Perception of legal liability by registered nurses in Korea

Nurse Education Today (2007) 27, 617–626

Nurse Education Today intl.elsevierhealth.com/journals/nedt

Perception of legal liability by registered nurses in Korea Ki-Kyong Kim

a,*

, In-Sook Kim b, Won-Hee Lee

b

a

Department of Nursing, Wonju College of Medicine, Yonsei University, 162 Ilsan-dong, Wonju-city, Kangwon-Do 220-701, South Korea b College of Nursing, Yonsei University, South Korea Accepted 27 September 2006

KEYWORDS

Summary Liability to the nursing profession is imperative if nurses are to act as an autonomous body. Assessing and communicating effectively is a vital part of nursing for patient safety. This study was designed to identify the attitudes of Korean nurses toward liability in assessment and communication and to investigate the relationship among the variables (i.e., legal awareness, attitudes toward doctor’s duty to supervise nurses). The attitudes toward doctor’s duty reflect the status of nurses’ dependency on doctor’s supervision. The study participants were 288 registered nurses in RN-BSN courses at two colleges in Korea. The level of legal awareness was measured using a 25-item Legal Awareness Questionnaire developed by the authors. The measuring instrument for attitudes toward doctor’s duty to supervise nurses and nurses’ liability was the Attitude toward Duty and Liability Questionnaire, which was modified by the authors. There were significant correlation between attitude toward doctor’s duty and nurses’ liability, but not between legal awareness and liability attitude. The results of this study suggest that the present educational content aimed at improving liability attitudes of nurses should be refocused with attitude-oriented education and should include an understanding of the increased accountability that comes with greater autonomy in nursing practice. c 2006 Elsevier Ltd. All rights reserved.

Liability; Responsibility; Accountability



Introduction

* Corresponding author. Tel.: +82 33 741 0380 (office), 11 9020 4028; fax: +82 33 743 9490. E-mail addresses: [email protected] (K.-K. Kim), iskim@ yumc.yonsei.ac.kr (I.-S. Kim), [email protected] (W.-H. Lee).



Each nurse is responsible and accountable for his/ her individual nursing practice. The concept of accountability is seen as a fundamental attribute of the profession. While accountability of the occupation rests with the employer, accountability of the profession rests with the individual (Chitty,

0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.09.010

618 2001). The Washington Administrative Code (WAC 246-840-700) says that the nurse shall be responsible and accountable for the quality of nursing care given to clients. This responsibility cannot be avoided by accepting the orders or directions of another person. The Korea Ethical Code of Nursing, states that the nurse should assume responsibility and accountability for all individual judgments and actions (Article 7). Accountability may involve liability (Passos, 1973), which refers to the state of being held legally responsible for the harm caused to the other person (Bernzweig, 1996). The rule of personal liability requires the professional nurse to assume legal responsibility for patient harm or injury that occurs as a result of his or her negligence (Cherry and Jacob, 1999). Accountability implies that one has both the authority and autonomy in the areas of responsibility (Snowdon, 1993). That is to say, legal responsibility by nurses for their practice rests on the assumption that they are autonomous practitioners. In Korea, however, the difficulty in being held accountable arises from the absence of a law to endow nurses with rightful power to fulfill their responsibilities and freedom to exercise that power. The Korean Medical Service Act defines nursing practice as recuperative nursing, assistance in medical examination and treatment and health activity prescribed by Presidential Decree (Article 2). This act reinforces nurses’ lack of self-determination by requiring that nurses perform certain actions only when authorized by supervising doctors. Most of the therapeutic practice of nurses is regarded as assistance to the medical practice that requires a doctor’s supervision. The image of nursing as seen by the law is as a subordinate and paramedical practitioner. The paramedical view of nursing is most powerfully entrenched within the health care system (Rhodes, 1983). This view can also be partly found in the nursing laws of Japan (Public Health Nurse, Midwife and Nurse Act Article 2), Taiwan (Nurses’ Act Article 24), and Thailand (Professional Nursing and Midwife Act Section 4). This perspective shows a possible overall effect on nurses’ attitude toward liability and autonomy in nursing practice. For patient safety, effective assessment and communication are vital to nursing. The registered nurse collects data and communicates significant changes in client status to appropriate members of the health care team. This communication should take place in a time period consistent with the client’s need for care (WAC 246-840-700). Failure to perform a proper patient assessment or to notify the appropriate staff member is a common

