{"paper_id":"32f24ab0-38ce-481b-8654-5c98ea51d573","body_text":"Implementation of Medical Ethics and Data Protection in Healthcare Practice: A Cross- Sectional Study from Georgia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation of Medical Ethics and Data Protection in Healthcare Practice: A Cross- Sectional Study from Georgia Lela Shengelia, Sulkhan Inaishvili, Nino Grdzelidze This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8925027/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 17 You are reading this latest preprint version Abstract Background The assessment of healthcare systems has increased the importance of medical ethics, particularly regarding data protection and patient autonomy. In many settings, historical developments, evolving legal frameworks, and gaps in professional training continue to shape ethical practice within healthcare delivery. However, there is limited empirical evidence on how medical ethics and data protection standards are translated into routine healthcare practice, highlighting the need for systematic assessment within transitioning health systems such as Georgia. Objectives The purpose of the study was to explore the implementation of ethical practices in the Georgian healthcare sector, with particular attention to challenges of patient confidentiality and data protection. The awareness healthcare professionals had was also assessed, including their attitudes and practices concerning medical ethics and digital privacy. Methods A cross-sectional survey was conducted among 412 physicians and nurses across 30 hospitals in Georgia between May and November, 2024. A structured questionnaire was developed specifically for this study to assess the experience of healthcare professionals with ethical dilemmas and data protection, in particular sociodemographic characteristics, ethical perspectives and data protection practices. The internal consistency of ethics-related topics was verified (Cronbach’s α = 0.82), while data was analyzed using SPSS 20.0 with Chi-square tests and Cramér’s V to determine group differences. Results While 74.3% of participants reported that their ethical decisions were made based on standard operating protocols, 18.2% were unaware of such protocols, indicating a gap in institutional communication. Only 22.8% had consulted an ethics committee, while around 70% had received recent training in data protection. Nurses were significantly less aware of data protection measures compared to physicians (p < 0.05). Key challenges identified included limited cybersecurity infrastructure, underutilization of formal ethical support mechanisms, and disparities in continuous professional development. Conclusions Despite existing ethical frameworks, their inconsistent application and a lack of standardized training compromise ethical decision-making in the Georgian healthcare system. Institutional reforms are needed to improve ethical awareness, enhance cybersecurity, ensure compliance with data protection regulations such as the General Data Protection Regulation (GDPR), and promote continuous professional education. These measures are essential for safeguarding patient rights and building trust in the healthcare sector. Medical ethics Georgia patient autonomy GDPR data protection cybersecurity health workforce bioethics digital health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Since the inception of the International Code of Medical Ethics in 1949, the healthcare industry has seen numerous improvements to patient care, in particular confidentiality, autonomy, care and dignity. Without the guarantee of such benefits, many may delay seeking medical help as healthcare could potentially be intrusive. While patients are the primary beneficiaries of fundamental ethical principles, healthcare personnel also benefit from these rules. Operating within an ethical framework allows healthcare professionals to communicate openly and honestly with patients and their families regarding end-of-life care or to promptly inform patients of their emergency care options. When dealing with ethical dilemmas involving patients, their families, caregivers or coworkers, practitioners are able to recommend actions that prioritize the needs of the patient (1-8). Medical Ethics in the Union of Soviet Socialist Republics (USSR) After the Soviet Revolution, a system rooted in Socialist humanism called the Semashko health financing model was established in the Russian Soviet Federative Socialist Republic. In 1918, the People’s Commissariat of Public Health was formed to unify the medical and sanitary services of the country (9-10). The main goals of this system included the eradication of infectious diseases and the development of curative care. The Communist Party directed the healthcare system to implement extensive sanitary measures (10), including: a) Improving health conditions in populated areas by protecting soil, water, and air from pollution; b) Organizing public catering on scientific and hygienic principles; c) Launching initiatives to prevent the outbreak and spread of infectious diseases; d) Creating a comprehensive health legislation code; e) Combating social diseases such as tuberculosis, venereal diseases, and alcoholism; f) Providing qualified medical and pharmaceutical services to all citizens free of charge. The Soviet Government issued a series of policies to further unify the administrative and operational frameworks of medical and sanitary institutions. Key policies included those on health insurance (1917), the nationalization of pharmacies and medical property (1918), maternal and childcare provisions (1918) and compulsory smallpox vaccinations (1919) (11). The Health Legislation Code served as the primary moral guideline for Soviet doctors, who were committed to enhancing the well-being of the Soviet populace. Subsequently, the Soviet Constitution enshrined the right to health protection, declaring that citizens of the USSR had the right to receive support in old age and in sickness or disability. It guaranteed every citizen access to free medical aid and reinforced the protection of public health (12). Soviet public health initiatives significantly increased labor productivity and improved hygiene in both industry and agriculture. Concurrently, extensive measures were undertaken to enhance living conditions, with Soviet health services playing a crucial role (9). The USSR allocated resources for social insurance benefits, pensions, free or subsidized accommodation in sanatoria and holiday homes, support for large families and single mothers, free medical aid, and various initiatives aimed at boosting the welfare of the working class. These efforts had a profoundly positive impact on the health of Soviet citizens (12). However, from its inception, the Soviet Health System was based on paternalism, which restricted the freedom of choice of a patientby acting irrespective of the patient’s opinion, believing it to be in their best interest (7). Thus, violations of the ethical norms of patients were frequent occurrences in the USSR. Moreover, the Soviet legacy of institutionalizing people with chronic diseases lasted long after the collapse of the Soviet Empire. In the early 50s of the last century, new mental health legislation was adopted, and those with mental health problems and learning disabilities were isolated from society and confined to psychiatric hospitals (9; 10). This approach had significant consequences for individuals with mental health issues and those with learning disabilities (11). The Russian Association of Psychiatrists espoused the belief that mental illness was a trait of capitalist societies and would eventually vanish under communism. Individuals who were unable to conform to socialist standards due to mental health issues were viewed as underdeveloped. Citizens faced arrest for distributing pamphlets or writing articles critiquing the regime (12). While the USSR no longer exists, the paternalistic traditions and established institutional norms continue to influence contemporary ethical consciousness and professional practices in Georgia (13; 14). Medical Ethics in Georgia Historically, medicine in Georgia has strongly been influenced by a blend of cultural and religious traditions that have shaped its ethical foundations. The first Georgian medical book, Karabadin , written in the 10 th century, not only consisted of the medical knowledge of that era, including aspects of Sumerian medicine, but also embedded principles of respect, beneficence, and justice, reflecting a holistic approach to patient care that honors the dignity of every individual ( 15 ). Another key source of medical knowledge is the Karabadin medical book (an updated and edited version of the 10 th century text) authored by the doctor and thinker Zaza Panaskerteli-Tsitsishvili. Considered an ancient Georgian pharmacopoeia, the book, written in the 15th century, contains a wealth of medical knowledge, including herbal remedies, surgical techniques, and ethical guidelines for medical practitioners. The book emphasizes several ethical aspects, such as prioritizing patient well-being and comfort, maintaining patient confidentiality and privacy, and upholding high standards of professional behavior and integrity (15). Another significant medical manuscript is Yadigar Daud , created by King Davit XI. This manuscript offers valuable insights into the medical practices and ethical considerations of its time. It includes guidelines on medical ethics, emphasizing the moral responsibilities of physicians towards their patients, cultural sensitivity in understanding and respecting patients' cultural and religious beliefs, and holistic care by addressing the physical, mental, and emotional well-being of patients (16). These texts and the principles they embody have played a crucial role in shaping the ethical landscape of Georgian medicine, ensuring that it upholds the highest standards of patient care and professional conduct (16). After the collapse of the Soviet Union, the country initiated a prolonged and complex process of reforms, and only by the end of the century was the country capable of implementing new regulations for professional medical activities (17, 18). On May 6, 2003 the Congress of Georgian Physicians adopted the Code of Medical Ethics of Georgia. This code sets out the fundamental ethical principles that govern a physician’s professional behavior towards patients, colleagues and society, and marked the beginning of the development of medical ethics in modern Georgia (19). At present, the professional activities of physicians are regulated by a range of declarative legal and ethical documents at both the national and international levels. These provisions serve to define the scope of medical responsibility, safeguard patient rights, and establish a foundation for ethical clinical practice (20-25). Since 2011, the country has implemented a law on personal data protection which was amended in 2013 and strengthened the safety and protection of medical information (26). The country further implemented the Universal Health Care Program in the same year, though the poor quality of healthcare services remained an issue. Consequently, the government of Georgia implemented hospital accreditation procedures to improve patient safety, care quality, and operational effectiveness. It acts as a standard for organizations aiming to fulfill global requirements, ensuring that medical facilities follow the strictest guidelines for patient care, safety and administration (27). According to Article 4, Paragraph 1 of Annex 1 of the State Program for Universal Health Care , approved by Decree No. 36 of the Government of Georgia on February 21, 2023, a medical facility is defined as an institution that has obtained international accreditation (28). A formal certification process ensures that reliable medical facilities follow internationally recognized standards. Hospitals are evaluated by independent external organizations to verify if they meet these strict requirements, which include staff qualifications, clinical procedures, infection control, and patient safety. Accreditation is a continuous commitment to maintaining and improving healthcare quality, not