (46.4) 75 (32.2)
under NHA in your practice
Engage in professional development to stay updated 12 (5.2) 74 (31.8) 147 (63.1)
with the latest medical advancements and practices
Table 4.4 shows that the majority of the respondents (41.2%) don’t check NHA before carrying
out a medical task, 33.5% of the respondents do not and 33.5% of the respondents occasionally
review the NHA to ensure compliance with its medico-legal obligations, 42.1% of the
respondents occasionally access resources or support that would be helpful in fulfilling their
medico-legal responsibilities under the NHA, majority of the respondents (81.6%) consistently
obtain informed consent from the patients before performing medical procedures or treatments,
85.4% consistently ensure accurate and up -to-date medical records for patients. Also, 44.2%
constantly seek legal advice or consult medico-legal experts regarding their obligations under
NHA, 67.4% are consistent in providing healthcare users information on the risks, benefits and
alternatives to treatments, 78.1% constantly refer patients to appropriate specialists or collaborate
with other healthcare providers for comprehensive patient care, 46.4% of the respondents are
occasionally confronted with decisions relating to medico-legal issues under NHA and more than
half (63.1%) do engage in professional development to keep them updated with the latest
medical advancements and practices.
59
Practice of NHA
100.0%
90.0%
80.0%
70.0%
60.0%
52.4%
50.0% 47.6%
40.0%
30.0%
20.0%
10.0%
0.0%
Poor practice Good practice
Figure 4.3: Respondents’ level of NHA practice
Figure 4.3 shows that less than half (47.6%) of the respondents had good practice of NHA while
52.4% had poor practice of NHA.
60
4.5 Hypotheses Testing
Table 4.5.1 Association between Practice of NHA and Socio-demographic Characteristics
Variable Practice of NHA X2 p-value
Poor Practice Good Practice
Frequency (%) Frequency (%)
Age 0.92 0.82
≤ 30 years 45 (36.9) 45(40.5)
31-40 years 44 (36.1) 38(34.2)
41-50 years 18 (14.7) 18(16.2)
51-60 years 15 (12.3) 10(9.01)
Sex 0.15 0.70
Male 41(33.6) 40 (36.0)
Female 81 (66.4) 71 (64.0)
Marital Status 1.07 0.79
Single 45 (36.9) 44 (39.6)
Married 75 (61.5) 66 (59.5)
Widowed 1 (0.8) 1 (0.9)
Divorced 1 (0.8) 0 (0)
Ethnicity 4.43 0.49
Yoruba 102 (83.6) 90 (81.1)
Igbo 12 (9.8) 9 (8.11)
Hausa 1 (0.82) 0 (0.00)
Edo 1 (0.82) 5 (4.50)
Igala 1 (0.82) 1 (0.90)
Others 5 (4.10) 6 (5.41)
Years of Practice 1.74 0.78
1-5 51 (41.8) 47 (42.3)
6-10 23(18.9) 25 (22.5)
11-15 23 (18.9) 16 (14.4)
16-20 7 (5.74) 9 (8.1)
Above 20 18 (14.8) 14 (12.6)
Job Category 16.3 0.012
Nursing 57(46.7) 70 (63.1)
Medical Practice 31 (25.4) 13 (11.7)
Pharmacy 9 (7.4) 5 (4.50)
Medical Laboratory 12 (9.8) 15 (13.5)
Science
Medical 11 (9.02) 4 (3.60)
Rehabilitation
Others 2 (1.64) 4 (3.60)
61
Table 4.51 shows that only job category was significantly associated with practice of obligations
under the NHA by Respondents
NHA
(χ2= 16.3, p=0.012).
62
Table 4.5.2: Association between Knowledge of NHA and reading and possession of NHA
Variable Knowledge of NHA X2 p-value
Poor Knowledge Good Knowledge
Reading of NHA 6.53 0.01*
No 90 (66.2%) 48 (49.5%)
Yes 46 (33.8%) 49 (50.5)
Possession of NHA 3.89 0.04*
No 126 (92.7%) 82 (84.5%)
Yes 10 (7.3%) 15 (15.5%)
Table 4.5.2 shows that there was a significant association between knowledge of NHA and
reading of NHA (χ2= 6.53, p=0.01) and possession of NHA (χ2= 3.89, p=0.04). Thus, the null
hypothesis was rejected
63
Table 4.5.3: Association between Perception of NHA and reading and possession of NHA
Variable Perception of NHA X2 p-value
Negative Perception Positive Perception
Reading of NHA 2.86 0.09
No 78 (64.5%) 60 (53.6%)
Yes 43 (35.5%) 52 (46.4)
Possession of NHA 4.46 0.04*
No 113 (93.4%) 95 (84.8%)
Yes 8 (6.6%) 17 (15.2%)
Table 4.5.3 shows that there was a significant association between perception of NHA and
possession of NHA (χ2= 4.46, p=0.04). Thus, the null hypothesis was rejected. However, there
was no significant association between perception of NHA and reading of NHA (χ2= 2.86,
p=0.09). Thus, the null hypothesis was accepted.
64
Table 4.5.4: Association between Practice of NHA and reading and possession of NHA
Variable Practice of NHA X2 p-value
Poor Practice Good Practice
Reading of NHA 13.46 <0.01*
No 86 (70.5%) 52 (46.9%)
Yes 36 (29.5%) 59 (53.2)
Possession of NHA 0.21 0.64
No 110 (90.2%) 98 (88.3%)
Yes 12 (9.8%) 13 (11.7%)
Table 4.5.4 show that there was a significant association between practice of NHA and reading of
NHA (χ2= 13.46, p=<0.01). Thus, the null hypothesis was rejected. However, there was no
significant association between practice of NHA and possession of NHA (χ2= 0.21, p=0.64).
Thus, the null hypothesis was accepted.
65
Table 4.5.5: Multivariate regression of Reading the NHA and possessing a copy of the NHA
Number of obs =233