K.-K. Kim et al. allegation in malpractice cases (Chapman and Mason, 1994; Fiesta, 1988). The ANA (1989) has summarized the most frequent allegations of negligence leveled against nurses in malpractice cases, including failure to monitor the patient and report significant findings. This requirement for 24 h continuous care is significant because it is unique to the nursing profession and places nurses in a position to provide effective care based on sound knowledge and understanding of the patient. Accordingly, it is necessary that the nurse be responsible and accountable for patient assessment and communication regardless of supervision by the doctor. The development of accountability is considered to be an important component of professionalism. Accountable nurses are reported to have higher job satisfaction, provide improved quality of care and attend to patient safety and partnership with other healthcare professionals (Rowe, 2000; Snowdon, 1993; UKCC, 1989). Korean nurse educators have developed a range of post-registration education programs (i.e., continuing education programs, RN-BSN program) to enhance the willingness of nurses to take responsibility for their own liability. However, the general goal of most education programs for nurses is acquisition of legal knowledge. There are three traditional legal education goals in the USA: knowledge, skill, and attitude (Williams and William, 1995). Nurses who are knowledgeable of the law can better identify, predict, prevent, or handle medical-legal problems (Marble et al., 1999).One recent study concluded that legal ignorance on the part of physicians may result both in unnecessary suffering for patients and their families and in inappropriate use of scarce medical resources (McCrary et al., 1994). Nevertheless, changing attitudes is more important than imparting information about particular doctrines and laws (Williams and William, 1995). Attitude has three components: affective, cognitive and behavior. A tendency to behave in a certain way towards people or events is determined by affective and cognitive components of personality (Breckler, 1984). Attitude and behavior are closely linked to one another (Fishbei and Ajzen, 1972). To promote responsible nursing behavior, educational efforts need to be directed toward improvement of positive attitude toward liability in nursing practice.

Purpose of the study The purpose of this study was to identify the attitudes of Korean nurses toward legal liability in

Perception of legal liability by registered nurses in Korea patient assessment and communication and to examine the relationship among the variables (i.e., legal awareness, attitudes toward doctor’s duty to supervise nurses). In attempting to explain individual differences in attitudes toward liability, the present study assessed the level of legal awareness of nurses and their attitudes toward doctor’s duty to supervise nurses. The ultimate goal of the study was to provide ideas to be used in the development of post-registration education strategies to help nurses change their attitudes toward legal liability.

Definition of terms  Legal awareness Legal awareness refers to the nurses’ level of knowledge about the law, legal duties, and the legal system related to nursing practice.  Attitude toward doctor’s duty to supervise nurses Duty refers to a legal obligation owed by one party to another (Helm, 2003). Attitude toward duty refers to the way nurses think about the doctor’s obligation to direct and supervise nurses in patient care.  Attitude toward nurses’ liability As noted above, liability refers to the state of being held legally responsible for the harm caused to the other person (Bernzweig, 1996). Attitude toward liability describes how nurses think about accepting legal responsibility.

Table 1

619

Method A survey design with a cross-sectional method was used to examine the attitudes of Korean nurses toward liability and to examine the relationship among the variables. Because of the convenience in collecting data from a large number of study participants, a self-completed questionnaire survey was chosen.

