1. Introduction

The training of good professionals, with the necessary technical knowledge, does not always lead to the training of «good» professionals ⁽¹⁾, since distortions related to the processes of care are found, despite the codes of each professional ⁽², ³⁾. In order to comply with current legislation and fight corruption, an instrument that can benefit organizations is the code of conduct ⁽⁴⁾.

A code of conduct is a compendium of norms or rules developed within a referential framework for the correct development of the people who are part of an organization ⁽⁵⁾, which serves as an instrument to apply ethical and moral rules in daily actions ⁽⁶⁾. It seeks to guide the managerial and operational functions in an environment in which values are practiced ⁽⁷, ⁸⁾, or qualities discovered or built in people, after the succession of events, situations or things that deserve esteem, being the ideals from which conduct is regulated ⁽⁹, ¹⁰⁾.

Normative statements may relate to employment, working conditions, respect for the environment, data protection, and may contain commitments by the organization and its employees to third parties regarding the quality of services and corporate image ⁽¹¹-¹³⁾. Thus, a code of conduct is of a normative and binding nature for the members of an organization, and covers obligations within the sphere of duty and governance ⁽¹⁴⁾.

For some authors, codes of conduct are an instrument of strategic management, supporting the decision making of organizations and influencing the behavior of management personnel, impacting on the productivity of companies. For others, they are instruments that make the company’s capabilities known, improving its image; however, they should be understood as a complement to the institution’s legislation ⁽¹⁵, ¹⁶⁾.

The implementation of a comprehensive code of conduct marks the behavior expected from health professionals, avoiding acts that may harm the behavior of the health team and poor patient care ⁽¹⁷⁾, being fundamental for maintaining a safe professional practice or exercise ⁽¹⁸⁾, favoring communication and teamwork ⁽¹⁹⁾, establishing the limits within which the profession must operate ⁽²⁰, ²¹⁾, identifying the consequences of acting in a contrary manner, preventing internal and external conflicts and ⁽²²⁾ celebrating the performance of their duties ⁽²³⁾ with more organizations opting for this tool ⁽²⁴⁾.

The Mexican Institute of Social Security (IMSS) has its Code of Conduct for public servants ⁽²⁵⁾ which is disseminated to all personnel, both managerial and operational, expecting its application; therefore, the purpose of this study is to determine the degree of knowledge and application of the code of conduct by IMSS public servants in Tlaxcala.

2. Material and methods

An observational, retrospective, retrolective, unicentric and homodemic study with descriptive cross-sectional design was carried out in the Operative Body of Decentralized Administration of the Social Security in Tlaxcala, including the secondary results of the self-evaluation of the knowledge and application of the Code of Conduct made to the Public Servants assigned to the Chief of Medical Benefits Services and their Medical Units, as part of the verification of their compliance, secondary to the dissemination of the current institutional legislation, taking for the sample size a reliability of 99% and a margin of error of 10%.

The variables to be studied correspond to the position or category, institutional seniority and seniority in the current position, degree of knowledge, result or level obtained from the application of the self-evaluation instrument and the application or compliance in the performance of functions of the eleven principles of the Code of Conduct of Public Servants of the Mexican Social Security Institute: service, use of the position, use and allocation of resources, responsibility, honesty, honesty, solidarity, professional development, management of information, equity and impartiality and health, safety and conservation of the environment.

For data collection, an electronic form was used, consisting of 86 items: the first 5 collected labor and training data of the participants, the following 4 addressed the definitions contained for the approach of the principles, two with multiple choice and two dichotomous answers, with true and false answers; the following 77 items, corresponding to the actions that should and should not be performed in compliance with the 11 principles, with dichotomous answers (should, should not), which was previously reviewed by a team of experts and piloted in a group of Internal Medicine Doctors.

To determine the level of the degree of knowledge and application, the following scores and grades or levels were established based on the semantic differential and the evaluation dimension: outstanding = 76 - 81 points, outstanding = 70 - 75 points, good = 64 - 69 points, sufficient = 58 - 63 points and deficient = 57 points or less.