W = Wilks' lambda L = Lawley-Hotelling trace
P = Pillai's trace R = Roy's largest root
Source Statistic df F(df1, df2 = F Prob>F
Model W 0.8917 2 6.0 456.0 4.48 0.0002 e
P 0.1102 6.0 458.0 4.45 0.0002 a
L 0.1193 6.0 454.0 4.51 0.0002 a
R 0.0972 3.0 229.0 7.42 0.0001 u
Residual 230
Reading W 0.9252 1 3.0 228.0 6.15 0.0005 e
NHA P 0.0748 3.0 228.0 6.15 0.0005 e
L 0.0809 3.0 228.0 6.15 0.0005 e
R 0.0809 3.0 228.0 6.15 0.0005 e
Possessing W 0.9768 1 3.0 228.0 1.80 0.1474 e
a copy of P 0.0232 3.0 228.0 1.80 0.1474 e
NHA L 0.0237 3.0 228.0 1.80 0.1474 e
R 0.0237 3.0 228.0 1.80 0.1474 e
Residual 230
Total 232
e = exact, a = approximate, u = upper bound on F
Table 4.5.4 shows that multivariate regression. Table 4.8 shows that the model was statistically
significant irrespective of the test (all the p-values for the model were <0.001). Reading the NHA
was a statistically significant predictor in the model (all the p-value were <0.001) while
possessing a copy of the NHA document was not a statistically significant predictor in the model.
66
4.6 Discussion of Findings
The study assessed the knowledge, perception and practice of healthcare workers under NHA.
The sociodemographic characteristics of the respondents shows that majority of the healthcare
workers were nurses (54.5%). This finding was in accordance with the report of survey carried
out on healthcare professionals' knowledge and perceptions of their training in ethics,
confidentiality, and medico-legal issues where majority of the healthcare workers were nurses. 126
It was also revealed that more than half of the healthcare workers did not read the National
Health Act. This finding was in concordance with the Nigeria’s National Health Act of health
professionals where they had a poor understanding of the Act, with only 17.7% having read it. 127
while majority of the healthcare workers do not possess a copy of the NHA.
The findings of the study revealed that many of the healthcare workers assented to keeping user’s
relevant information about their health status and treatment confidential and this was contrary to
the report of Barnie where majority (73.6%) of the health workers had fairly adequate knowledge
about ethics, confidentiality and medico-legal issues.128
The findings from the study also shows that more than half of the healthcare workers do not
obtain informed consent from the user before performing surgical procedures on the users. This
finding was in accordance with the report on survey carried out on medico-legal issues where
126
127
Association 260.
128
67
92.2% were not trained to respond effectively face possibleto address medicolegal issues, but
only a few (34.4%) tried to obtained a proper informed consent for a surgical procedure.129
Majority of the healthcare workers (87.1%) do explain the risks and implications of refusal of
treatment to the user and ensuring that the patients have an understanding of the medical
treatment and procedures the health professionals will be providing to them. This finding is the
same with the report on knowledge of ethics by ????????where the study found that 74% had
knowledge of ethics, confidentiality and medico-legal concepts.
The healthcare workers assented to keeping user’s health record and ensuring that non-healthcare
workers will have access to the user’s health record.
This study shows that 58.4% of the respondents had poor knowledge of NHA while 41.6% had
good knowledge of NHA and these findings were in acconcordance with many previous studies
on knowledge of healthcare workers under NHA in Nigeria. Previous studies revealed that
knowledge was only adequate in about a third of the Physicians that participated in the study. 130
Most resident doctors (94.2%) had limited knowledge. 131 A study in India shows that 95.2% of
resident doctors have poor knowledge of NHA.132 Another study found that 81.2% of doctors
had poor knowledge of medical ethics.133
The findings from this study also shows that 51.9% of the respondents had negative perception
of NHA while 48.1% had positive perception of NHA. This is contrary to the report of survey
129
Ismail Zaed and others, ‘Medicolegal Issues: Perception, Awareness, and Behavioral Changes Among Italian
Neurosurgical Community: Survey-Based Analysis’ (2021) 154 World Neurosurgery e774.
130
Adejumo OA and others, ‘Knowledge of the National Health Act among Physicians in Two Tertiary Hospitals in
Southern Nigeria’ (2022) J.2022 5(2) 31st December 2022 85.
131
Taufik Suryadi, Kulsum, Kulsum ‘Knowledge and Attitude Among Resident Doctors Related to Ethical and
Medicolegal Issues in a Teaching Hospital’. Jurnal Pendidikan Kedokteran Indonesia: The Indonesian Journal of
Medical Education, [S.l.], v. 11, n. 4, p. 349-362, dec. 2022. ISSN 2654-5810.
132
Ibid.
133
AWIP Ranasinghe and others, ‘Medical Ethics: Knowledge, Attitude and Practice among Doctors in Three
Teaching Hospitals in Sri Lanka’ (2020) 21 BMC Medical Ethics 69.
68
carried out on perception of Nigerian nurses where 89.10% of the healthcare workers had good
perceptions.134
The findings also show that less than half (47.6%) of the respondents had good practice of
obligations under the NHA while 52.4% had poor practice of sameNHA. This runs contrary to
the survey on practice among healthcare workers in Nigeria where there weare good practices
towards COVID-19.135
TIn this findings in this study also shows that only job category was significantly associated with
practice of obligations under the NHA among the health workers (p=0.012).
At multivariate analysis, it shows that the model (reading the NHA and possessing a copy of the
NHA) was statistically significant irrespective of the test (all the p-values for the model were
<0.001). Reading the NHA was a statistically significant predictor in the model (all the p-value
were <0.001) while possessing a copy of the NHA document was not a statistically significant
predictor in the model.
Although, this study found an association between knowledge of NHA and reading and
possession of NHA, this shows that there is poor knowledge of the NHA provisions as well as
the reading of the NHA, this is also applicable to the possession of the NHA; there is also poor
knowledge due to not owning a copy of the NHA at hand. It also shows that there was a
significant association between perception of NHA and possession of NHA (p=0.04).
134
Kabir Ozigi Abdullahi, Shahrzad Ghiyasvandian and Marzieh Hasanpour, ‘Theory-Practice Gap: The Knowledge
and Perception of Nigerian Nurses’ (2022) 27 Iranian Journal of Nursing and Midwifery Research 30.
135
Francis Enenche Ejeh and others, ‘Knowledge, Attitude, and Practice among Healthcare Workers towards
COVID-19 Outbreak in Nigeria’ (2020) 6 Heliyon e05557.
69
Results also shows that there was a significant association between practice of NHA obligations
and reading of NHA (p=<0.01) but there was no significant association between practice of NHA
obligations and possession of NHA.
70
CHAPTER FIVE
SUMMARY, CONCLUSION, AND RECOMMENDATIONS
5.1 Summary and Conclusion