Participants and procedures Participants were 288 registered nurses enrolled in a two-year RN-BSN program at two Colleges in Seoul and Wonju, Korea. All participants were female nurses who were working in hospitals. The mean age was 26.70 (SD = 3.11) years, with a range of 22–49, and 49.7% of the respondents were between 26 and 30. Seventy-six percent had less than five years work experience, 96.5% were staff nurses, and 53.8% worked on general units. One third had taken continuing education courses on nursing law. All 288 nurses who participated in a course on nursing law & ethics between March 2004 and March 2005 at the colleges were invited to participate in the present study. Informed consent was obtained from all nurses following receipt of information on the purpose and nature of the study through a letter which was distributed with the questionnaire. The nurses were assured that their participation was entirely voluntary and informed of their right to withdraw at any time, and that anonymity and confidentiality would be

Demographic characteristics of participants (n = 288)

Variables

Classification

Frequency

Percent

Age

Mean (SD) = 26.70 (3.11) 21–25 years 26–30 years 31–35 years over 35 years

117 143 23 5

40.6 49.7 8.0 1.9

less than 5 years more than 5 years–less than 10 years more than 10 years

219 59

76.0 20.5

10

3.5

Staff nurse Charge/Head nurse General unit Special Unit Others

278 8

96.5 2.8

155 104 29

53.8 36.1 10.0

Yes No

94 194

32.6 67.4

Work experience

Status

Department

Continuing education on health law

620

K.-K. Kim et al.

maintained. The unequal power relationship between nurses enrolled in BSN program and tutors was therefore recognized and care was taken not to exploit this relationship (Table 1).

Measures In addition to a brief demographics questionnaire, two questionnaires were developed for use in the present study. The first was the ‘‘Legal Awareness Questionnaire’’. This questionnaire was developed from items from a legal textbook, and the items were adapted according to questionnaires used in other studies (Kim, 2003; Mun and Lee, 1999). Content validity of the questionnaire items was established by one lawyer, one jurist, and two professors who majored in nursing law. They critiqued each item twice and evaluated whether or not the study contained all the essential knowledge related to nursing practice. The questionnaire was composed of true (=1) or false (=0) questions and consisted of 25 questions grouped into 5 categories: the right to health care, legislative process & health law system, principles of civil & criminal liability, discipline, and legal duties. In this research, higher scores indicated higher levels of knowledge. The second questionnaire was the ‘‘Attitude toward Duty and Liability Questionnaire’’. Each question used in a study by Kim (1999) was modified to measure attitude toward doctor’s duty to supervise and nurses’ liability for malpractice. Participants were given three case scenarios in which nurses Table 2

were found liable for negligence in monitoring and reporting (Mc Millan v. Durant, 1993; Kim, 1999; Pozgar, 1996; Seoul District Court Judge, 1995; Supreme Court Decision, 1994; scenarios are provided in Table 2) and asked to make case-related judgements. Participants answered three questions measuring their attitude toward doctor’s duty on a 4-point Likert scale: very necessary (4 points), necessary (3), somewhat necessary (2), and unnecessary (1). The estimate of internal consistency for the questions on duty was alpha = .68. Higher scores indicated positive nurses’ attitudes toward doctor’s duties. The participants were given three questions and asked to judge the liable person in each case. The judgements of the participants were classified into three liability groups (doctor, nurse, both doctor & nurse). The present study operationalized liability attitude as a judgement pattern. The study assumed that participants who judged nurses’ liability expressed positive attitude toward liability. It was expected that the group that judged liability for both doctor and nurse would be more positive than the group for doctor’s liability. Questions regarding liability attitude were given scores with increasing value according to the judgment pattern. The doctor’s liability counted as one point, both liability as two, and nurses’ liability as three. Higher scores indicated a more positive attitude toward liability. A pilot study to check the applicability of these questions was conducted with 50 clinical nurses.

Three case scenarios related to nurses’ liability for negligent assessment and communication