just a badge of honor (28). This study was thus conducted in order to measure patient safety and the implementation of ethical standards, including the current level thereof, for the further improvement of healthcare services. The General Objective of the Study The main objective of the study was to explore the implementation of ethical practices in the Georgian healthcare sector, with particular attention to challenges of patient confidentiality and data protection. Specific Objectives of the Study To assess and compare the level of knowledge, attitude and practice of medical ethics including privacy and confidentiality principals among medical staff. To explore the medical staff's experience with ethical dilemmas particularly those involving patient privacy and data protection. To explore the medical staff’s sources from which they derived their ethical understanding, including guidance related to privacy and confidentiality. Provide recommendations for policymakers to strengthen ethical standards and privacy protections in healthcare practice. Methodology A cross-sectional study was conducted involving doctors and nurses from 30 hospitals and clinics in Georgia, which employ 20% of the country's medical professionals ( 21 ). Study Population The study focused on medical doctors and nurses working in both inpatient and outpatient facilities. Doctors included in the study were those who directly consulted with patients and managed their care. Nurses were included in the study if they were involved in patient care and were under the supervision and guidance of doctors. Since both groups are central to ethical decision-making in healthcare, their perspectives offer valuable insights into the level of knowledge, attitudes, and perceptions regarding medical ethics in Georgia. Validation The participants’ knowledge of medical ethics, data protection, and ethical challenges was assessed using a self-administered questionnaire. The instrument was developed based on a literature review and subsequently adapted to reflect the Georgian healthcare context and study objectives. Ethical approval was granted by the Ethics Committee of the University of Georgia. Originally developed in English, the questionnaire was translated into Georgian and then back again to ensure accuracy. It was pre-tested in two healthcare facilities with a sample of doctors and nurses. Feedback from the pre-test was used to refine the wording and eliminate ambiguity. The questionnaire was specifically developed for the purposes of this study based on existing literature on medical ethics and data protection. An English-language version of the instrument is provided as Supplementary Material 1. Questionnaire and Variables The questionnaire was comprised of three sections: Sociodemographic Data including age, gender and profession, years of experience, and place of work; Ethical Perspectives which consisted of 12 statements related to key ethical principles such as respect for patient autonomy, confidentiality, informed consent, and professional duty. Each statement was rated on a 5-point Likert scale, followed by response analysis to assess trends in ethical attitudes among healthcare professionals: 1 – Strongly disagree 2 – Disagree 3 – Neutral 4 – Agree 5 – Strongly agree In the final section, Sources and Preferences , participants indicated their sources of ethical knowledge (GDPR training, hospital policies and personal experience) and preferences when seeking guidance on legal or ethical dilemmas. The internal consistency of the Ethical Perspectives section was evaluated using Cronbach’s alpha (α = 0.82), indicating good reliability. Bias To reduce the possibility of bias, standardized data collection instruments were introduced. A validated questionnaire was adapted to Georgia and used. To address selection bias, participants were recruited based on inclusion criteria, and medical staff from different backgrounds and facilities were included in the research. To ensure privacy, participants were informed about anonymity and the confidentiality of their responses. They were further informed that there were no right or wrong answers, and thus encouraged to respond honestly. Data was collected in a neutral and non-judgmental manner. The responses were then systematically analyzed in order to address researcher interpretation bias. Sampling and Data Collection A total of 430 doctors and nurses were randomly selected and invited to take part in the study. With a refusal rate of just 4%, the final sample comprised 412 participants (236 doctors and 176 nurses), making it a representative subset of Georgia’s healthcare workforce. Data was collected from May to November 2024 via Google Forms. The participants were recruited based on their respective health facilities on a voluntary basis and questionnaires were distributed electronically through institutional channels. Participants were required to give informed consent before proceeding. The hospitals included in the study represented a diverse range of institutional types, encompassing urban and rural settings, and included public, private, and university-affiliated hospitals from the various regions of Georgia. This diversity strengthens the generalizability of the findings within the context of the national healthcare system. As the hospitals participating in the study provide services not only for adults but also for children, these results were included. Sample Size Determination The sample size was calculated based on an assumed 50% prevalence of adequate knowledge of medical ethics and data protection - a conservative estimate used to ensure the maximum required sample size. A 95% confidence level and a ± 5% margin of error were applied. Using the standard formula for sample size calculation for proportions in a finite population (approximately 20,000 healthcare professionals in Georgia), the minimum required sample size was determined to be 377 participants. To account for potential non-response, the target sample was increased to 430. Ultimately, 412 participants completed the survey, resulting in a response rate of 96%, which exceeds the threshold for statistical reliability. As the proportion of missing data was low, analyses were conducted by using complete cases, and no data imputation was performed. Data Analysis Data was analyzed using SPSS version 20.0. Descriptive statistics were calculated using proportions and percentages. Differences in ethical attitudes between doctors and nurses were examined using Chi-Square tests, with Cramér’s V used to measure the strength of associations. Effect sizes were categorized as small (< 0.1), medium (0.1–0.5), or large (> 0.5). A p-value of < 0.05 was considered statistically significant. The internal consistency of the key attitudinal items in the Ethical Perspectives section was assessed using Cronbach’s alpha, which resulted in a value of 0.82, indicating good reliability. Test-retest reliability was also evaluated by administering the questionnaire to a subgroup of 15 participants two weeks after the initial test. The resulting correlation coefficient (r = 0.87) demonstrated strong temporal stability. Ethical Considerations The study was exempted from a full review by the Institutional Review Board of the University of Georgia. Informed consent was obtained electronically, with all participants required to acknowledge their willingness to participate before accessing the survey. Participation was entirely voluntary, and no incentives were provided. Results Sociodemographic Details Out of the 412 participants, 57% were doctors and 43% were nurses. The average age of doctors was 43 (SD = 1.57) and nurses 57 (SD = 4.77). Among doctors, 60% were female and 40% male. All participating nurses were female. Only 39.6% of participants were based in the capital, with the remaining respondents employed in the various regions of Georgia. In terms of work experience, 44% (n = 182) had over 15 years of experience, 41% (n = 170) had between 5 and 14 years, and 15% (n = 60) had less than 5 years of professional experience. Sources of Medical Ethics and Dilemmas Study results showed that 88.6% of respondents (CI: 85.0–91.5) reported taking part in CPD activities, although these training sessions only partially addressed the four core principles of medical ethics. Specifically, 75.2% (CI: 70.9–79.1) attended training workshops on medical ethics, and 68.2% (CI: 63.2–72.8) received training on personal data protection. Notably, attendance for medical ethics training over the last 24 months was split between doctors and nurses, based on the ratio of 57.3% for doctors and 42.7% for nurses. Ethical Dilemmas in Practice Most respondents reported infrequent encounters in terms of ethical challenges that related to new diagnostic or treatment methods, with 32.8% selecting “rarely” and 41.0% selecting “very rarely”. Similarly, social inequality or restrictions of patient rights were experienced “rarely” (32.8%) or “very rarely” (41.0%). Both doctors and nurses reported “rarely” or “very rarely” using new methods of treatment and diagnosis (doctors at 57.3% while nurses were 42.7%). Doctors reported slightly higher use across all categories, and very few nurses reported frequent usage of new methods. Regarding patient education, responses were more varied: 27.2% reported doing so “frequently”, while 26.5% indicated they did so “rarely”. Involuntary hospitalization was reported as occurring “very rarely” at 47.6% and “rarely” at 29.9%. The breakdown of responses on Involuntary Hospitalization by doctors compared to nurses was 31% and 69% respectively. Descriptive statistics from Likert-scale responses showed that disagreements among professionals were not prevalent, with 39.3% responding “rarely” and 34.0% “very rarely”. Regarding unfavorable working conditions, 39.6% selected “rarely” as their response. Similarly, 43.0% reported that patient refusal of treatment “rarely” created challenges. Waiting time for therapeutic treatment was described as a “rare” challenge by 41.5% of respondents. Technical issues related to the universal health insurance system were also marked “rare” at 34.2%. Finally, 43.7% reported that the discontinuation of life-sustaining treatment occurred “very rarely”. The distribution of responses regarding unfavorable working conditions in their departments was split between doctors (30%) and nurses (70%) for each response category. Ethical Decision-Making in Hospitals Descriptive statistics from Likert-scale responses were used to assess the ethical decision-making processes within hospitals. Most respondents (74.3%) confirmed the existence of a protocol for handling ethical issues. However, 18.2% were unsure of its existence, and 7.5% reported that no such protocol was in place. The ratio of doctors to nurses that believed improvements needed to be made to the aforementioned protocols was 1:2.5. When asked about encountering situations requiring ethical decisions, nearly half (45.4%) of the participants reported having experienced such cases, while 40.3% stated they had not. Doctors more frequently recalled encountering issues regarding ethical cases (112) compared to nurses (75). Nurses were far more unsure as to if they had encountered ethical issues (43 compared to 16 for doctors), with a notable portion of nurses responding “no” (100) - far higher than doctors (66). Despite the frequency of ethical challenges, only 22.8% of respondents reported consulting an ethics committee, while a significant 72.1% had not. A significantly larger proportion of both doctors and nurses have not approached an ethics committee, with only a minority having done so and very few being unsure. Data Protection in the Healthcare Sector Most participants (79.6%) were aware of data protection regulations applicable to their workplace. However, 10.9% were uncertain, and 9.5% reported not being aware. A significant majority (84.7%) stated that patient data protection measures were in place, although 14.1% were unsure and 1.2% indicated that such measures were not implemented. With regard to data protection protocols during surgical procedures, 65.5% confirmed their existence, 26% were unsure, and 8.5% stated that no such protocols were in place. Most