Appropriateness and Applicability of the Patient Bill of Rights from the Viewpoint of Nurses in Lorestan University of Medical Sciences: Barriers and Operational Solutions

Author: Toulabi T. ¹, Kordestani-Moghadam P. ², Pournia Y. ³

¹Assistant Professor, Nursing and Midwifery Faculty, Lorestan University of Medical Sciences, Khorramabad, Iran.
²Instructor, PhD Student, Nursing and Midwifery Faculty, Lorestan University of Medical Sciences, Khorramabad, Iran.
³Instructor, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran.

 

ABSTRACT

This research was designed to determine the appropriateness and applicability of the Patient Bill of Rights from the viewpoint of nurses in Lorestan University of Medical Sciences to identify barriers and provide operational solutions in 2012. This is a descriptive-analytical study. Out of 440 questionnaires delivered to the nurses, 294 were completed. The data collection tool was a questionnaire related to the five domains of the Patient Bill of Rights including right to receive appropriate services, right to receive appropriate and adequate information, right to choose and decide on health services freely, respecting patient privacy and observing the principle of confidentiality, and finally right to get access to effective complaint handling system. The mean scores for appropriateness (350.16±7.23) and applicability (282.57±54.22) of the Patient Bill of Rights were high. Shortage of work force, nurses and patients’ unawareness of the major barriers of application, provision of necessities for internalization, establishment of the committee of the Patient Bill of Rights, and paying attention to nurses’ rights were the solutions proposed. Enhancing stakeholder’ s awareness and providing necessities by managers can help in the operationalization of the Bill.

INTRODUCTION

One of the most important aspects of a person’s existence is his or her physical, mental, spiritual, and social health. According to Act 29 of the Constitution of the Islamic Republic of Iran, the fulfillment of this health is one of the most important governmental commitments in Iran. Accordingly, the Ministry of Health in Iran is responsible for providing the society with appropriate health services. Thus, the Patient Bill of Rights has been formulated according to exalted human values, Islamic and Iranian cultures, and equality of inherent dignity of all recipients of health services, with the purpose of preserving, promoting, and strengthening human relationships between health care providers and recipients¹. Parsapour et al. study on the attitudes of physicians, patients, and nurses showed a consensus among the research population on the necessity of observing the aspects of patient rights². Formulation and notification of the Patient Bill of Rights are invaluable measures in fulfilling patient rights. However, following the provisions of the bill is possible only when stakeholders’ rights are considered comprehensively, barriers and operational solutions for the application of the Bill are identified, and respecting patient rights is considered as one of the evaluation indices of health care centers³.

Given the increasing growth of science and technology, and to preserve the health and privacy of health care recipients, the patients’ bills.

of rights have been regularly reviewed in various countries. In Germany, the new patients’ rights act was passed in the German Civil Code (BGB) in 2013 since the previous act was not transparent and reliable⁴, so that the new act ensures the right of patients for self-determination⁵. In Belgium, the patients’ rights act was revised in 2002 to guarantee the establishment of a true communication between physicians and patients, to give priority of decision to adolescents rather than to their physicians or parents, and to lower the barriers for adolescents to use the healthcare system^6,7.

Joolaee and Hajbabaee in an article reviewed 26 papers regarding the Patient Bill of Right in Iran (approved in 2002). The reviewed studies showed that the Patient Bill of Rights in Iran does not include all the essential aspects and domains of patient rights. They stated that formulation of a more comprehensible patient bill of right is unavoidable⁸. Therefore, the new Patient Bill of Rights was formulated by the experts in the Ministry of Health (2009). However, there is a considerable distance between the formulation and realization of the provisions of the bill, and conducting filed studies are needed. Therefore, this study was conducted to determine the appropriateness and applicability of the Patient Bill of Rights from nurse’s viewpoint in the health centers of Lorestan University of Medical Sciences to identify barriers and provide operational solutions in 2012.