Case I: On the night after thyroidectomy surgery, the male patient complained of having difficulty in breathing to the doctor. The doctor ordered the nurse to check the patient’s vital signs every 2 h and call him immediately if she noticed any deterioration in the patient’s condition. The nurse checked the patient’s vital signs only once at 3 a.m., and failed to respond to several calls from family members until the patient left the room and collapsed due to breathing problems at 6 a.m. Despite attempt’s from the doctor to resuscitate the patient, the patient finally became comatose and suffered permanent brain damage. Case II: A patient was diagnosed as having depression and was admitted to the psychiatric unit of the hospital for suicidal tendencies. After admission, the patient often said to the doctor that he felt like killing himself. The doctor documented the conversation with the patient on the medical record, and requested that the patient was thoroughly watched for any attempt to commit suicide. In the evening, the nurse aid reported to nurse that she saw the patient hanging from the hooks on the wall of the shower room. Although they tried to resuscitate him, he had already suffered permanent brain damage. Case III: The patient was born prematurely and suffered intercranial bleeding that required the insertion of a shunt in order to relieve pressure on the brain and prevent brain damage. The patient underwent three shunt revisions by a neurosurgeon over a period of time. The child was diagnosed as URI and admitted to hospital at 18 months for IV hydration. The mother said that the child did not seem to be acting normally. The nurse and nursing supervisor observed that the child had normal respiration, with good color, and was resting comfortably. During this time there was no attempt to contact the doctor on call. Several minutes after the nurse left the room, the mother noted that the child had stopped breathing. After he was resuscitated, a neurosurgeon tapped the shunt and drained off the excess fluid. It was discovered that the child’s shunt had become blocked at the abdominal end of the shunt. This placed pressure on his brain, causing him to stop breathing. As a result, the child suffered permanent brain damage

Perception of legal liability by registered nurses in Korea

Data analysis Descriptive statistics were used to analyze data for demographic characteristics, level of legal awareness, and attitude toward duty and liability. Chisquare and ANOVA were used to analyze legal awareness and attitudes according to liability groups and demographic background. The relationship between the level of awareness and attitudes was calculated with Pearson correlation coefficient. Stepwise regression was conducted to examine the predictor of liability attitude. All statistical analysis was conducted using SPSS/PC 12.0 program.

Results The level of legal awareness Most of the nurses were aware of the stipulations of The Rights to Health in Korean Constitutional Law (83.7%) and the Universal Declaration of Human Rights (93.1%). However, few nurses (18.4%) gave a correct answer to the process of legislation but 59% were aware of the hospital’s right to sue negligent nurses to recoup financial losses. About the wrongful birth cases, 61.1% answered that the parents have no right to claim damages for loss of an opportunity to abort. Less than a third of nurses (31.6%) knew the criminal liability for unauthorized injection of an anesthetic. Regarding consent, 35.4% knew that oral consent has the same legal effect as written consent (Table 3). The level of legal awareness and attitude toward duty by liability group in the cases The mean scores were 16.82 (SD = 2.56) for legal awareness, 3.11 (SD = .59) for attitude toward duty and 2.11 (SD = .28) for liability. The majority of the participants replied that both parties were responsible for malpractice (in case 1 = 88.5%, in case 2 = 82.6%, in case 3 = 82.6%). The participants were grouped according to their judgements. Group 1 judged that it was doctor’s liability for malpractice, Group 2 judged that it was both parties and Group 3, that it was the nurse. An ANOVA was then used to determine differences in the level of legal awareness and attitude score of duty among the three groups. In every case, there was no significant difference for the level of legal awareness among the three groups. For cases 2 and 3, there were significant differences in attitude toward doctor’s duty among the three groups (Table 4).

621

The level of legal awareness and attitude toward duty and liability by demographic characteristics The overall score of legal awareness and the two attitudes were compared to demographic variables. A significant difference in the level of legal awareness was found according to the nursing department (p < .05), and a significant difference in the score of liability attitude was found according to status (p < .05). Staff nurses in this study, had an more positive attitude of accepting responsibility for their actions than nurse in administration (Table 5). Correlations among variables and predictors of liability attitude A correlation matrix (Table 6) was generated to develop an understanding of the relationships among the study variables. Liability attitude was negatively correlated with attitude toward doctor’s duty (r = .177, p < .01). There was no relation between the scores for legal awareness and liability attitude. Multiple regression was used to identify the variable predicting liability attitude (Table 7). Of the control variables, attitude toward doctor’s duty was highly correlated to the liability attitude score (B = .180, p < .01). These findings show that the nurses had a more positive liability attitude when they needed less direction and supervision from the doctors.