doctors and nurses responded “yes” regarding the implementation of necessary data protection measures for patient information. However, a significantly higher proportion of nurses (44) than doctors ( 14 ) responded that they were unsure of protection measures. Data Protection Measures Data protection was a key focus of the study. A large majority of doctors (159) and nurses (190) answered “yes”, indicating high confidence in data protection implementation. More nurses (44) than doctors ( 14 ) were again unsure, with very few respondents (2 doctors, 3 nurses) answering “no”. Approximately 70% of doctors and 63% of nurses mentioned that they have specific protocols for data protection in surgical procedures. However, 30% doctors and 37% nurses indicated that they were uncertain of these protocols. Regarding consent for blood transfusions, most participants (81.6%) indicated that written consent was obtained. A smaller proportion reported the use of verbal (2.4%) or electronic consent (3.4%), while 8% were unsure. In terms of how patient consent was generally obtained by doctors compared to nurses, 85% of doctors and 78% of nurses reported written consent as the primary method. For pediatric hospitalizations, restricted access (28.2%) and encrypted records (15.5%) were the most mentioned protective measures, though a notable portion (33.7%) were uncertain about the specific practices used. Regarding the handling of sensitive information in pediatric care, parental consent procedures (34.7%) and secure databases (23.3%) were most frequently cited, with 23.8% of respondents unsure of the protective protocols in place. Only half of the participants reported the existence of a formal system for reporting data breaches. In contrast, 17.7% stated there was no such system, and 32.3% were uncertain. While strong data protection measures, including encryption, restricted access, and regular security audits are vital for preventing unauthorized access to personal data, 43.4% of respondents were uncertain about how often data audits occur. Quarterly (19.4%) and monthly (17.5%) audits were the most frequently reported frequencies, while 6.8% indicated they were unaware if audits were being carried out. In the event of a data breach, the most common response protocol reported was immediate notification (43%), followed by notification within 24 hours (21.4%). However, 26.5% of participants were unsure about the procedures in place. Cybersecurity Cybersecurity in Georgia’s healthcare sector concentrates on safeguarding electronic health records and digital infrastructure from unauthorized access, misuse, and disclosure. The findings indicate that 55.8% of respondents confirmed their hospital had a cybersecurity system, while 38.6% were unsure, and 5.6% stated that no system was in place. General Data Protection Regulation (GDPR) Regarding GDPR compliance, 51.5% of participants believed that their hospital’s data processing systems comply with the GDPR. Meanwhile, 37.9% were unsure, and 9% indicated only partial compliance. About 53.4% of respondents confirmed undergoing regular GDPR training, while 30.8% were unsure, and 15.8% reported no training. Only 59.2% of respondents mentioned that they followed standard procedures when handling patient data requests under the GDPR, while 21.8% handled it case by case, and 18.9% reported no structured approach. Around 65% of healthcare providers reported having a system in place for collecting patient feedback on data protection. About 38.3% of respondents reported reviewing their data protection policies “as needed”, while 26.7% were unsure, and only 13.6% reviewed their policies monthly. The attitudes of doctors differed from those of nurses in several areas. In some cases, the differences were supported by both statistical significance and a strong effect size (Cramér’s V > 0.25). Notably, doctors and nurses showed significant differences in their knowledge of medical ethics (p = 0.003), awareness of cybersecurity (p = 0.001), understanding of the General Data Protection Regulation (GDPR) (p = 0.004), and data protection measures (p = 0.004). Although differences in attitudes toward confidentiality (p = 0.341) and paternalism (p = 0.341) were not statistically significant, the effect size (Cramér’s V > 0.25) suggests a meaningful practical difference between the two groups in these areas. A detailed comparison of these findings is presented in Table 1 . [Insert Table 1 here] Table 1 Comparison of Data Protection and Medical Ethics Awareness Between Doctors and Nurses Variable Doctors (%) Nurses (%) p-value Cramér’s V (approx.) Strength of Association Aware of data protection law 85 75 0.004 0.17 Weak-to-moderate GDPR compliance awareness 84 73 0.004 0.18 Weak-to-moderate Knowledge of medical ethics 89 73 0.003 0.22 Moderate Doctors demonstrated consistently higher awareness than nurses across all assessed domains. The differences were statistically significant (p < 0.01) but of modest magnitude. Cramér’s V values (0.17–0.22) indicate weak-to-moderate associations between professional groups and knowledge levels, suggesting that while doctors generally exhibited greater awareness, the overall effect size was moderate rather than strong. Data Protection: A Critical Weakness The study identified two interrelated gaps that expose patient data to significant risk, namely inadequate cybersecurity infrastructure and infrequent audits, along with poorly defined incident response protocols. Inadequate cybersecurity infrastructure is a challenge for the Georgian healthcare sector since many institutions lack basic safeguards such as encryption, firewalls, and intrusion detection systems, compounded by infrequent audits and poorly defined incident response protocols. Discussion and conclusion Georgia’s healthcare sector underwent numerous stages of healthcare reform that also led to various changes in ethical standards. However, the four pillars of medical ethics - respect for autonomy, beneficence, non-maleficence and justice - were far more protected during the early developmental stages of Georgian society than later under the Semashko healthcare system. Even though the International Code of Medical Ethics was developed in 1949 and ratified by numerous United Nations countries, many, including the USSR, did not adhere to it ( 29 , 30 ). While data protection is an integral part of ethical practice that reflects the principles of autonomy and justice, significant challenges were present during the Soviet and Post-Soviet period. Since then, Post-Soviet Georgia has made several efforts to promote fairness and trust in the healthcare sector, to improve confidentiality and responsible data handling processes and to protect individuals’ rights to control their personal information. However, the cross-sectional study highlighted that complex ethical issues were often overlooked, resolved informally, or defaulted to hierarchical decision-making, potentially undermining patient-centered care. Medical ethics need to be strengthened not only in the Georgian healthcare sector but also other post-soviet countries. Armenia and Azerbaijan, Georgia’s neighbors, also brought their national legislation, guidelines and standards in line with international human rights standards, also undergoing significant challenges during the implementation process ( 31 , 32 ). Additionally, the finding that doctors demonstrated higher levels of awareness compared to nurses across all the research domains may be due to several contextual factors, namely that doctors in Georgia generally have more frequent exposure to policy updates, training opportunities, and continuing professional education programs related to ethical and legal standards. Moreover, their clinical decision-making responsibilities often require a more detailed understanding of data protection, GDPR compliance, and medical ethics principles. In contrast, nurses, despite their central role in patient care, may have fewer structured opportunities for ethics-related professional development. These results highlight the need to strengthen ethics and legal training components in nursing education and to ensure that both professional groups receive regular, institutionally supported updates on evolving ethical and regulatory frameworks ( 33 , 34 ). Moreover, ethical dilemmas related to autonomy appear to be underreported or go unrecognized. The findings further reveal a healthcare environment in which formal mechanisms to protect patient autonomy are present in theory yet inconsistently recognized and applied in practice. Although autonomy-protecting procedures may be technically in place, they are not fully embedded in routine clinical practice. Despite recent regulations being implemented regarding accreditation and approaches to staff training, disparities and inconsistent access to continuous professional development (CPD) still present a challenge. Ethical training of medical professionals is included in the medical curricula in the European Union and focuses on clinical ethics, human rights and bioethics, with emphasis on patient information confidentiality, informed consent, equity and solidarity in healthcare ( 35 , 36 ). Although Georgia also integrated medical ethics into its medical curricula and protocols and Continues Professional Development training exist, limited familiarity with real-world ethical dilemmas and underutilization of support structures (such as ethics committees) reduce the system’s ability to uphold patient autonomy consistently. For meaningful change, it is essential to institutionalize ethics training, ensure regular engagement with ethics support structures, and integrate case-based learning into everyday clinical settings. The limited use of ethics committees may be due to a low awareness of their function, limited institutional visibility, and uncertainty among healthcare workers about when and how to seek ethical consultation. In some hospitals, such committees exist only formally or are viewed as administrative rather than supportive structures. Hierarchical work environments may also discourage open discussion of ethical dilemmas, particularly among nurses. To address these gaps, institutions should increase awareness of the committees’ purpose through regular training, integrate ethics consultation into routine clinical decision-making, and ensure that committees are interdisciplinary, active, and easily accessible. Strengthening institutional support and including ethics oversight in accreditation and professional development frameworks could further promote their effective use and enhance ethical practice across healthcare settings. This study has several limitations that should be acknowledged. First, the use of a convenience sampling approach limits the generalizability of the findings, as participants may not be fully representative of all healthcare professionals in Georgia. Second, data were obtained through self-reported questionnaires, which may be subject to reporting bias or social desirability effects, potentially influencing participants’ responses regarding ethical knowledge and practices. Third, although hospitals from different regions were included, regional representation may still be uneven, with some areas underrepresented due to variations in institutional accessibility and participant availability. Despite these limitations, the study provides valuable empirical insights into healthcare professionals’ ethical awareness and practices in Georgia and establishes a foundation for future, larger-scale comparative research. Overall, greater institutional commitment to ethics infrastructure is essential to foster a culture of ethical reflection and accountability within the healthcare system. Recognizing that even highly committed clinicians may fall short without systemic support highlights the need for strong institutional mechanisms to ensure up-to-date, high-quality care. By addressing both technological and regulatory shortcomings, Georgia’s hospitals can significantly strengthen data protection, reduce institutional risk, and build a more trustworthy digital health environment. Abbreviations GDPR General Data Protection Regulation USSR the Union of Soviet Socialist Republics Declarations Human Ethics and Consent to Participate: This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the University of Georgia (Approval No: 11-32284). Participation in the survey was entirely voluntary, with informed consent obtained from all respondents prior to data collection. No personally identifiable information was collected, ensuring anonymity and confidentiality throughout the study. Consent for Publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to ethical and data protection restrictions related to participant confidentiality but are available from the corresponding author on reasonable request, subject to institutional approval. Competing Interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions L.S. and S.I. conceived of the study and developed research design and methodology. L.S. provided oversight of data collection processes and supervised the ethical approval procedures. S.I. conducted the statistical analyses and interpretation of the findings. N.G. facilitated institutional engagement by coordinating communication with hospitals and clinical staff, contributed substantially to the administration of the survey, and participated in both data collection and preliminary data analysis. All authors contributed to the literature review and contextual framing of the study. S.I. drafted the initial manuscript, while L.S. undertook critical revisions for important intellectual content. All authors read and approved the final version of the manuscript and accept responsibility for the integrity and accuracy of the work. Acknowledgements: Not applicable. References Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract [Internet]. 