The study examined the knowledge, perception and practice of NHA among healthcare workers.
The aim of the study was to assess the knowledge, perception and practice of NHA. The study
design was cross- sectional study. The findings of the study showed that more than half of the
respondents had poor knowledge of NHA while 41.6% had good knowledge of NHA and
perceived that practice does not influence their knowledge. It also shows that majority of the
respondents had negative perception of NHA and less than half (47.6%) of the respondents had
good practice of NHA while 52.4% had poor practice of NHA. The findings of the study also
revealed that only job category was significantly associated with practice of NHA among the
health workers (p=0.012). The study also shows that there was an association between
knowledge of NHA and reading and possession of NHA. There was an association between the
practice and reading of NHA and the perception of NHA and the possession of NHA among
healthcare workers. Also, reading the NHA was a statistically significant predictor in the model
(all the p-value were <0.001) while possessing a copy of the NHA document was not a
statistically significant predictor in the model.
The study concluded that the knowledge, perception and practice of NHA among the healthcare
workers is poor. There is a need to institute programs that target the understanding of the HCW
about knowledge, practice and perception so as to improve the practice of healthcare workers in
Nigeria.
71
5.2 Policy Recommendations
The recommendations that were made based on the findings of this study include the following:
 There is the need for the healthcare workers to receive further in-service training on
medico-legal issues related to their responsibilities.
 Healthcare workers should develop a good reading habit and possess a copy of the
National Health Act so as to promote the influence of good knowledge and practice
among health assistants.
 Healthcare professionals should be educated during pre-service and professional training
about the nature and implications of medico-legal matterobligations which will help to
improve the quality of care and service delivery.
 Healthcare professionals need inclusive and culturally relevant training based on practical
situations to deepen their knowledge of the NHA.
 There is the need for routine seminars to guide and sensitize the healthcare workers on
their obligations under the NHA.
5.3 Limitation of the Study
A major limitation to this study is the unwillingness to fill the questionnaire. Some of the
respondents were not willing to fill the questionnaire thereby turning down the request to fill it;
some were not willing to provide details as they felt insecure while some were very busy going
about with their business activity. However, with perseverance, the researcher was able to get
enough data for the study. This study did not assess factors influencing practice, however
72
statistical analysis was used to determine the socio-demographic characteristics associated with
practice of NHA among the health workers in the study setting.
5.4 Suggestion for Further Studies
To further improve knowledge on this subject matter, more researches need to be carried out
with mixed methods research to collect robust data and give meaning and explanations to the
quantitative data. Also, researches that will make use of more sophisticated econometric analysis
are recommended.
5.5 Contribution to Knowledge
The uniqueness of the study is based on the context of Osun State which is a rural zone, where
there is dearth of empirical data on the phenomenon of the study. The study covers the gaps
employing primary sources of data collection (structured questionnaire) to interview healthcare
workers in Osun State. It employed both descriptive and logistic regression method of analysis,
using the theory of social learning in an attempt to bridge the gap thereby contributing to the
body of knowledge.
73
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80
APPENDIX
INSTITUTE OF ADVANCED CLINICAL SCIENCES EDUCATION
UNIVERSITY OF MEDICAL SCIENCES, ONDO.
Dear Respondent,
I am a postgraduate student of the above-named University, conducting research on
‘Knowledge, Perception and Practice of Medico-legal Obligations under the National
Health Act among Healthcare workers in Selected Hospitals Osun State’ Your honest
response is highly appreciated. All information would be kept confidential.
Thank you.
Deborah Komolafe
Please indicate your consent to participate in this study
Section A: Socio-demographic Characteristics of Respondents
Please tick (√) and fill in the gaps as appropriate.
1. Sex: Male Female