Discussion This study examined the legal awareness, attitudes toward liability and doctor’s duty to supervise nurses among registered nurses in Korea. Findings from this study indicate that respondents had high levels of legal awareness except for items related to informed consent. While the doctor has legal responsibility for obtaining informed consent, the nurse has some legal and ethical responsibility in this process. This research demonstrated general acceptance of nurses’ liability because the majority of the participants judged that both parties would be held liable for malpractice in all three cases. If the goal of effective and comprehensive health care is to be attained, then accountability among all healthcare professionals must be reciprocal in nature. Mutual accountability does exist between the professions of nursing and medicine in the context of patient care (Stanley, 1983). However, it is imperative that nursing begins to develop separate legal accountability as a profession in order to clarify the professional boundaries

622 Table 3

K.-K. Kim et al. Correct item response rate (n = 288)

Categories

Items

Correct response (n)

Percent

Right to health care

The provisions of right to health in Korea Constitutional Law The provisions of right to health in the Universal Declaration of Human Rights(1948) & The Covenant on Economic, Social and Cultural Rights (1966)

241 268

83.7 93.1

Legislative process & legal system

Process of administrative legislation Types of law Administrative body related to nursing service Nurse licensing law in the Medical service Act

53 189 173 273

18.4 65.6 60.1 94.8

Principles of civil liability

Definition of malpractice Vicarious liability Hospital can sue nurses to recoup financial losses suffered due to the negligence of the nurses Wrongful life case, right to not give birth with impediment Wrongful birth case, parent’s right to claim damages for loss of chance to abort Wrongful birth case, parent’s right to claim damages for birth impaired baby

201 211 170

69.8 73.3 59.0

171 176

59.4 61.1

194

67.4

Definition of probation Difference between civil suit and criminal suit Criminal liability for misappropriate use of drug Criminal liability for removal from life sustaining machine after family’s request Criminal liability for unauthorized practice related to injection of an anesthetic

215 226 204 253

74.7 78.5 70.8 87.8

91

31.6

Grounds for license revocation Grounds for license suspension Confidentiality (disclosure of information) Legal effect of oral consent Patient’s verbal opinion has priority to written consent Situation in which the physician can proceed without requesting consent from the patient Affirmative duty related to doctor’s order being harmful to patient Refusal to administrate anesthetic and protect the patient’s safety when nurse knows the surgeon’s order is inappropriate

211 178 184 102 160 220

73.3 61.8 63.9 35.4 55.6 76.4

277

96.2

201

69.8

Principles of criminal liability

Discipline Legal duties

of nursing and cooperate with the medical profession. In some areas it has become difficult to distinguish the boundaries between nursing and medical care. As a result, there is considerable debate about who is ultimately responsible for the care of patients and clients. If the ultimate responsibility for patient care continues to rest with the doctor, this would appear to imply that doctors consider themselves accountable and that, in the hierarchy of the team, the nurse is, therefore, not accountable and cannot be held liable. These findings indicate that the attitude of the participants was to accept the doctor’s direction and supervision of nurses in patient monitoring and notification. This high dependency on another medical professional reflects nurses’ experience

of low autonomy. Further, the study findings indicate that the attitude toward the doctor’s duty was a unique predictor of liability attitude. As nurses needed less direction from the medical doctors, their acceptance of personal liability increased. This indicates that the major barriers to accepting full liability include the lack of autonomy in nursing practice. An autonomous profession must be self-governing and self-regulating (Fleming, 1998). Authority is a necessary condition for both autonomy and accountability (Batey and Lewis, 1982). That is to say, it may be difficult to require individual nurses to be autonomous and accountable in their actions if they do not have authority. Unfortunately, nursing in Korea is not a fully autonomous profession; it

Perception of legal liability by registered nurses in Korea Table 4

Level of legal awareness and attitude scores of duty grouped by judgement (n = 288)

Liability group

n (%)

Legal awareness M (SD)

Total Case 1 Group Group Group Case 2 Group Group Group Case 3 Group Group Group

623

F

Physician’s duty p

16.82 (2.56) 1 2 3

– 255 (88.5) 33 (11.5)

– 16.84 (2.61) 16.67 (2.17)

.139

.710

1 2 3

33 (11.5) 238 (82.6) 17 (5.9)

16.55 (2.83) 16.84 (2.48) 16.82 (2.56)

.358

.699

1 2 3

14 (4.9) 182 (63.2) 92 (31.9)