2021;30(1):17–28. Available from: http://dx.doi.org/10.1159/000509119 Grisso T, Appelbaum PS. 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Schizophr Bull [Internet]. 2010;36(1):33–5. Available from: http://dx.doi.org/10.1093/schbul/sbp119 Pelto-Piri V, Engström K, Engström I. Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care. BMC Med Ethics [Internet]. 2013;14(1):49. Available from: http://dx.doi.org/10.1186/1472-6939-14-49 Panaskerteli-Tsitsishvili Z. Karabadine : The Ancient Georgian Pharmacopeia 15th-century. Tbilisi: Georgian National Academy of Sciences, 1976. Lortkipanidze D, Kiknadze Z, Baramidze G. Historical Georgian Medical Manuscripts . 1998.Tbilisi: Georgian National Museum. Gamkrelidze A, Atun R, Gotsadze G, MacLehose L. Healthcare Systems in Transition Georgia. World Health Organization. 2002. Volume 4.2nd edition Chanturidze T, Ugulava T, Durán A, Ensor T, Richardson E. Health Systems in Transition Georgia. World Health Organization . 2009. Volume 11. 8th edition საქართველოს ექიმის ეთიკის კოდექსი[cited 2025 Jul 28]. Available from: http://chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.afdg.ge/PDFs/AFDG-kodeksi.pdf ექიმის პროფესიული საქმიანობის წესები[cited 2025 Jul 28]. Available from: http://chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.afdg.ge/PDFs/AFDG-tsesebi.pdf NCDC.Ge [Internet]. Ncdc.ge. [cited 2025 Jul 28]. Available from: https://test.ncdc.ge/Pages/User/Documents.aspx?ID=18524102-82a2-4be6-9e81-9a84e10c283a Convention for the protection of Human Rights and dignity of the human being with regard to the application of biology and medicine: Convention on Human Rights and Biomedicine - Explanatory Report - [1997] COETSER 1 (4 April 1997) [Internet]. Worldlii.org. [cited 2025 Jul 28]. Available from: http://www.worldlii.org/int/other/COETSER/1997/1.html WHO. Patients' rights [cited 2025 Jul 28]. Available from: http://chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://iris.who.int/bitstream/handle/10665/330516/WH-1996-Sep-Oct-p4-5-eng.pdf Universal declaration on bioethics and human rights [Internet]. Unesco.org. 2023 [cited 2025 Jul 28]. Available from: https://www.unesco.org/en/ethics-science-technology/bioethics-and-human-rights Policy [Internet]. Wma.net. [cited 2025 Jul 28]. Available from: https://www.wma.net/policy/ Richardson E, Berdzuli N. Health Systems in Transition . Georgia. World Health Organization. 2017; Volume10. პერსონალურ მონაცემთა დაცვის შესახებ [cited 2025 Jul 27]. Available from: http://file:///C:/Users/shengelia_unfpa/Downloads/პერსონალურ%20მონაცემთა%230დაცვის%20შესახებ%20მოქმედი%20კანონი_1711019935.pdf Gov.ge. სამართლებრივი აქტები [cited 2025 Jul 28]. Available from: https://www.moh.gov.ge/general-info.php?id1=6&lang=1 Ethics . (n.d.). The British Medical Association Is the Trade Union and Professional Body for Doctors in the UK. https://www.bma.org.uk/advice-and-support/ethics Devaney, S. (2016). Ethics for Healthcare Regulators: Annex to ’Striking the Balance: Upholding the 7 Principles in Regulation. The University of Manchester . https://www.research.manchester.ac.uk/portal/en/publications/ethics-for-healthcare-regulators(b984401a-486d-4517-80da-e32dc0bc3595).html Human Rights and Biomedicine. 2025. The Government of the Republic of Armenia has approved the rules of professional ethics of the healthcare professionals. https://www.coe.int/en/web/human-rights-and-biomedicine/-/the-government-of-the-republic-of-armenia-has-approved-the-rules-of-professional-ethics-of-the-healthcare-professionals#:~:text=Newsroom&text=During%20the%20regular%20sitting%20of,Rights%20in%20Biomedicine%22%20in%20Armenia. Namazova, A. a. G., & Taghi-Zada, T. Q. G. (2015). Bioethics in Azerbaijan: History and development of bioethics in Azerbaijan. Asian Bioethics Review , 7 (5), 433–439. https://doi.org/10.1353/asb.2015.0044 Vlahou A, Hallinan D, Apweiler R, Argiles A, Beige J, Benigni A, Bischoff R, Black PC, Boehm F, Céraline J, Chrousos GP, Delles C, Evenepoel P, Fridolin I, Glorieux G, van Gool AJ, Heidegger I, Ioannidis JPA, Jankowski J, Jankowski V, Jeronimo C, Kamat AM, Masereeuw R, Mayer G, Mischak H, Ortiz A, Remuzzi G, Rossing P, Schanstra JP, Schmitz-Dräger BJ, Spasovski G, Staessen JA, Stamatialis D, Stenvinkel P, Wanner C, Williams SB, Zannad F, Zoccali C, Vanholder R. Data Sharing Under the General Data Protection Regulation: Time to Harmonize Law and Research Ethics? Hypertension. 2021 Apr;77(4):1029-1035. doi: 10.1161/HYPERTENSIONAHA.120.16340. Epub 2021 Feb 15. PMID: 33583200; PMCID: PMC7968961. Bakier, M. C. (2025, October 14). The European Health Data Space and the GDPR: striking the balance between innovation and rights. Taylor Wessing . https://www.taylorwessing.com/de/global-data-hub/2025/eu-digital-laws-and-gdpr/gdh---european-health-data-space-and-the-gdpr Kirkov V, Vodenicharova A, Markova K, Borisova L, Popova K (2024) Bioethics in the education of the future healthcare professionals. Pharmacia 71: 1-5. https://doi.org/10.3897/pharmacia.71.e121139 Claudot F, Alla F, Ducrocq X, Coudane H. Teaching ethics in Europe. J Med Ethics. 2007 Aug;33(8):491-5. doi: 10.1136/jme.2006.017921. PMID: 17664312; PMCID: PMC2598173. Additional Declarations No competing interests reported. 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Without the guarantee of such benefits, many may delay seeking medical help as healthcare could potentially be intrusive. While patients are the primary beneficiaries of fundamental ethical principles, healthcare personnel also benefit from these rules. Operating within an ethical framework allows healthcare professionals to communicate openly and honestly with patients and their families regarding end-of-life care or to promptly inform patients of their emergency care options. When dealing with ethical dilemmas involving patients, their families, caregivers or coworkers, practitioners are able to recommend actions that prioritize the needs of the patient (1-8).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMedical Ethics in the\\u003c/strong\\u003e\\u003cstrong\\u003e\\u0026nbsp;Union of Soviet Socialist Republics (USSR)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAfter the Soviet Revolution, a system rooted in Socialist humanism called the Semashko health financing model was established in the Russian Soviet Federative Socialist Republic. In 1918, the People\\u0026rsquo;s Commissariat of Public Health was formed to unify the medical and sanitary services of the country (9-10). The main goals of this system included the eradication of infectious diseases and the development of curative care. The Communist Party directed the healthcare system to implement extensive sanitary measures (10), including:\\u003c/p\\u003e\\n\\u003cp\\u003ea) Improving health conditions in populated areas by protecting soil, water, and air from pollution;\\u003c/p\\u003e\\n\\u003cp\\u003eb) Organizing public catering on scientific and hygienic principles;\\u003c/p\\u003e\\n\\u003cp\\u003ec) Launching initiatives to prevent the outbreak and spread of infectious diseases;\\u003c/p\\u003e\\n\\u003cp\\u003ed) Creating a comprehensive health legislation code;\\u003c/p\\u003e\\n\\u003cp\\u003ee) Combating social diseases such as tuberculosis, venereal diseases, and alcoholism;\\u003c/p\\u003e\\n\\u003cp\\u003ef) Providing qualified medical and pharmaceutical services to all citizens free of charge.\\u003c/p\\u003e\\n\\u003cp\\u003eThe Soviet Government issued a series of policies to further unify the administrative and operational frameworks of medical and sanitary institutions. Key policies included those on health insurance (1917), the nationalization of pharmacies and medical property (1918), maternal and childcare provisions (1918) and compulsory smallpox vaccinations (1919) (11).\\u003c/p\\u003e\\n\\u003cp\\u003eThe Health Legislation Code served as the primary moral guideline for Soviet doctors, who were committed to enhancing the well-being of the Soviet populace. Subsequently, the Soviet Constitution enshrined the right to health protection, declaring that citizens of the USSR had the right to receive support in old age and in sickness or disability. It guaranteed every citizen access to free medical aid and reinforced the protection of public health (12).\\u003c/p\\u003e\\n\\u003cp\\u003eSoviet public health initiatives significantly increased labor productivity and improved hygiene in both industry and agriculture. Concurrently, extensive measures were undertaken to enhance living conditions, with Soviet health services playing a crucial role (9). The USSR allocated resources for social insurance benefits, pensions, free or subsidized accommodation in sanatoria and holiday homes, support for large families and single mothers, free medical aid, and various initiatives aimed at boosting the welfare of the working class. These efforts had a profoundly positive impact on the health of Soviet citizens (12).\\u003c/p\\u003e\\n\\u003cp\\u003eHowever, from its inception, the Soviet Health System was based on paternalism, which restricted the freedom of choice of a patientby acting irrespective of the patient\\u0026rsquo;s opinion, believing it to be in their best interest (7). Thus, violations of the ethical norms of patients were frequent occurrences in the USSR. Moreover, the Soviet legacy of institutionalizing people with chronic diseases lasted long after the collapse of the Soviet Empire. In the early 50s of the last century, new mental health legislation was adopted, and those with mental health problems and learning disabilities were isolated from society and confined to psychiatric hospitals (9; 10). This approach had significant consequences for individuals with mental health issues and those with learning disabilities (11).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe Russian Association of Psychiatrists espoused the belief that mental illness was a trait of capitalist societies and would eventually vanish under communism. Individuals who were unable to conform to socialist standards due to mental health issues were viewed as underdeveloped. Citizens faced arrest for distributing pamphlets or writing articles critiquing the regime (12). \\u0026nbsp;While the USSR no longer exists, the paternalistic traditions and established institutional norms continue to influence contemporary ethical consciousness and professional practices in Georgia (13; 14).