Abstract
Patients’ rights observance is one of the effective measures of patients’ satisfaction of health care services. We performed this study at the aim of evaluation of nurses’ awareness of patients’ rights in a teaching hospital in Tehran.
This cross-sectional study was conducted in 2010. In this study 156 nurses were randomly selected. Two-part questionnaire was used for data collection. The validity and reliability of questionnaire was determined and then it was distributed between subjects. The data were analyzed by SPSS version 15 using descriptive and inferential statistics. Our results showed that %58.33, %39.10 and % 2.56 of nurses have good, medium, and poor levels of awareness respectively. We observed a significant relationship between nurses awareness and work experience (P=0.008) and concurrent work in public and private hospitals (P=0.01). The most of the nurses (%95.51) were aware of “right to privacy protection and ensure confidentiality of information” and the least of them (%33.97) were aware of “right to receiving necessary information about the health care providers, the rate of tariff and insurance coverage”.
According to our survey it is concluded that implementation of Patients’ Right Charter in this hospital is accompanied by some limitations which necessitates promotion of the nurses’ awareness about patients’ rights. Taken together in order to enhance nurses’ awareness special measures and strategies should be considered.
Keywords: Nurses, Patients rights, Teaching hospital
Introduction
Despite of presentation of medical ethics as a new science in academic teaching, the ethical concepts have been alongside the medicine, and its antiquity back to the medicine history. For instance, literatures such as Hippocratic Oath letter, liturgy of Ibn Maymun, and Shirazi ethics ordinance are the old literatures in which the principles such as the necessity of patient preference defender on the physician and observing the principle of confidentiality have been emphasized. However, in the past literature using “physician’s commitment and pledge” term was more common rather than “patient rights” (1–3).
Human being is a creature with physical, mental and spiritual dimensions which has rights during the health and illness. Patient rights are the very expectations he has from the health care services and must encompass his physical, mental, spiritual and social needs which are manifested as criteria, standards, rules and laws (4, 5). Emphasis on patient rights in the health care services particularly maintains patient dignity as a rank of a human, and is considered important especially when patient’s vulnerability easily expose him to the violations and weaknesses of the health care system (6). Considering that health is the most important existence aspect of every person and according to the Article 29 of the Constitution, providing health is the most important commitment of the government of Islamic Republic of Iran; because of this, in 2002, for the first time the Patients’ Right Charter was developed in Iran and was notified by Department of Health, Treatment and Medical Education (7). The Patients’ Right Charter of Iran was approved by Health Policy Council with a new and comprehensive viewpoint aimed to clarify the rights of the health services recipients and observance of moral standards in the treatment and medical fields in November 26th, and in December 1st it was communicated to the relevant centers (1, 8, 9). In this charter patient satisfaction is considered as one of the characteristics of hospital effectiveness (9). Today, the issues related to the quality of health care services, attention to the patients as customers and accomplishing their satisfaction are the main priorities and are of high importance. One of the important factors in patient satisfaction is regarding their demands and observing their rights and providing care along with respect (6). Awareness of the patients rights and observing them accomplishes more satisfaction of the patient, physician and other medical team and hospital staff and will lead to the spread of good morals among patients and medical team; so eventually the moral status of all the individuals such as patients and medical team will be upgraded, but otherwise provided not observing these rights, it would lead to distrust to health care team. If there is no trust between medical staff and patients, it would lead to damages and losses for the patient and the medical team. Furthermore, it would lead to terrible and unpleasant occurrences which are difficult to compensate and would be followed by the legal prosecution (5, 10). Protecting the patient rights by the nurses only will be possible when they have gained necessary knowledge about it and suitable conditions be provided for respecting these rights (11). Appropriate care and observing patient rights require nurses’ knowledge which would be possible through different ways such as side studies, retraining courses, and academic courses during education (5). In the studied researches about the nurses’ level of knowledge from patient rights, several aspects were mentioned.
Nasiriani et al (5) and Houshmand et al (11) reported good nurses’ level of knowledge in Yazd hospitals and teaching public wards of Tehran Hospitals respectively. Mohammadi et al. observed moderate and Parsinia et al obtained weak nurses knowledge in Tehran and Karaj hospitals respectively (10). The clinical researchers in different wards of teaching hospitals have reported that the patients’ rights have been ignored or have not been considered seriously due to shortage of nursing staff, high number of patients in the hospitals, psychological pressures and etc. Taken together, we decided to evaluate the nurses’ knowledge about patients’ rights in one of the teaching hospitals of Tehran City.