17.36 (2.37) 16.76 (2.59) 16.82 (2.56)

.361

.697

M (SD) 3.11 3.08 – 3.09 3.03 3.13 3.30 3.13 2.76 3.13 3.64 3.25 2.79

Liability

F

p

M (SD)

(.59) (.70)

2.11 (.28) 2.11 (.32)

(.71) (.64) (.74) (.64) (.74) (.83) (.80) (.50) (.71) (.90)

.214

.644

3.033

.050

14.224

.000

1.94 (.41)

2.27 (.54)

Note. Group 1 = judged doctor’s liability for malpractice (score = 1); Group 2 = judged both doctor and nurse’s liability (score = 2); Group 3 = judged nurse’s liability (score = 3).

Table 5 Level of legal awareness and the attitude score of duty and liability according to demographic characteristics (n = 288) Variables

n

Legal awareness M (SD)

Total Age 21–25 years 26–30 years 31–35 years over 35 years

117 143 23 5

16.91 16.61 17.70 17.00

Work experience 0–5 years 6–10 years over 11 years

219 59 10

16.80 (2.57) 16.92 (2.55) 16.80 (2.70)

278 8

16.79 (2.57) 17.63 (1.93)

155 104 29

16.45 (2.40) 17.14 (2.74) 17.69 (2.42)

F (t)

Doctor’s duty P

16.82 (2.56)

F (t)

P

9.34 (1.77)

M (SD)

F (t)

p

6.33 (.84)

1.281

.281

9.18 (1.76) 9.36 (1.77) 10.13 (1.46) 8. 6 (2.41)

2.188

.090

6.29 (.82) 6.38 (.82) 6.30 (.88) 6.0 (1.58)

.549

.649

0.48

.953

9.31 (1.73) 9.47 (1.86) 9.20 (2.15)

.242

.785

6.31 (.79) 6.44 (.93) 6.30 (1.25)

.606

.546

.829

.363

9.31 (1.77) 10.13 (1.55)

1.658

.199

6.35 (.84) 5.75 (.71)

3.946

.048

4.270

.015

9.25 (1.77) 9.45 (1.82) 9.38 (1.57)

.408

.665

6.30 (.79) 6.35 (.86) 6.48 (1.02)

.618

.540

Experience with legal continuing education Yes 94 16.43 (2.45) 3.396 No 194 17.02 (2.59)

.066

9.16 (1.77) 9.42 (1.76)

1.409

.236

6.28 (.88) 6.36 (.82)

.637

.425

Status Staff nurse Charge/Head nurse Department General unit Special unit Others

(2.54) (2.59) (2.64) (2.45)

M (SD)

Liability

Missing values excluded.

has historically been, and still is, controlled by the medical profession and regulations that support that control. One of the greatest barriers for Korean nurses striving to achieve autonomy may be the regulation system that gives the medical profession overall power.

The Medical Service Act defines the practice of medicine quite broadly and indeterminately. Vagueness in the definition of limits in the scope of practice makes it difficult to distinguish the boundaries and liability between nursing and physicians. Under the vagueness of role and liability, it

624

K.-K. Kim et al.

Table 6

Pearson correlation matrix (1)

(1) The level of legal awareness (2) The attitude toward doctor’s duty (3) The attitude toward liability *

(2)

(3)

1.00 .109 .010

1.00 .177*

1.00

p < .01 level (two-tailed test).