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMedical Ethics in Georgia\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eHistorically, medicine in Georgia has strongly been influenced by a blend of cultural and religious traditions that have shaped its ethical foundations. The first Georgian medical book, \\u003cem\\u003eKarabadin\\u003c/em\\u003e, written in the 10\\u003csup\\u003eth\\u003c/sup\\u003e century, not only consisted of the medical knowledge of that era, including aspects of Sumerian medicine, but also embedded principles of respect, beneficence, and justice, reflecting a holistic approach to patient care that honors the dignity of every individual (\\u003cstrong\\u003e15\\u003c/strong\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eAnother key source of medical knowledge is the\\u003cem\\u003e\\u0026nbsp;Karabadin\\u0026nbsp;\\u003c/em\\u003emedical book (an updated and edited version of the 10\\u003csup\\u003eth\\u003c/sup\\u003e century text) authored by the doctor and thinker Zaza Panaskerteli-Tsitsishvili. Considered an ancient Georgian pharmacopoeia, the book, written in the 15th century, contains a wealth of medical knowledge, including herbal remedies, surgical techniques, and ethical guidelines for medical practitioners. The book emphasizes several ethical aspects, such as prioritizing patient well-being and comfort, maintaining patient confidentiality and privacy, and upholding high standards of professional behavior and integrity (15).\\u003c/p\\u003e\\n\\u003cp\\u003eAnother significant medical manuscript is \\u003cem\\u003eYadigar Daud\\u003c/em\\u003e, created by King Davit XI. This manuscript offers valuable insights into the medical practices and ethical considerations of its time. It includes guidelines on medical ethics, emphasizing the moral responsibilities of physicians towards their patients, cultural sensitivity in understanding and respecting patients\\u0026apos; cultural and religious beliefs, and holistic care by addressing the physical, mental, and emotional well-being of patients (16). These texts and the principles they embody have played a crucial role in shaping the ethical landscape of Georgian medicine, ensuring that it upholds the highest standards of patient care and professional conduct (16).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAfter the collapse of the Soviet Union, the country initiated a prolonged and complex process of reforms, and only by the end of the century was the country capable of implementing new regulations for professional medical activities (17, 18). On May 6, 2003 the Congress of Georgian Physicians adopted the Code of Medical Ethics of Georgia. This code sets out the fundamental ethical principles that govern a physician\\u0026rsquo;s professional behavior towards patients, colleagues and society, and marked the beginning of the development of medical ethics in modern Georgia (19).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAt present, the professional activities of physicians are regulated by a range of declarative legal and ethical documents at both the national and international levels. These provisions serve to define the scope of medical responsibility, safeguard patient rights, and establish a foundation for ethical clinical practice (20-25). Since 2011, the country has implemented a law on personal data protection which was amended in 2013 and strengthened the safety and protection of medical information (26). The country further implemented the Universal Health Care Program in the same year, though the poor quality of healthcare services remained an issue. Consequently, the government of Georgia implemented hospital accreditation procedures to improve patient safety, care quality, and operational effectiveness. It acts as a standard for organizations aiming to fulfill global requirements, ensuring that medical facilities follow the strictest guidelines for patient care, safety and administration (27).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAccording to Article 4, Paragraph 1 of Annex 1 of the \\u003cem\\u003eState Program for Universal Health Care\\u003c/em\\u003e, approved by Decree No. 36 of the Government of Georgia on February 21, 2023, a medical facility is defined as an institution that has obtained international accreditation (28). A formal certification process ensures that reliable medical facilities follow internationally recognized standards. Hospitals are evaluated by independent external organizations to verify if they meet these strict requirements, which include staff qualifications, clinical procedures, infection control, and patient safety. Accreditation is a continuous commitment to maintaining and improving healthcare quality, not just a badge of honor (28).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was thus conducted in order to measure patient safety and the implementation of ethical standards, including the current level thereof, for the further improvement of healthcare services.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eThe General Objective of the Study\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe main objective of the study was to explore the implementation of ethical practices in the Georgian healthcare sector, with particular attention to challenges of patient confidentiality and data protection.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSpecific Objectives of the Study\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cul\\u003e\\n \\u003cli\\u003eTo assess and compare the level of knowledge, attitude and practice of medical ethics including privacy and confidentiality principals among medical staff.\\u003c/li\\u003e\\n \\u003cli\\u003eTo explore the medical staff\\u0026apos;s experience with ethical dilemmas particularly those involving patient privacy and data protection.\\u003c/li\\u003e\\n \\u003cli\\u003eTo explore the medical staff\\u0026rsquo;s sources from which they derived their ethical understanding, including guidance related to privacy and confidentiality.\\u003c/li\\u003e\\n \\u003cli\\u003eProvide recommendations for policymakers to strengthen ethical standards and privacy protections in healthcare practice.\\u003c/li\\u003e\\n\\u003c/ul\\u003e\"},{\"header\":\"Methodology\",\"content\":\"\\u003cp\\u003eA cross-sectional study was conducted involving doctors and nurses from 30 hospitals and clinics in Georgia, which employ 20% of the country's medical professionals (\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003ch3\\u003eStudy Population\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study focused on medical doctors and nurses working in both inpatient and outpatient facilities. Doctors included in the study were those who directly consulted with patients and managed their care. Nurses were included in the study if they were involved in patient care and were under the supervision and guidance of doctors. Since both groups are central to ethical decision-making in healthcare, their perspectives offer valuable insights into the level of knowledge, attitudes, and perceptions regarding medical ethics in Georgia.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eValidation\\u003c/h2\\u003e \\u003cp\\u003eThe participants\\u0026rsquo; knowledge of medical ethics, data protection, and ethical challenges was assessed using a self-administered questionnaire. The instrument was developed based on a literature review and subsequently adapted to reflect the Georgian healthcare context and study objectives. Ethical approval was granted by the Ethics Committee of the University of Georgia. Originally developed in English, the questionnaire was translated into Georgian and then back again to ensure accuracy. It was pre-tested in two healthcare facilities with a sample of doctors and nurses. Feedback from the pre-test was used to refine the wording and eliminate ambiguity.\\u003c/p\\u003e \\u003cp\\u003eThe questionnaire was specifically developed for the purposes of this study based on existing literature on medical ethics and data protection. An English-language version of the instrument is provided as Supplementary Material 1.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eQuestionnaire and Variables\\u003c/h3\\u003e\\n\\u003cp\\u003eThe questionnaire was comprised of three sections: \\u003cem\\u003eSociodemographic Data\\u003c/em\\u003e including age, gender and profession, years of experience, and place of work; \\u003cem\\u003eEthical Perspectives\\u003c/em\\u003e which consisted of 12 statements related to key ethical principles such as respect for patient autonomy, confidentiality, informed consent, and professional duty. Each statement was rated on a 5-point Likert scale, followed by response analysis to assess trends in ethical attitudes among healthcare professionals:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003e1 \\u0026ndash; Strongly disagree\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e2 \\u0026ndash; Disagree\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e3 \\u0026ndash; Neutral\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e4 \\u0026ndash; Agree\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003e5 \\u0026ndash; Strongly agree\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eIn the final section, \\u003cem\\u003eSources and Preferences\\u003c/em\\u003e, participants indicated their sources of ethical knowledge (GDPR training, hospital policies and personal experience) and preferences when seeking guidance on legal or ethical dilemmas.\\u003c/p\\u003e \\u003cp\\u003eThe internal consistency of the \\u003cem\\u003eEthical Perspectives\\u003c/em\\u003e section was evaluated using Cronbach\\u0026rsquo;s alpha (α\\u0026thinsp;=\\u0026thinsp;0.82), indicating good reliability.\\u003c/p\\u003e\\n\\u003ch3\\u003eBias\\u003c/h3\\u003e\\n\\u003cp\\u003eTo reduce the possibility of bias, standardized data collection instruments were introduced. A validated questionnaire was adapted to Georgia and used. To address selection bias, participants were recruited based on inclusion criteria, and medical staff from different backgrounds and facilities were included in the research.\\u003c/p\\u003e \\u003cp\\u003eTo ensure privacy, participants were informed about anonymity and the confidentiality of their responses. They were further informed that there were no right or wrong answers, and thus encouraged to respond honestly. Data was collected in a neutral and non-judgmental manner. The responses were then systematically analyzed in order to address researcher interpretation bias.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSampling and Data Collection\\u003c/h2\\u003e \\u003cp\\u003eA total of 430 doctors and nurses were randomly selected and invited to take part in the study. With a refusal rate of just 4%, the final sample comprised 412 participants (236 doctors and 176 nurses), making it a representative subset of Georgia\\u0026rsquo;s healthcare workforce. Data was collected from May to November 2024 via Google Forms. The participants were recruited based on their respective health facilities on a voluntary basis and questionnaires were distributed electronically through institutional channels. Participants were required to give informed consent before proceeding.\\u003c/p\\u003e \\u003cp\\u003eThe hospitals included in the study represented a diverse range of institutional types, encompassing urban and rural settings, and included public, private, and university-affiliated hospitals from the various regions of Georgia. This diversity strengthens the generalizability of the findings within the context of the national healthcare system. As the hospitals participating in the study provide services not only for adults but also for children, these results were included.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSample Size Determination\\u003c/h2\\u003e \\u003cp\\u003eThe sample size was calculated based on an assumed 50% prevalence of adequate knowledge of medical ethics and data protection - a conservative estimate used to ensure the maximum required sample size. A 95% confidence level and a\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5% margin of error were applied. Using the standard formula for sample size calculation for proportions in a finite population (approximately 20,000 healthcare professionals in Georgia), the minimum required sample size was determined to be 377 participants. To account for potential non-response, the target sample was increased to 430. Ultimately, 412 participants completed the survey, resulting in a response rate of 96%, which exceeds the threshold for statistical reliability. As the proportion of missing data was low, analyses were conducted by using complete cases, and no data imputation was performed.