MATERIAL AND methods

This descriptive study was conducted on all the nurses in health care centers in Khorramabad (west of Iran). Out of 340 questionnaires delivered to the nurses, 294 were completed, showing an 86.47% rate of questionnaire completion. The data collection tool was a questionnaire consisting of two parts. The first part included the demographic information and the second part  related to the five domains of the Patient Bill of Rights,  as well as 37 provisions including right to receive appropriate services, right to receive appropriate and adequate information, right to choose and decide on health services freely, respecting patient privacy and observing the principle of confidentiality, and finally right to get access to effective complaint handling system, which had been formulated in 14, 4, 7, 9, and 3 provisions respectively by the experts of the Health Ministry. The data collection method was based on self-reporting, and the subjects were asked to rate the appropriateness and applicability of each provision from 1, as the lowest, to 10 as the highest level of appropriateness and applicability. The total scores were between 37 and 370. The scores below 120 were considered as low, between 120 and 240 as moderate, and between 241 and 370 as high appropriateness and applicability levels. The barriers and solutions were identified and provided based on the answers to open questions. The Patient Bill of Rights was formulated through the participation of experts and stakeholders within three years, and was notified after it was approved by the Policy-Making Committee of the Health Ministry. In addition, the draft of the bill had been sent to 48 experts in the fields of medicine, medical ethics, law, jurisprudence, and philosophy to evaluate its content, out of whom 21 experts had provided their comments. The comments had been examined and necessary corrections had been made in the draft⁸. Therefore, the validity of the questionnaire was considered as confirmed. Its reliability was confirmed by applying the test-retest method on 10 nurses in a one-week interval (r=0.823).

The dependent t-test was used to investigate the relationships between the total means of the domains and position as well as gender, and Pearson correlation was applied to study the correlation between the total means of the domains and age as well as working experience. Moreover, the relationships between the domains and type of hospital, ward, age, education, position, gender, employment status, and working experience were investigated through chi-square test. The total mean of all the domains of the Patient Bill of Rights was investigated in terms of type of hospital, ward, age, education, employment status, and working experience via the ANOVA. This study was approved by the Ethics Committee of Lorestan University of Medical Sciences.

RESULTS

The results showed that 86.7% of the nurses were female, 37.4% were tenured, the mean age was 32.39 years old, the mean work experience was 8.66 years, and 91.5% had bachelor’s degree in nursing. The means of appropriateness (350.16±27.23) and applicability (282.57± 54.22) of the bill from the nurses’ viewpoint were found to be high.

The dependent t-test did not show significant relationships between gender and position, and the means of appropriateness and applicability of the domains of the bill. Right to receive appropriate services (99%), respecting patient privacy and observing the principle of confidentiality (98%), right to get access to effective complaint handling system (96.6%), right to receive appropriate and adequate information (96.4%), and finally right to choose and decide on health services freely (94.9%) had the highest frequencies of appropriateness of the bill domains,  respectively. Moreover, respecting patient privacy and observing the principle of confidentiality (90.6%), right to receive appropriate services (76.9%), right to get access to effective complaint handling system (71.8%), right to receive appropriate and adequate information (62.9%), and right to choose and decide on health services freely (62.6%) had respectively the highest rates of applicability from the nurse’s viewpoint.

As shown in Tables 1 and 2, the appropriateness of the domains of the bill in Shohada Ashayer Hospital was more than that in other hospitals, so that domains 1, 2, and 4 did not show low appropriateness, and the highest frequency was reported for high appropriateness. However, chi-square test did not show significant differences in any of the cases. The highest frequency of high appropriateness of the domains of the bill was reported by female nurses (68.7%), and chi-square test showed a statistically significant difference (p<0.03).

Chi-square test showed a statistically significant difference between the nurses’ education (p<0.03), so that the highest level of appropriateness was found for the nurses with bachelor’s degree (72.8%). Additionally, the highest rates of appropriateness were reported for the nurses in the age group of under 25 years old (35%), the nurses (68%) compared to the nursing managers, and the nurses with work experience of less than 10 years (65.3%).

Moreover, the female nurses (71.4%), the nurses in the age group of under 25 years old (37.4%), the holders of bachelor’s degree (76.5%), the nurses with work experience of less than 10 years (53.4%), and the nurses (73.1%) compared to the managers believed more strongly than other nurses that the applicability of the domains of the bill was high. However, no significant differences were found through chi-square test.

 

Table 1. Comparison between the levels of appropriateness of domains 1, 2, and 4 of the Patient Bill of Rights from the viewpoint of the nurses in Lorestan University of Medical Sciences in 2012 in terms of hospital.