2. Marital status: Single Married Widowed Divorced Separated
3. Age in years: _______________
4. Number of years of practice: 1-5 6 –10 11- 15 16- 20 Above 20
5. Ethnicity: Yoruba Igbo Hausa Edo Igala Others______
6. Job category: Nursing ( ) Medical practice ( ) pharmacy ( ) Medical Laboratory Science ( )
Medical rehabilitation ( ) Others, please specify __________________________
7. Have you read National Health Act (NHA)? Yes ( ) No ( )
8. Do you possess a copy of the NHA document? Yes ( ) No ( )
Section B: Knowledge of National Health Acts of Respondents
Please tick (√) as appropriate.
SN Questions Yes No I don’t Know
81
According to the National Health Act (NHA),
1. Do healthcare workers have a right to refuse persons
emergency medical treatment?
2. Can a healthcare worker refuse to treat user who is physically
abusive?
3. Can a healthcare worker refuse to treat user who is verbally
abusive?
4. Can a healthcare worker refuse to treat user who sexually
harasses the health worker?
5. Do healthcare workers have an obligation to give a user
relevant information pertaining to the state of health and
necessary treatment relating to the health status?
6. Do healthcare workers have an obligation to give a user
relevant information pertaining to the user’s right to refuse
health services?
7. Do healthcare workers have an obligation to explain the
implications, risks or obligations of such refusal to the user?
8. Do healthcare workers have an obligation to keep records
9. Do healthcare workers have an obligation to keep all