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData Analysis\\u003c/h2\\u003e \\u003cp\\u003eData was analyzed using SPSS version 20.0. Descriptive statistics were calculated using proportions and percentages. Differences in ethical attitudes between doctors and nurses were examined using Chi-Square tests, with Cram\\u0026eacute;r\\u0026rsquo;s V used to measure the strength of associations. Effect sizes were categorized as small (\\u0026lt;\\u0026thinsp;0.1), medium (0.1\\u0026ndash;0.5), or large (\\u0026gt;\\u0026thinsp;0.5). A p-value of \\u0026lt;\\u0026thinsp;0.05 was considered statistically significant.\\u003c/p\\u003e \\u003cp\\u003eThe internal consistency of the key attitudinal items in the \\u003cem\\u003eEthical Perspectives\\u003c/em\\u003e section was assessed using Cronbach\\u0026rsquo;s alpha, which resulted in a value of 0.82, indicating good reliability. Test-retest reliability was also evaluated by administering the questionnaire to a subgroup of 15 participants two weeks after the initial test. The resulting correlation coefficient (r\\u0026thinsp;=\\u0026thinsp;0.87) demonstrated strong temporal stability.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eEthical Considerations\\u003c/h2\\u003e \\u003cp\\u003eThe study was exempted from a full review by the Institutional Review Board of the University of Georgia. Informed consent was obtained electronically, with all participants required to acknowledge their willingness to participate before accessing the survey. Participation was entirely voluntary, and no incentives were provided.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec16\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eSociodemographic Details\\u003c/h2\\u003e\\n \\u003cp\\u003eOut of the 412 participants, 57% were doctors and 43% were nurses. The average age of doctors was 43 (SD\\u0026thinsp;=\\u0026thinsp;1.57) and nurses 57 (SD\\u0026thinsp;=\\u0026thinsp;4.77). Among doctors, 60% were female and 40% male. All participating nurses were female. Only 39.6% of participants were based in the capital, with the remaining respondents employed in the various regions of Georgia. In terms of work experience, 44% (n\\u0026thinsp;=\\u0026thinsp;182) had over 15 years of experience, 41% (n\\u0026thinsp;=\\u0026thinsp;170) had between 5 and 14 years, and 15% (n\\u0026thinsp;=\\u0026thinsp;60) had less than 5 years of professional experience.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eSources of Medical Ethics and Dilemmas\\u003c/h2\\u003e\\n \\u003cp\\u003eStudy results showed that 88.6% of respondents (CI: 85.0\\u0026ndash;91.5) reported taking part in CPD activities, although these training sessions only partially addressed the four core principles of medical ethics. Specifically, 75.2% (CI: 70.9\\u0026ndash;79.1) attended training workshops on medical ethics, and 68.2% (CI: 63.2\\u0026ndash;72.8) received training on personal data protection. Notably, attendance for medical ethics training over the last 24 months was split between doctors and nurses, based on the ratio of 57.3% for doctors and 42.7% for nurses.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec18\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eEthical Dilemmas in Practice\\u003c/h2\\u003e\\n \\u003cp\\u003eMost respondents reported infrequent encounters in terms of ethical challenges that related to new diagnostic or treatment methods, with 32.8% selecting \\u0026ldquo;rarely\\u0026rdquo; and 41.0% selecting \\u0026ldquo;very rarely\\u0026rdquo;. Similarly, social inequality or restrictions of patient rights were experienced \\u0026ldquo;rarely\\u0026rdquo; (32.8%) or \\u0026ldquo;very rarely\\u0026rdquo; (41.0%). Both doctors and nurses reported \\u0026ldquo;rarely\\u0026rdquo; or \\u0026ldquo;very rarely\\u0026rdquo; using new methods of treatment and diagnosis (doctors at 57.3% while nurses were 42.7%). Doctors reported slightly higher use across all categories, and very few nurses reported frequent usage of new methods.\\u003c/p\\u003e\\n \\u003cp\\u003eRegarding patient education, responses were more varied: 27.2% reported doing so \\u0026ldquo;frequently\\u0026rdquo;, while 26.5% indicated they did so \\u0026ldquo;rarely\\u0026rdquo;. Involuntary hospitalization was reported as occurring \\u0026ldquo;very rarely\\u0026rdquo; at 47.6% and \\u0026ldquo;rarely\\u0026rdquo; at 29.9%. The breakdown of responses on Involuntary Hospitalization by doctors compared to nurses was 31% and 69% respectively.\\u003c/p\\u003e\\n \\u003cp\\u003eDescriptive statistics from Likert-scale responses showed that disagreements among professionals were not prevalent, with 39.3% responding \\u0026ldquo;rarely\\u0026rdquo; and 34.0% \\u0026ldquo;very rarely\\u0026rdquo;. Regarding unfavorable working conditions, 39.6% selected \\u0026ldquo;rarely\\u0026rdquo; as their response. Similarly, 43.0% reported that patient refusal of treatment \\u0026ldquo;rarely\\u0026rdquo; created challenges.\\u003c/p\\u003e\\n \\u003cp\\u003eWaiting time for therapeutic treatment was described as a \\u0026ldquo;rare\\u0026rdquo; challenge by 41.5% of respondents. Technical issues related to the universal health insurance system were also marked \\u0026ldquo;rare\\u0026rdquo; at 34.2%. Finally, 43.7% reported that the discontinuation of life-sustaining treatment occurred \\u0026ldquo;very rarely\\u0026rdquo;. The distribution of responses regarding unfavorable working conditions in their departments was split between doctors (30%) and nurses (70%) for each response category.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eEthical Decision-Making in Hospitals\\u003c/h2\\u003e\\n \\u003cp\\u003eDescriptive statistics from Likert-scale responses were used to assess the ethical decision-making processes within hospitals. Most respondents (74.3%) confirmed the existence of a protocol for handling ethical issues. However, 18.2% were unsure of its existence, and 7.5% reported that no such protocol was in place. The ratio of doctors to nurses that believed improvements needed to be made to the aforementioned protocols was 1:2.5.\\u003c/p\\u003e\\n \\u003cp\\u003eWhen asked about encountering situations requiring ethical decisions, nearly half (45.4%) of the participants reported having experienced such cases, while 40.3% stated they had not. Doctors more frequently recalled encountering issues regarding ethical cases (112) compared to nurses (75). Nurses were far more unsure as to if they had encountered ethical issues (43 compared to 16 for doctors), with a notable portion of nurses responding \\u0026ldquo;no\\u0026rdquo; (100) - far higher than doctors (66). Despite the frequency of ethical challenges, only 22.8% of respondents reported consulting an ethics committee, while a significant 72.1% had not.\\u003c/p\\u003e\\n \\u003cp\\u003eA significantly larger proportion of both doctors and nurses have not approached an ethics committee, with only a minority having done so and very few being unsure.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec20\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eData Protection in the Healthcare Sector\\u003c/h2\\u003e\\n \\u003cp\\u003eMost participants (79.6%) were aware of data protection regulations applicable to their workplace. However, 10.9% were uncertain, and 9.5% reported not being aware. A significant majority (84.7%) stated that patient data protection measures were in place, although 14.1% were unsure and 1.2% indicated that such measures were not implemented. With regard to data protection protocols during surgical procedures, 65.5% confirmed their existence, 26% were unsure, and 8.5% stated that no such protocols were in place.\\u003c/p\\u003e\\n \\u003cp\\u003eMost doctors and nurses responded \\u0026ldquo;yes\\u0026rdquo; regarding the implementation of necessary data protection measures for patient information. However, a significantly higher proportion of nurses (44) than doctors (\\u003cspan class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e) responded that they were unsure of protection measures.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec21\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eData Protection Measures\\u003c/h2\\u003e\\n \\u003cp\\u003eData protection was a key focus of the study. \\u003cstrong\\u003eA\\u003c/strong\\u003e large majority of doctors (159) and nurses (190) answered \\u0026ldquo;yes\\u0026rdquo;, indicating high confidence in data protection implementation. More nurses (44) than doctors (\\u003cspan class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e) were again unsure, with very few respondents (2 doctors, 3 nurses) answering \\u0026ldquo;no\\u0026rdquo;.\\u003c/p\\u003e\\n \\u003cp\\u003eApproximately 70% of doctors and 63% of nurses mentioned that they have specific protocols for data protection in surgical procedures. However, 30% doctors and 37% nurses indicated that they were uncertain of these protocols.\\u003c/p\\u003e\\n \\u003cp\\u003eRegarding consent for blood transfusions, most participants (81.6%) indicated that written consent was obtained. A smaller proportion reported the use of verbal (2.4%) or electronic consent (3.4%), while 8% were unsure. In terms of how patient consent was generally obtained by doctors compared to nurses, 85% of doctors and 78% of nurses reported written consent as the primary method.\\u003c/p\\u003e\\n \\u003cp\\u003eFor pediatric hospitalizations, restricted access (28.2%) and encrypted records (15.5%) were the most mentioned protective measures, though a notable portion (33.7%) were uncertain about the specific practices used. Regarding the handling of sensitive information in pediatric care, parental consent procedures (34.7%) and secure databases (23.3%) were most frequently cited, with 23.8% of respondents unsure of the protective protocols in place. Only half of the participants reported the existence of a formal system for reporting data breaches. In contrast, 17.7% stated there was no such system, and 32.3% were uncertain.\\u003c/p\\u003e\\n \\u003cp\\u003eWhile strong data protection measures, including encryption, restricted access, and regular security audits are vital for preventing unauthorized access to personal data, 43.4% of respondents were uncertain about how often data audits occur. Quarterly (19.4%) and monthly (17.5%) audits were the most frequently reported frequencies, while 6.8% indicated they were unaware if audits were being carried out.\\u003c/p\\u003e\\n \\u003cp\\u003eIn the event of a data breach, the most common response protocol reported was immediate notification (43%), followed by notification within 24 hours (21.4%). However, 26.5% of participants were unsure about the procedures in place.\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec22\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eCybersecurity\\u003c/h2\\u003e\\n \\u003cp\\u003eCybersecurity in Georgia\\u0026rsquo;s healthcare sector concentrates on safeguarding electronic health records and digital infrastructure from unauthorized access, misuse, and disclosure. The findings indicate that 55.8% of respondents confirmed their hospital had a cybersecurity system, while 38.6% were unsure, and 5.6% stated that no system was in place.\\u003c/p\\u003e\\n \\u003cdiv id=\\\"Sec23\\\" class=\\\"Section3\\\"\\u003e\\n \\u003ch2\\u003eGeneral Data Protection Regulation (GDPR)\\u003c/h2\\u003e\\n \\u003cp\\u003eRegarding GDPR compliance, 51.5% of participants believed that their hospital\\u0026rsquo;s data processing systems comply with the GDPR. Meanwhile, 37.9% were unsure, and 9% indicated only partial compliance. About 53.4% of respondents confirmed undergoing regular GDPR training, while 30.8% were unsure, and 15.8% reported no training. Only 59.2% of respondents mentioned that they followed standard procedures when handling patient data requests under the GDPR, while 21.8% handled it case by case, and 18.9% reported no structured approach. Around 65% of healthcare providers reported having a system in place for collecting patient feedback on data protection. About 38.3% of respondents reported reviewing their data protection policies \\u0026ldquo;as needed\\u0026rdquo;, while 26.7% were unsure, and only 13.6% reviewed their policies monthly.