Method
This was a descriptive cross-sectional study in which the nurses’ knowledge about patient rights was determined. The study samples consisted of 156 nurses who have been selected randomly from one of the teaching hospitals of Tehran. The inclusion criterion was having more than 6 months work experience. The data collection instrument was a two-part questionnaire; the first part included the demographic information (age, gender, marital status, work experience, educational level, etc.); the second part consisted of 10 questions according to the 10 section of Patients’ Rights Charter of Iran (11). This part determined the following areas about patient rights:
Right to receive essential information about health care providers, rate of tariff, target insurance coverage if sent to the other medical centers.
Right to give informed consent for participation in educational and research activities.
Right to receive respectful and quick treatment and care regardless of cultural and racial factors.
Right to recognize the admission location and the health care staff.
Right to access to the health care team during hospitalization, transmission and discharge.
Right to know essential information about the diagnosis, treatment and disease progression process.
Right to know about the probable complications, treatment options and participate in the ultimate treatment choosing.
Right to make a decision about the presence of those who are not directly involved in the treatment process.
Right to announce personal satisfaction from ending the treatment and referring to other centers, and
Right to preserve privacy and being ensured about confidentiality of all of the medical information.
The answers of the study subjects to the questions were quantified by measuring a three-score scale; “good” (3 scores), “moderate” (2 scores) and “weak” (1 scores). The maximum score in the questionnaire was 30 scores which were considered 21–30 as high knowledge, 10–20 as moderate knowledge and less than 10 as weak knowledge.
The validity was done using content validity i.e. the questionnaire was given to 10 faculty members of Universities of Tehran and after collecting the comments, the relevant comments were applied. The reliability was done using retest. The validated questionnaire was given to 10 eligible study subjects for reliability and in both stages the questionnaire was completed with a 10-day interval and the required correlation of the first and second answers and confidence was obtained r = 0.90 and finally these people were excluded from the study population. The questionnaires were completed during two weeks by direct referring of the researcher to the wards. In order to observe ethics, confidentiality and integrity, the mentioned questionnaires were anonymous and in all stages of the study the information were collected confidential and were kept by the researcher. All the data were analyzed using SPSS software version 15.
Results
The review of the demographic variables indicated that the majority of the nurses were females (76.28%) with mean age of 34.31 ± 7.3. Most of them (91.2%) had bachelor degree and were married (62.82%). In terms of employment and work experience, almost half of nurses (47.43%) were contractual, 46.79% had 6–10 years of work experiences, 30.99% never passed any course about “patient rights” and 30.99% of them had the simultaneous experience in public and private sectors. No association between the variables of gender, age, degree and marital status and nurses’ knowledge about patient rights was found. There was no significant difference between them in terms of work section, work experience and simultaneous work in the public and private sectors, however there was a significant difference between their level of knowledge about patient rights and simultaneous work in the public and private hospitals and work experience (table 1).
Table 1.
Demographic data of the nurses from knowledge about the patient rights
| Statistical indicators | Number (percent) | Statistical test | |
|---|---|---|---|
| Variables | |||
| Sex | Female | 119 (76.28) | T = 0.102 P = 0.37 |
| Male | 37 (23.71) | ||
| Marital status | Married | 98 (62.82) | T = 0.08 P = 5.38 |
| Single | 58 (38.17) | ||
| Educational level | High school graduated | 7 (4.48) | F = 2.56 P = 0.407 |
| Technician | 3 (1.92) | ||
| Bachelor | 142 (91.02) | ||
| Master | 4 (2.56) | ||
| Employment status | Recruitment plan | 26 (6.66) | F = 2.56 P = 1.93 |
| Contract - corporate | 13 (8.33) | ||
| Contract | 74 (47.33) | ||
| Official | 43 (27.56) | ||
| Type of hospital | Public | 103 (69) | T = 1.31 P = 0.017 |
| Private-public | 53 (30.99) | ||
| Work experience (year) | 1–5 | 43 (27.56) | F = 5.34 P = 0.008 |
| 6–10 | 73 (46.79) | ||
| 11–15 | 22 (14.10) | ||
| > 16 | 18 (11.53) | ||
| Hospital ward | Intensive | 33 (21.15) | F = 1.68 P = 0.19 |
| Emergency | 52 (33.33) | ||
| Surgery | 21 (13.46) | ||
| Internal | 31 (19.87) | ||
| Orthopedics | 19 (12.17) | ||
The findings of the study about the nurses level of knowledge in different areas indicated that the highest level of knowledge (95.51%) was in the area of “right to preserve privacy and being ensured about confidentiality of all medical information” and the lowest level was “right to receive essential information about health care providers, rate of tariff, target insurance coverage if sent to the other medical centers”.
Discussion
Observing patients rights is the most important ethical issue in a hospital which should absolutely be considered. Regarding patients’ rights and respecting them are two main factors for patients’ care. It is important that medical staff pay enough attention to its various aspects. Observing patients rights means the accountability of all health care staff to the patients at the time of treatment and care giving (12,13).