Table 7

Predictor of attitude toward liability

Prediction variable The attitude toward doctor’s duty

b .180

R2

F

p

.033

9.514

.002

may be natural for Korean nurses to have high dependency on supervision from the medical profession. Korean nurses have not yet achieved an independent ‘‘Nursing Practice Act’’ reflecting the nurses’ image as autonomous professionals. For a long time, the Korean Nurses Association has worked to have a Nursing Practice Act passed in order to have legislation on the power or right of self government and to extend accountability for the care provided. Other perceived barriers to nurses’ autonomy include a lack of recognition of the nurses’ professional role, and the dominance of the medical profession (Pollard, 2003). Autonomy is a multifaceted concept and yet, if nurses have the courage to embrace both the traditional values of nursing and the expertise that their caring role brings to health care, they will be able to develop their own competence and autonomous practice (Cutts, 1999). If a certain practice becomes generally accepted, it will be recognized as a ‘‘standard practice’’ (Helm, 2003). A nurse is required to repeat assessment of any abnormal vital signs and to notify the doctor if a patient’s status worsens in any way. Both of these actions by the nurse have been generally accepted as ‘‘standard practice’’ by the Korean nursing community. Most nurses (77.4%) responded that patient assessment was an independent practice of nurses (Mun and Lee, 1999). Nurses can practice autonomously and not under the supervision of a doctor when they practice according to the standards of care. This suggests the need for a clear definition of the nurses’ professional role and the establishment of a standard to enhance nurses’ autonomous decision making.

The results of the present study failed to support the notion of a reciprocal relationship between legal awareness and attitude toward liability. Knowledge of law increases confidence in clinical decision making and, ideally, makes nurses less averse to legal risk (Marble et al., 1999), but the findings showed that only knowledge of law was not associated with a willingness to accept legal responsibility. Attitudes are influenced by a variety of factors, including past experience, knowledge and one’s general beliefs (Chan and Cheng, 2001). These results suggest the need for turning from knowledge-oriented education to attitude-oriented education to promote positive attitudes to liability in nursing practice. Education that influences attitude changes is the most intangible and most difficult to convey. Nevertheless, a curriculum should offer cognitive and affective experience that may effectively lead to attitude changes. Therefore, post-registration program should facilitate nurses’ understanding the concepts of accountability and autonomy and promote recognition for the nurses’ professional role. Also, these programs should offer critical insights into how nursing is perceived within the current law and how to increase nurses’ acceptance of the image of nursing as autonomous professionals. The results of this study also provide an educational insight into the role of autonomy in the development of positive attitude toward liability. One of the greatest barriers to nurses’ autonomy was thought to be the absence of regulations to endow authority for nurses. In this situations moral regulation play an important role in guiding autonomous behavior. Finally, strategies may also be more effective if they aim to enhance the moral accountability of nurses through familiarity with ethics codes and ethics training. Korean nurses may experience the intrinsic dilemma of having to accept full accountability without gaining inherent authority, legal authority. Nevertheless, greater accountability comes with greater autonomy in nursing practice even before laws are passed. Several limitations were identified in this study. First, any interpretations and generalizations of the present findings must be carefully made due to the sampling method. Second, the measures for liability used in the study may not have completely assessed the full domain of legal accountability. Relatively few items were used to assess each of the attitudes toward duty and liability. Third, the decision to scale the liability attitude has not yet been verified. Fifth, western literature was mainly used due to the lack of research on this topic in Korea. This was also a problem in under-

Perception of legal liability by registered nurses in Korea standing characteristics of Korean nursing. Finally, it was not possible to confirm the causal direction of the findings.

Conclusions In summary, the present study explored the levels of legal awareness and acceptance of liability among nurses and determined possible predictors of liability attitude. While these nurses had a high legal awareness, they also had an attitude that supported doctor’s supervision of nurses. In addition, the majority of the participants had a passive attitude toward full liability in all cases. Nurses identified themselves as independent and autonomous practitioners involved in clinical decision-making, but there was evidence of a reluctance to practice autonomously and to therefore be held fully responsible for nursing actions. It is argued that although nursing is maturing in its professional growth, legal issues such as a passive attitude toward full liability need to be addressed. The results of this study failed to show support for a reciprocal relationship between legal awareness and liability attitude, but there is an indication that nurses’ attitude toward liability are not positively enhanced by only increasing legal knowledge. Educators will need to consider and offer cognitive and affective experiences for creating positive attitudes toward liability. Despite several limitations, the results of the present study have made an important contribution to understanding the nurses’ attitude toward liability. The first was the assessment of a broad range, rather than merely a single set, of predictors. These findings can provide a foundation for the development of legal accountability in a theoretical framework. In addition, information about legal awareness and liability attitude and their correlates may be used to develop educational strategies to improve the autonomy and legal accountability of nurses.

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