information relating to the user’s health status, and treatment
confidential?
10. Do healthcare workers have an unhindered access to health
records?
11. Do healthcare workers have an obligation to protect the health
records?
12. Do healthcare workers have a right to take health records out
of the hospital if necessary?
13. Are there circumstances when a healthcare worker can remove
such tissue, blood or organ without the consent of the person?
14. Do healthcare workers have an obligation to use tissue
removed or blood or a blood product withdrawn from a living
person for only medical and dental purposes?
15. Does the NHA establish a National Health Insurance Scheme
(NHIS)?
16. Does the NHA establish a Basic healthcare provision fund?
17. Does the NHA establish a Vulnerable group fund?
Section C: Perception of National Health Acts of Respondents

Please indicate the extent you agree or disagree with the following statements
S/N Items Strongly Disagree Undecided Agree Strongly
Disagree Agree
1. There is need for seminar to
82
guide the health workers on
NHA
2. Healthcare workers
obligations under the NHA
lay a burden on the
healthcare workers
3. Healthcare worker’s rights
under the NHA favour
healthcare workers at the
expense of healthcare users
4. NHA provisions are
necessary for quality
healthcare provision
5. NHA does not effectively
address legal aspects of
healthcare delivery
6. It is difficult to comply with
medico-legal requirements
outlined in the NHA
7. NHA need amendments of
the medico-legal provisions
8. Adequate support and
resources are not provided to
healthcare practitioners to
meet their medico-legal
responsibilities under NHA
Section D: Practice of National Health Acts of Respondents
Please indicate how often you engage in the following

S/N Items Never Sometime Always
s
1. Check NHA before you carry out a medical task that you
don’t do frequently
2. Review the NHA to ensure compliance with its medico-legal
obligations in your medical practice
3. Access resources or support that you think would be helpful
in fulfilling your medico-legal responsibilities under the
NHA
4. Obtain informed consent from patients before performing
medical procedures or treatments
5. Ensure accurate and up -to-date medical records for patients
6. Seek legal advice or consulted with medico-legal experts
regarding your obligations under NHA
7. Provide healthcare users information on the risks, benefits
and alternatives to treatments
83
8. Refer patients to appropriate specialists or collaborate with
other healthcare providers for comprehensive patient care
when necessary
9. Confronted with decisions related medico-legal issues under
NHA in your practice
10. Engage in professional development to stay updated with the
latest medical advancements and practices
Thank you for your time
84
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KNOWLEDGE, PERCEPTION AND PRACTICE OF MEDICOLEGAL OBLIGATIONS

UNDER THE NATIONAL HEALTH ACT AMONG HEALTHCARE WORKERS IN

Deborah, Jesutofunmi KOMOLAFE

MATRIC NO: HLP/22/3979

I, KOMOLFE, Deborah Jesutofunmi with Matriculation number HLP/22/3979 hereby affirm

represents the culmination of countless hours of research, analysis, and dedication.

errors and inconsistencies in the study.