Promoting patients rights is a multidimensional issue and in order to achieve it, comprehensive efforts should be done. World Health Organization has offered some strategies such as active participation of health care recipients and providers’ policy making and extending educational programs for health care providers and entire community (11).
The findings of the study showed that nurses’ level of knowledge about patients’ rights in terms of the variables such as type of the hospital, work experience, degree, age and gender was good, moderate and weak in 58.33%, 39.10%, and 2.56% of them respectively. In the studies conducted in Karaj hospitals (10) and the public wards of teaching hospitals of Tehran (11) also the nurses’ level of knowledge reported as weak. Today patients are more aware of their rights and physicians’ responsibilities and commitments and also hospitals’ managements regarding their rights (14) and they are more insisting on their principle rights (2). Therefore it is highly needed that nurses with low level of knowledge, and the other health care providers be aware of Patients Right Charter and increase their knowledge. Mohammadi et al. determined the reasons of the nurses low level of knowledge as lack of institutionalization and regulation of the rights (12); lack of adequate time for studying and researching due to various obstacles such as poor economic conditions; lack of positive vision in selecting nursing profession; tough job conditions in the hospitals such as large number of the patients versus staff shortages, and lack of necessary facilities such as adequate and suitable libraries (5).
The results indicated that there was a significant and direct association between level of knowledge and simultaneous jobs in the public and private hospitals (P=0.01) i.e. the nurses who provided services simultaneously in the public and private hospitals had higher level of knowledge. The reason might be due to regulations and rules which are performed more in the private hospitals compared to the public hospitals i.e. no implementation of Patients Right Charter which may be followed by punishment.
The findings of the present study indicated that in the area of “right to preserve privacy and being ensured about confidentiality of all the medical information”, the nurses had the highest level of knowledge. In the Patients Right Charter codified in 2009 it says observance of the principle of confidentiality is necessary about all the information related to the patient except for the cases the law excluded (1). In a comparative study about the Patients’ Right Charter in the selected countries with Iran in 2007, it was indicated that regulations of Iran for the right of the confidentiality of the patient information and medical records is similar to the other countries such as Hungary, Hong Kong, New Zealand, United States, South Africa, European Union and Lithuania (14). Unlike the above results, in Canada it was indicated that 84% of the medical staff did not have enough knowledge about commitments and obligations of the law about confidentiality of the information and privacy of the patients’ information (15).
Our findings indicated that there was a direct and significant association between level of knowledge and work experience (P= 0.008) and the level of knowledge of the study subjects from Patients Rights Charter was increased by increasing work experience which was in accordance with the studies of Nasiriani et al. and Parsinia et al. (5, 10). In addition, the study indicated that there was no association between level of knowledge and degree and increasing degree had no effect on the level of knowledge. In a study in Karaj it was mentioned that the level of knowledge of the technicians was higher in comparison with supervisors and matrons and the most important reasons were sense of job security, professional status and disregardness of matrons and supervisors to the important tasks (10).
The findings indicated that nurses in the area of “right to receive essential information about health care providers, rate of tariff, target insurance coverage if sent to the other medical centers” had the lowest level of knowledge. The Patients Right Charter codified in 2009 states that information must be given to the patient at the right time and appropriate condition by considering individual characteristics such as language, degree and perception; however the patient has the right to access all the information recorded in his/her clinical records (16, 17). In the Patients’ Right Charter of some countries such as Canada and United States unlike the other countries such as Iran, Hong Kong, New Zealand, Africa, European Union, Lithuania, “right to ask for explanation about the costs” has been discussed (14).
The results indicated that 66% of the nurses was aware of the “right to access to the health care providers during hospitalization”, instead of 90% of Turkish nurses (17).
Nowadays ethical and legal concepts such as patient rights are included in the educational curriculum of Greek and Turkey (18, 19). According to the considerable gap between development and realization of the patient rights (20) and the increased knowledge, claims and demands of the patients and also the results of this study, in order to observe patients right the following solutions are suggested:
- Encouraging the nurses to consider Patients’ Right Charter seriously.
- Establishing and empowering the sanction of Patients’ Right Charter
- More emphasizing on concepts of professional ethics and patient rights in teaching nursing students
- Attending expertise meetings with presence of beneficiaries for evaluating barriers and presenting strategies in order to implement the Patients Right Charter as soon as possible
- Providing periodic educational programs for health care providers and patients about patient rights
Conclusion
Generally, since 41.6% of the nurses of the study had not a proper level of knowledge about patient rights and considering the fact that awareness and knowledge can be the base of nurses’ performance and also patients increasingly are getting informed about their rights, the implementation of Patients Right Charter is highly recommended. This wills increase nurses knowledge about patient rights. Holding educational programs, seminars, workshops and academic panels for nurses, and nursing students help overcome difficulties.