\\u003c/p\\u003e\\n \\u003cp\\u003eThe attitudes of doctors differed from those of nurses in several areas. In some cases, the differences were supported by both statistical significance and a strong effect size (Cram\\u0026eacute;r\\u0026rsquo;s V\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.25). Notably, doctors and nurses showed significant differences in their knowledge of medical ethics (p\\u0026thinsp;=\\u0026thinsp;0.003), awareness of cybersecurity (p\\u0026thinsp;=\\u0026thinsp;0.001), understanding of the General Data Protection Regulation (GDPR) (p\\u0026thinsp;=\\u0026thinsp;0.004), and data protection measures (p\\u0026thinsp;=\\u0026thinsp;0.004). Although differences in attitudes toward confidentiality (p\\u0026thinsp;=\\u0026thinsp;0.341) and paternalism (p\\u0026thinsp;=\\u0026thinsp;0.341) were not statistically significant, the effect size (Cram\\u0026eacute;r\\u0026rsquo;s V\\u0026thinsp;\\u0026gt;\\u0026thinsp;0.25) suggests a meaningful practical difference between the two groups in these areas. A detailed comparison of these findings is presented in Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e[Insert\\u003c/strong\\u003e Table \\u003cspan class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e \\u003cstrong\\u003ehere]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u0026nbsp;\\u003ctable id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eComparison of Data Protection and Medical Ethics Awareness Between Doctors and Nurses\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003ccolgroup cols=\\\"6\\\"\\u003e\\u003c/colgroup\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eVariable\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eDoctors (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eNurses (%)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003ep-value\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eCram\\u0026eacute;r\\u0026rsquo;s V (approx.)\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eStrength of Association\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eAware of data protection law\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e85\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e75\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.004\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.17\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eWeak-to-moderate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eGDPR compliance awareness\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e84\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e73\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.004\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.18\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eWeak-to-moderate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eKnowledge of medical ethics\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e89\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e73\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e0.003\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e0.22\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\"\\u003e\\n \\u003cp\\u003eModerate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n \\u003c/table\\u003e\\n \\u003c/div\\u003e\\n \\u003cp\\u003eDoctors demonstrated consistently higher awareness than nurses across all assessed domains. The differences were statistically significant (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01) but of modest magnitude. Cram\\u0026eacute;r\\u0026rsquo;s V values (0.17\\u0026ndash;0.22) indicate weak-to-moderate associations between professional groups and knowledge levels, suggesting that while doctors generally exhibited greater awareness, the overall effect size was moderate rather than strong.\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n\\u003c/div\\u003e\\n\\u003cdiv id=\\\"Sec24\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003eData Protection: A Critical Weakness\\u003c/h2\\u003e\\n \\u003cp\\u003eThe study identified two interrelated gaps that expose patient data to significant risk, namely inadequate cybersecurity infrastructure and infrequent audits, along with poorly defined incident response protocols. Inadequate cybersecurity infrastructure is a challenge for the Georgian healthcare sector since many institutions lack basic safeguards such as encryption, firewalls, and intrusion detection systems, compounded by infrequent audits and poorly defined incident response protocols.\\u003c/p\\u003e\\n \\u003cdiv id=\\\"Sec25\\\" class=\\\"Section3\\\"\\u003e\\u003cbr\\u003e\\u003c/div\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Discussion and conclusion\",\"content\":\"\\u003cp\\u003e Georgia’s healthcare sector underwent numerous stages of healthcare reform that also led to various changes in ethical standards. However, the four pillars of medical ethics - respect for autonomy, beneficence, non-maleficence and justice - were far more protected during the early developmental stages of Georgian society than later under the Semashko healthcare system. Even though the International Code of Medical Ethics was developed in 1949 and ratified by numerous United Nations countries, many, including the USSR, did not adhere to it (\\u003cspan class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e While data protection is an integral part of ethical practice that reflects the principles of autonomy and justice, significant challenges were present during the Soviet and Post-Soviet period. Since then, Post-Soviet Georgia has made several efforts to promote fairness and trust in the healthcare sector, to improve confidentiality and responsible data handling processes and to protect individuals’ rights to control their personal information. However, the cross-sectional study highlighted that complex ethical issues were often overlooked, resolved informally, or defaulted to hierarchical decision-making, potentially undermining patient-centered care. Medical ethics need to be strengthened not only in the Georgian healthcare sector but also other post-soviet countries. Armenia and Azerbaijan, Georgia’s neighbors, also brought their national legislation, guidelines and standards in line with international human rights standards, also undergoing significant challenges during the implementation process (\\u003cspan class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eAdditionally, the finding that doctors demonstrated higher levels of awareness compared to nurses across all the research domains may be due to several contextual factors, namely that doctors in Georgia generally have more frequent exposure to policy updates, training opportunities, and continuing professional education programs related to ethical and legal standards. Moreover, their clinical decision-making responsibilities often require a more detailed understanding of data protection, GDPR compliance, and medical ethics principles. In contrast, nurses, despite their central role in patient care, may have fewer structured opportunities for ethics-related professional development. These results highlight the need to strengthen ethics and legal training components in nursing education and to ensure that both professional groups receive regular, institutionally supported updates on evolving ethical and regulatory frameworks (\\u003cspan class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eMoreover, ethical dilemmas related to autonomy appear to be underreported or go unrecognized. The findings further reveal a healthcare environment in which formal mechanisms to protect patient autonomy are present in theory yet inconsistently recognized and applied in practice. Although autonomy-protecting procedures may be technically in place, they are not fully embedded in routine clinical practice. Despite recent regulations being implemented regarding accreditation and approaches to staff training, disparities and inconsistent access to continuous professional development (CPD) still present a challenge. Ethical training of medical professionals is included in the medical curricula in the European Union and focuses on clinical ethics, human rights and bioethics, with emphasis on patient information confidentiality, informed consent, equity and solidarity in healthcare (\\u003cspan class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e). Although Georgia also integrated medical ethics into its medical curricula and protocols and Continues Professional Development training exist, limited familiarity with real-world ethical dilemmas and underutilization of support structures (such as ethics committees) reduce the system’s ability to uphold patient autonomy consistently. For meaningful change, it is essential to institutionalize ethics training, ensure regular engagement with ethics support structures, and integrate case-based learning into everyday clinical settings.\\u003c/p\\u003e\\u003cp\\u003eThe limited use of ethics committees may be due to a low awareness of their function, limited institutional visibility, and uncertainty among healthcare workers about when and how to seek ethical consultation. In some hospitals, such committees exist only formally or are viewed as administrative rather than supportive structures. Hierarchical work environments may also discourage open discussion of ethical dilemmas, particularly among nurses. To address these gaps, institutions should increase awareness of the committees’ purpose through regular training, integrate ethics consultation into routine clinical decision-making, and ensure that committees are interdisciplinary, active, and easily accessible. Strengthening institutional support and including ethics oversight in accreditation and professional development frameworks could further promote their effective use and enhance ethical practice across healthcare settings.\\u003c/p\\u003e\\u003cp\\u003eThis study has several limitations that should be acknowledged. First, the use of a convenience sampling approach limits the generalizability of the findings, as participants may not be fully representative of all healthcare professionals in Georgia. Second, data were obtained through self-reported questionnaires, which may be subject to reporting bias or social desirability effects, potentially influencing participants’ responses regarding ethical knowledge and practices. Third, although hospitals from different regions were included, regional representation may still be uneven, with some areas underrepresented due to variations in institutional accessibility and participant availability.\\u003c/p\\u003e\\u003cp\\u003e Despite these limitations, the study provides valuable empirical insights into healthcare professionals’ ethical awareness and practices in Georgia and establishes a foundation for future, larger-scale comparative research. Overall, greater institutional commitment to ethics infrastructure is essential to foster a culture of ethical reflection and accountability within the healthcare system.\\u003c/p\\u003e\\u003cp\\u003eRecognizing that even highly committed clinicians may fall short without systemic support highlights the need for strong institutional mechanisms to ensure up-to-date, high-quality care. By addressing both technological and regulatory shortcomings, Georgia’s hospitals can significantly strengthen data protection, reduce institutional risk, and build a more trustworthy digital health environment.