Dr. Oluwadamilola Adejumo

KNOWLEDGE, PERCEPTION AND PRACTICE OF MEDICOLEGAL OBLIGATIONS

CHAPTER ONE- INTRODUCTION

1.1 Background to the Study-------------------------------------------------------------------1

1.2 Statement of the Problem------------------------------------------------------------------3

1.3 Research Questions-------------------------------------------------------------------------5

1.4 Research Objectives------------------------------------------------------------------------5

1.5 Significance of the Study -----------------------------------------------------------------5

1.6 Scope of the Study--------------------------------------------------------------------------9

1.7 Structure of the Study----------------------------------------------------------------------9

CHAPTER TWO- LITERATURE REVIEW------------------------------------------------11

2.1 The Conceptual review----------------------------------------------------------------------11

2.1.1 Concept of Medico-legal Obligations of Healthcare Workers ------------------------11

2.1.2 Knowledge and Perception of Medico-Legal Obligations of Healthcare Workers--17

2.1.3 Knowledge, Awareness and Practice of Medicolegal Obligations --------------------20

2.1.4 Medicolegal Obligations of Healthcare Workers in Nigeria ---------------------------22

2.1.6 NHA And Medico-Legal Obligations Under The NHA---------------------------------29

2.1.7 Factors Affecting the Knowledge, Perception and Practice of

Medicolegal Obligations Under NHA Among Healthcare Workers---------------------33

2.2 Conceptual Framework------------------------------------------------------------------------36

2.3 Empirical Literature Review------------------------------------------------------------------37

2.4 Theoretical Review-----------------------------------------------------------------------------39

2.4.1 Socio-Ecological Model Theory---------------------------------------------------------------39

2.4.2 Theory of Planned Behaviour (TPB)--------------------------------------------------------40

2.5 Research Hypotheses--------------------------------------------------------------------------41

CHAPTER THREE- METHODOLOGY--------------------------------------------------------43

3.1 Research Design--------------------------------------------------------------------------------43

3.2 Study Setting------------------------------------------------------------------------------------43

3.3 Study Population-------------------------------------------------------------------------------43

3.4 Sample Size and Sampling Technique------------------------------------------------------43

3.5 Research Instrument---------------------------------------------------------------------------44

3.6 Validity and Reliability of Instrument------------------------------------------------------45

3.7 Procedure for Data Collection---------------------------------------------------------------45

3.8 Method of Data Analysis----------------------------------------------------------------------45

3.9 Estimation Technique-------------------------------------------------------------------------46

3.10 Ethical Considerations------------------------------------------------------------------------47

CHAPTER FOUR- PRESENTATION OF RESULT AND DISCUSSION----------------48

4.1 Socio-demographic Characteristics of Respondents--------------------------------------49

4.3 Perception of National Health Acts of Respondents-------------------------------------54

4.4 Practice of National Health Acts of Respondents---------------------------------------57

4.5 Hypotheses Testing and Inferential Statistics--------------------------------------------60

4.6 Discussion of Findings---------------------------------------------------------------------66

CHAPTER FIVE- SUMMARY, CONCLUSION, POLICY RECOMMENDATION

5.1 Summary and Conclusion-----------------------------------------------------------------70

5.2 Policy Recommendation-------------------------------------------------------------------71

5.3 Limitation of the Study---------------------------------------------------------------------71

5.4 Suggestion for Further Studies------------------------------------------------------------72

5.5 Contribution to Knowledge----------------------------------------------------------------72

his strength and grace throughout the period of this program.

how privileged I am to work with you.

of encouragement. God bless you sir.