The analysis of the variables was carried out using the SPSS statistical package for Windows, with which, for nominal and ordinal variables, frequencies and percentages were applied; for quantitative variables, the mean and standard deviation were applied.

In accordance with article 17 of the Regulations of the General Health Law on Health Research, this is considered risk-free research, and the use of the results of the surveys was authorized by the Chief of Medical Services. The protocol was submitted to the Local Health Research Committee 2902 of the Mexican Social Security Institute, and was approved with registration number R-20202902-003.

3. Results

A total of 217 public servants participated (Figure 1), with a seniority of 12.7 ± 7.8 years and 6.2 ± 6.6 years in their current position. The largest number of participants corresponded to non-family physicians (14.7%), followed by family physicians (12.4%), general nurse assistants (11.5%), medical unit directors (7.8%), hospital clinical coordinators, as well as regional coordinators (5.1%); the rest corresponded to the other clinical and non-clinical categories. The staff with more than 20 years of seniority, by age group, are the technical personnel for patient care and orientation, the auxiliary warehouse personnel and the head nurse on the floor. On the other hand, the conservation technical personnel, cleaning and hygiene auxiliary personnel, ambulance operators and office auxiliary personnel are the youngest with less than 5 years of seniority (Figure 2).

Source: Planning Coordination and Institutional Liaison Forms, IMSS Tlaxcala, 2019.

Figure 1 Unit of assignment of public servants 

Source: Planning Coordination and Institutional Liaison Forms, IMSS Tlaxcala, 2019.

Figure 2 Civil servants by category and seniority. 

Regarding the operational definitions for the application of the Code of Conduct, 50.9% are aware of what the Code of Conduct is, 22.9% are aware of what a public servant is, 100% are aware of what a beneficiary is and 92.1% are aware of what a user is.

In relation to values, for «willingness to serve» the level of knowledge and application was outstanding, for «use of public office» it was outstanding, for «use and allocation of resources» it was outstanding, as well as for «responsibility»; The level of knowledge and application of the Code was outstanding for «honesty», outstanding for «honesty», outstanding for «solidarity», «professional development», «information management» and «equity and impartiality», and outstanding for «health, safety and environmental conservation», as can be seen in Figure 3.

Source: Planning Coordination and Institutional Liaison Forms, IMSS Tlaxcala, 2019.

Figure 3 Level of knowledge and application of the Code’s values. 

The knowledge and degree of application of the Code of Conduct are presented in Figure 4, and by category can be seen in Figure 5.

Source: Planning Coordination and Institutional Liaison Forms, IMSS Tlaxcala, 2019.

Figure 4 Degree of knowledge and application of the Code of Conduct. 

Source: Planning Coordination and Institutional Liaison Forms, IMSS Tlaxcala, 2019.

Figure 5 Level of knowledge and application of the Code of Conduct by category. 

By seniority groups, the group of less than 5 years had an outstanding knowledge and application in 25%, remarkable in 65.9% and good in 9.1%; the group of 6 to 10 years, outstanding in 58.1% and remarkable in 41.9%; the group of 11 to 15 years, outstanding in 60.6%, remarkable in 36.4% and good in 36.4%. 6%, outstanding in 36.4% and good in 3%; the 16 to 20 years group, outstanding in 56.8%, outstanding in 35.1%, good in 5.4% and sufficient in 2.7%; and the 21 years and older group, outstanding in 48.8%, outstanding in 43.9%, good in 4.9% and sufficient in 2.4%.

4. Discussion

According to Vargas (2015) ⁽²⁶⁾, a public administration oriented to serve the public or the collective as the origin of its performance, forces it to rethink and redesign its functions and processes under new forms of organization that favor transparency and accountability and take into consideration the opinions of service users, involving them, in addition, in decision-making and processes for their attention. This requires the implementation of codes directed to public servants with the establishment of values that favor efficient performance in a harmonious environment.