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cp\\u003eGDPR \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;General Data Protection Regulation\\u003c/p\\u003e\\n\\u003cp\\u003eUSSR \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; the Union of Soviet Socialist Republics\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eHuman Ethics and Consent to Participate:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the University of Georgia (Approval No: 11-32284). Participation in the survey was entirely voluntary, with informed consent obtained from all respondents prior to data collection. No personally identifiable information was collected, ensuring anonymity and confidentiality throughout the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for Publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and/or analysed during the current study are not publicly available due to ethical and data protection restrictions related to participant confidentiality but are available from the corresponding author on reasonable request, subject to institutional approval.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026rsquo; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eL.S. and S.I. conceived of the study and developed research design and methodology. L.S. provided oversight of data collection processes and supervised the ethical approval procedures. S.I. conducted the statistical analyses and interpretation of the findings. N.G. facilitated institutional engagement by coordinating communication with hospitals and clinical staff, contributed substantially to the administration of the survey, and participated in both data collection and preliminary data analysis. All authors contributed to the literature review and contextual framing of the study. S.I. drafted the initial manuscript, while L.S. undertook critical revisions for important intellectual content. All authors read and approved the final version of the manuscript and accept responsibility for the integrity and accuracy of the work.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements:\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003cstrong\\u003e\\u003cbr clear=\\\"all\\\"\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eVarkey B. Principles of clinical ethics and their application to practice. Med Princ Pract [Internet]. 2021;30(1):17\\u0026ndash;28. Available from: http://dx.doi.org/10.1159/000509119\\u003c/li\\u003e\\n \\u003cli\\u003eGrisso T, Appelbaum PS. Assessing competence to consent to treatment: A guide for physicians and other health professionals. vii [Internet]. 1998;211. Available from: https://psycnet.apa.org/fulltext/1998-07232-000.pdf\\u003c/li\\u003e\\n \\u003cli\\u003eBeauchamp T. 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Available from: http://chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.afdg.ge/PDFs/AFDG-tsesebi.pdf\\u003c/li\\u003e\\n \\u003cli\\u003eNCDC.Ge [Internet]. Ncdc.ge. [cited 2025 Jul 28]. Available from: https://test.ncdc.ge/Pages/User/Documents.aspx?ID=18524102-82a2-4be6-9e81-9a84e10c283a\\u003c/li\\u003e\\n \\u003cli\\u003eConvention for the protection of Human Rights and dignity of the human being with regard to the application of biology and medicine: Convention on Human Rights and Biomedicine - Explanatory Report - [1997] COETSER 1 (4 April 1997) [Internet]. Worldlii.org. [cited 2025 Jul 28]. Available from: http://www.worldlii.org/int/other/COETSER/1997/1.html\\u003c/li\\u003e\\n \\u003cli\\u003eWHO. Patients\\u0026apos; rights [cited 2025 Jul 28]. 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Available from: http://file:///C:/Users/shengelia_unfpa/Downloads/პერსონალურ%20მონაცემთა%230დაცვის%20შესახებ%20მოქმედი%20კანონი_1711019935.pdf\\u003c/li\\u003e\\n \\u003cli\\u003eGov.ge. სამართლებრივი აქტები [cited 2025 Jul 28]. Available from: https://www.moh.gov.ge/general-info.php?id1=6\\u0026amp;lang=1\\u003c/li\\u003e\\n \\u003cli\\u003e\\u003cem\\u003eEthics\\u003c/em\\u003e. (n.d.). The British Medical Association Is the Trade Union and Professional Body for Doctors in the UK. https://www.bma.org.uk/advice-and-support/ethics\\u003c/li\\u003e\\n \\u003cli\\u003eDevaney, S. (2016). Ethics for Healthcare Regulators: Annex to \\u0026rsquo;Striking the Balance: Upholding the 7 Principles in Regulation. \\u003cem\\u003eThe University of Manchester\\u003c/em\\u003e. https://www.research.manchester.ac.uk/portal/en/publications/ethics-for-healthcare-regulators(b984401a-486d-4517-80da-e32dc0bc3595).html\\u003c/li\\u003e\\n \\u003cli\\u003eHuman Rights and Biomedicine. 2025. The Government of the Republic of Armenia has approved the rules of professional ethics of the healthcare professionals. https://www.coe.int/en/web/human-rights-and-biomedicine/-/the-government-of-the-republic-of-armenia-has-approved-the-rules-of-professional-ethics-of-the-healthcare-professionals#:~:text=Newsroom\\u0026amp;text=During%20the%20regular%20sitting%20of,Rights%20in%20Biomedicine%22%20in%20Armenia.\\u003c/li\\u003e\\n \\u003cli\\u003eNamazova, A. a. G., \\u0026amp; Taghi-Zada, T. Q. G. (2015). Bioethics in Azerbaijan: History and development of bioethics in Azerbaijan. \\u003cem\\u003eAsian Bioethics Review\\u003c/em\\u003e, \\u003cem\\u003e7\\u003c/em\\u003e(5), 433\\u0026ndash;439. https://doi.org/10.1353/asb.2015.0044\\u003c/li\\u003e\\n \\u003cli\\u003eVlahou A, Hallinan D, Apweiler R, Argiles A, Beige J, Benigni A, Bischoff R, Black PC, Boehm F, C\\u0026eacute;raline J, Chrousos GP, Delles C, Evenepoel P, Fridolin I, Glorieux G, van Gool AJ, Heidegger I, Ioannidis JPA, Jankowski J, Jankowski V, Jeronimo C, Kamat AM, Masereeuw R, Mayer G, Mischak H, Ortiz A, Remuzzi G, Rossing P, Schanstra JP, Schmitz-Dr\\u0026auml;ger BJ, Spasovski G, Staessen JA, Stamatialis D, Stenvinkel P, Wanner C, Williams SB, Zannad F, Zoccali C, Vanholder R. Data Sharing Under the General Data Protection Regulation: Time to Harmonize Law and Research Ethics? Hypertension. 2021 Apr;77(4):1029-1035. doi: 10.1161/HYPERTENSIONAHA.120.16340. Epub 2021 Feb 15. PMID: 33583200; PMCID: PMC7968961.\\u003c/li\\u003e\\n \\u003cli\\u003eBakier, M. C. (2025, October 14). The European Health Data Space and the GDPR: striking the balance between innovation and rights. \\u003cem\\u003eTaylor Wessing\\u003c/em\\u003e. https://www.taylorwessing.com/de/global-data-hub/2025/eu-digital-laws-and-gdpr/gdh---european-health-data-space-and-the-gdpr\\u003c/li\\u003e\\n \\u003cli\\u003eKirkov V, Vodenicharova A, Markova K, Borisova L, Popova K (2024) Bioethics in the education of the future healthcare professionals. Pharmacia 71: 1-5. https://doi.org/10.3897/pharmacia.71.e121139\\u003c/li\\u003e\\n \\u003cli\\u003eClaudot F, Alla F, Ducrocq X, Coudane H. Teaching ethics in Europe. J Med Ethics. 2007 Aug;33(8):491-5. doi: 10.1136/jme.2006.017921. PMID: 17664312; PMCID: PMC2598173.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Medical ethics, Georgia, patient autonomy, GDPR, data protection, cybersecurity, health workforce, bioethics, digital health\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8925027/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8925027/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe assessment of healthcare systems has increased the importance of medical ethics, particularly regarding data protection and patient autonomy. In many settings, historical developments, evolving legal frameworks, and gaps in professional training continue to shape ethical practice within healthcare delivery. However, there is limited empirical evidence on how medical ethics and data protection standards are translated into routine healthcare practice, highlighting the need for systematic assessment within transitioning health systems such as Georgia.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eObjectives\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe purpose of the study was to explore the implementation of ethical practices in the Georgian healthcare sector, with particular attention to challenges of patient confidentiality and data protection. The awareness healthcare professionals had was also assessed, including their attitudes and practices concerning medical ethics and digital privacy.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eA cross-sectional survey was conducted among 412 physicians and nurses across 30 hospitals in Georgia between May and November, 2024. A structured questionnaire was developed specifically for this study to assess the experience of healthcare professionals with ethical dilemmas and data protection, in particular sociodemographic characteristics, ethical perspectives and data protection practices. The internal consistency of ethics-related topics was verified (Cronbach’s α = 0.82), while data was analyzed using SPSS 20.0 with Chi-square tests and Cramér’s V to determine group differences.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWhile 74.3% of participants reported that their ethical decisions were made based on standard operating protocols, 18.2% were unaware of such protocols, indicating a gap in institutional communication. Only 22.8% had consulted an ethics committee, while around 70% had received recent training in data protection. Nurses were significantly less aware of data protection measures compared to physicians (p \\u0026lt; 0.05). Key challenges identified included limited cybersecurity infrastructure, underutilization of formal ethical support mechanisms, and disparities in continuous professional development.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eDespite existing ethical frameworks, their inconsistent application and a lack of standardized training compromise ethical decision-making in the Georgian healthcare system. Institutional reforms are needed to improve ethical awareness, enhance cybersecurity, ensure compliance with data protection regulations such as the General Data Protection Regulation (GDPR), and promote continuous professional education. These measures are essential for safeguarding patient rights and building trust in the healthcare sector.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Implementation of Medical Ethics and Data Protection in Healthcare Practice: A Cross- Sectional Study from Georgia\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-14 10:25:05\",\"doi\":\"10.21203/rs.3.rs-8925027/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-27T06:27:45+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-18T07:47:53+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"192352143450181154536111577806507027203\",\"date\":\"2026-04-18T05:08:58+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-16T09:26:51+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-16T01:44:11+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"275188464276529585896695908680910611086\",\"date\":\"2026-04-15T07:39:40+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"313781674234162857363992663969869545085\",\"date\":\"2026-04-15T04:59:30+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"208217107018466423667723396424724775626\",\"date\":\"2026-04-09T16:27:35+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"242488129203430028446855403368916264282\",\"date\":\"2026-04-09T15:55:26+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-04-09T01:59:03+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"193407275652240165096900946780318220037\",\"date\":\"2026-04-07T17:32:44+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"64773550009356906791012949328655874371\",\"date\":\"2026-04-07T16:58:08+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-04-07T15:18:38+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-03-13T04:33:57+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-03-05T06:50:41+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-03-04T12:54:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Health Services Research\",\"date\":\"2026-03-02T15:23:56+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-health-services-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bhsr\",\"sideBox\":\"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/BHSR/default.aspx\",\"title\":\"BMC Health Services Research\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"2d5c7f1d-f9b9-4b30-b571-e07f6cc5412c\",\"owner\":[],\"postedDate\":\"April 14th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-14T10:25:06+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-04-14 10:25:05\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8925027\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8925027\",\"identity\":\"rs-8925027\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}