References
- 1.Parsapoor A, Bagheri A, Larijani B. Patient’s right charter in Iran. J Med Ethics Hist Med. 2010;(Supplement):39–47. [In Persian] [Google Scholar]
- 2.Anonymous Patients Rights. http://www.pharmacoeconomy/80-1388-10-28-18-09-51/390-dr-ghiasi-html (accessed on 2010)
- 3.Hermans H. Patients rights in the European Union cross-border care as an example of the right to health care. European J Public Health. 1997;7(3):11–17. [Google Scholar]
- 4.Mohammad Nejad E. Nursing Ethics and Patient Rights. Proceedings of the 10th Asian Bioethics Conference and UNESCO Asian Pacific School of ethics Roundtable; Tehran, Iran. Tehran, Iran: Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences; 2009. [ in Persian] [Google Scholar]
- 5.Nsiriani KH, Salemi S, Salman Yazdi N, Hosseini F. Relationship between nurses knowledge respecting the rights of their patients and rate of its observance in hospitals of Yazd in 2001. Iran J Nurs. 2001;(22, 23):8–14. [In Persian] [Google Scholar]
- 6.Arab M, Zarei A. Determining awareness of private hospital managers in Tehran about patient rights and it effective factors. Payesh. 2009;8(1):25–30. [In Persian] [Google Scholar]
- 7.Rangraz Jeddi F, Rabii R. Amount of observance of patients’ right chater in Kashan public hospitals. Behbood. 2007;10(1):62–71. [In Persian] [Google Scholar]
- 8.Anonymous Patient’s Right Charter in Iran. http://www.bih.ir/201007112169.html (accessed on 2010)
- 9.Mossadegh Rad A, Esna Ashari P. Patients and physicians awareness of patients rights and its implementation at Beheshti Hospital in Isfahan. Iran J Med Edu. 2004;4(1):45–54. [in Persian] [Google Scholar]
- 10.Parsania M, Goodarzi M, Babaei Gh. Evaluation of nurses’ knowledge about patient rights working in Karaj hospitals. J Med Sci Islamic Azad Univ Mashhad. 2007;3(4):216–22. [in Persian] [Google Scholar]
- 11.Hooshmand A, Joolaee S, Mehrdad N, Bahrani N. Nurses’ information and their view points about Patients rights and practical facilitators in clinical nurses: viewpoint regarding patients’ right in Tehran teaching hospitals. Hayat. 2006;12(4):57–66. [in Persian] [Google Scholar]
- 12.Mohammadi M. Assessment of Knowledge and Attitude of Nurses About Patients Rights. Proceedings of the Symposium of Nurses and Law; Tehran, Iran. Nurses Organization of Health Ministry; 1998. [Google Scholar]
- 13.Ducinskiene D, Vladickiene J, Kalediene R, Haapala I. Awarness and practice of patients rights law in Lithuania. BMC Int Health Human Rights. 2006;2:10. doi: 10.1186/1472-698X-6-10. 6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Dargahi H, Eshaghi SH. Comparative study of patients’ right charter in representative countries along with Iran. Iran J Diabet Lipid Disorder. 2007;(Suppl):91–8. [in Persian] [Google Scholar]
- 15.Shrier I, Green S, Solin J, et al. Knowledge of and attitude toward patient confidentiality within three family medicine teaching units. Acad Med. 1998;73(6):710–2. doi: 10.1097/00001888-199806000-00021. [DOI] [PubMed] [Google Scholar]
- 16.Altun I, Ersoy N. Undertaking the role of patient advocate: a longitudinal study of nursing students. Nurs Ethics. 2003;10:462–71. doi: 10.1191/0969733003ne628oa. [DOI] [PubMed] [Google Scholar]
- 17.Ozdemir MH, Ergonen TA, Sonmez E, Can IO, Salacin S. The approach taken by physicians working at educational hospitals in Izmir towards patients rights. Patient Educ Couns. 2006;61:87–91. doi: 10.1016/j.pec.2005.02.013. [DOI] [PubMed] [Google Scholar]
- 18.Merakou K, Dalla-Vorgia P, Garanis-Papadatos T, Kourea-Kremastinou J. Satisfying patients rights: a hospital survey. Nurs Ethics. 2001;8:499–509. doi: 10.1177/096973300100800604. [DOI] [PubMed] [Google Scholar]
- 19.Buken NO, Buken E. Emerging health sector problems affecting patient rights in Turkey. Nurs Ethics. 2004;11:610–24. doi: 10.1191/0969733004ne742oa. [DOI] [PubMed] [Google Scholar]
- 20.Joolaee S, Nikbahkt-Nasrabadi A, Parsa-Yecta Z. The view of Patients and patients companions regarding patients’ rights: a phenomenological research. Hayat. 2005;23:5–20. [In Persian] [Google Scholar]