In order to guarantee compliance with the principles of legality, honesty, loyalty, impartiality and efficiency that govern public service, as set forth in the «Code of Ethics of Public Servants of the Federal Public Administration» published in the official gazette DOF on July 31, 2002, the Code of Conduct was established with the purpose of delimiting the actions that public servants of the Mexican Institute of Social Security (IMSS) must observe in the performance of their duties.25 Such documents are regularly disseminated to workers or officials without evaluating their application or knowledge of how to act during their performance, that is, their organizational conduct, as defined by ^{Pérez Zepeda (2016) (5)}.

Now, as ^{Gómez and Delgado (2018)} comment ⁽⁶⁾, the Code of Conduct is not only focused on clinical staff, but is also aimed at regulating the way non-clinical staff act during their performance. However, studies in this regard are scarce. ^{Authement (2017) (17)}, following the implementation of a Code of Conduct in a nursing school, observes a 25% decrease in acts of uncivil behavior, but does not assess the degree of awareness of the Code by students.

In another study conducted by Parra et al. (2017) ⁽²⁰⁾ in Nursing personnel, the application of their Code of Ethics was evaluated, reporting that 8 out of 10 staff members apply its principles. In the case of this work and with respect to nursing staff 9 out of 10 have an acceptable knowledge and application of the values of the Code of Conduct. For specialist nurses 10 out of 10 and for general and auxiliary nurses 10 out of 9.

For the medical area, there are no evaluations of the application of organizational values, only reviews of their deontological principles, the adoption of a North American model out of sync with Latin American needs whose theoretical assumptions are the plurality of moral subjects and multi-, inter- and transdisciplinary practices oriented to public and collective health, and the defense of the most vulnerable ⁽²⁾, finding in the medical specialist a knowledge and application of the Code of Conduct of 9 out of 10, against 100% of general practitioners.

In the case of stomatology, the studies found address the application of deontological values and/or principles in students, where their application was observed in 6 out of 10 students ⁽⁹⁾. Based on the results of this study, 100% of stomatologists had a good application and knowledge of the Code of Conduct; i.e., they were in the average.

For the rest of the auxiliary and support services, in the case of paraclinical professionals, knowledge and application is notable to outstanding, while among technicians there are 1 to 3 out of 10, where it is only good.

By age group, the intermediate groups of 6 to 10 years and 11 to 15 years show a better knowledge and application of the Code of Conduct than the extreme groups. However, the intermediate group of 11 to 15 years old is the most outstanding.

According to ^{Arroyo Chacón (2018) (22)}, in the Codes of Conduct, four types of observance behaviors are presented: mandatory, optimal, desirable and prohibited behaviors, in the case of the IMSS Code of Conduct, the first three are addressed as «the must» and the last one, as the «must not». In this regard, despite the fact that knowledge and application in general is remarkable to outstanding, we found areas of opportunity, both in the behaviors that should be undertaken, as well as in those that should not be performed in the exercise of the functions.

Regarding those values with lower results, we have some activities of honesty, use of the position, service, use and allocation of resources, honesty, information management, health, safety and environmental conservation, but, the strengths are outstanding in the values of responsibility, honesty, solidarity, information management and health, safety and environmental conservation.

As weaknesses of the study we can comment on the search for the schooling of the participants, however, in some cases, according to the category, it can be determined; on the other hand, the sex was not identified, this in order not to incur in situations that may mark discrimination according to NOM-R-025-SCFI-2015 in labor equality and non-discrimination. However, this study can be a starting point for other related research on deontological application and its impact on the performance of the functions of health personnel.

Finally, among the comments made by the participants to the evaluation exercise, is the recognition of having a Code of Conduct, the fact of performing this type of self-evaluations, suggesting that they be performed frequently and even that videos be edited and applications be made for their constant review.

5. Conclusions

The application and knowledge of the Code of Conduct in 5 out of 10 workers is outstanding and in 4 out of 10 it is remarkable. Responsibility and professional development are the most outstanding values, while honesty, use of public office and health, safety and environmental conservation are the weakest. The Coordinators of the Chief of Medical Services, the Deputy Chiefs of Nursing and the Nutrition staff show an outstanding knowledge and application of the Code, with 6 out of 10 staff members in the 6 to 10 year seniority group standing out. This situation has an impact on the quality of care provided in both clinical and non-clinical areas.