Hospital	Asalian		Shahid Madani		Psychiatric		Shohada Ashayer		Total domain score		P
Domain
	M	H	M	H	M	H	M	H	M	H
Domain 1: Right to receive appropriate services	0	30	0	119	0	15	3	127	3	291	0.28
	0	-10	0	-40	0	-5	-2	-43	-1	-99
Domain 2: Right to receive appropriate and adequate information	2	28	4	115	1	14	4	126	11	283	0.73
	0	-9	-1	-39	0	-4	(1.)	-42	-3	-96
Domain 4: Respecting patient privacy and observing the principle of confidentiality	0	30	2	117	0	15	4	126	6	288	0.63
	0	-10	0	-9	0	-5	-1	-42	-2	-98
Total score of the domains	0	30	0	119	0	15	2	128	2	292	0.46
	0	-10	0	-40	0	-5	0	-43	(0.)	-99

M=Moderate, H=high

 

Furthermore, no significant relationships were found between the total mean of all the domains and employment status, age group, education, and work experience through ANOVA, and between the total mean of all the domains and the means of work experience and age via Pearson correlation.

 

Table 2. Comparison between the levels of appropriateness of domains 3 and 5 of the Pa-tient Bill of Rights from the viewpoint of the nurses in Lorestan University of Medical Sci-ences in 2012 in terms of hospital.

Domain	Domain 3: Right to choose and decide on health services freely			Domain 5: Right to get access to effective complaint handling system
Hospital
	L	M	H	L	M	H
Asalian	0(0)	0(0)	30(10.2)	0(0)	1(0.3)	29(9.9)
Shahid Madani	2(0.7)	5(1.7)	112(38.1)	0(0)	4(1.4)	115(39.1)
Psychiatric	0(0)	0(0)	15(5.1)	0(0)	0(0)	15(5.1)
Shohada Ashayer	0(0)	8(2.7)	122(41.5)	1(0.3)	4(1.4)	125(42.5)
Total	2(0.7)	13(4.4)	279(94.4)	1(0.3)	9(3.1)	284(96.6)
p	0.426			0.938

M=Moderate, H=high, L=low

 

The highest frequency rates of appropriateness (26.5%) and applicability (27.9%) of the domains of the bill were found for emergency departments and ICU. Nevertheless, no significant differences were found in terms of ward. In addition, ANOVA did not show a significant relationship between the total mean of the domains and type of hospital. The highest rates of appropriateness (31.6%) and applicability (33%) of the bill domains were reported for Shohada Ashayer Hospital (Table 3), showing statistically significant differences between the hospitals (p<0.006).

 

Table 3. Comparison between the levels of appropriateness and applicability of the Patient Bill of Rights from the viewpoint of the nurses in Lorestan University of Medical Sciences in 2012 in terms of hospital

	Appropriateness					Applicability
Hospital	L	M	H	Total	p	L	M	H	Total	p
Asalian	0	11	19	30	0.006	4	8	18	30	0.000
	0	-3	-6	-10		-4	-2	-6	-10
Shahid Madani	3	12	104	119		0	8	111	119
	-1	-4	-35	-40		0	-2	-37	-40
Psychiatric	0	-1	10	15		0	1	12	15
			-3	-5		0	-3	-4	-5
Shohada Ashayer	6	31	93	130		1	32	97	130
	-2	-10	-31	-44		0	-10	-33	-44
Total	9	59	226	294		5	51	38	294
	-3	-20	-76	-100		-1	-17	-81	-100

M=Moderate, H=high, L=low

 

There was a significant relationship between the total mean of all the domains and type of hospital through ANOVA. The most important barriers mentioned by the nurses included shortage of manpower; patients, attendants, nurses, doctors, and health care staff’s unawareness of the five domains of the Patient Bill of Rights; lack of bill of rights for nurses and hospital staff; absence of structural and processing standards; and weak supervision of managers. On the other hand, the solutions recommended by the nurses for the better application of the Patient Bill of Rights included provision of necessities for internalization; public and specific training in hospitals; establishment of the committee of the Patient Bill of Rights; paying attention to nurses, doctors, and hospital staff’s rights; observance of the rights of hospital staff by patients, attendants, and authorities; supervision and control of managers for the optimal application of the bill and devotion of a portion of the evaluation score to it; performing periodical opinion polls on patients; standardization; allocation of human resources; inclusion of the Patient Bill of Rights in the curriculum for the students of medicine, nursing, and other related fields; and participation of the health care team in applying the bill.

DISCUSION

The observance of patient rights is one of the most important components of holistic, humanistic, and ethical health care. Numerous studies have been conducted on the importance and way of observing patient rights, and various rules and regulations have been formulated in this regard. However, the observance of patient rights is not fulfilled through issuing declarations and circulars. The results of the present research showed a consensus among all the nurses on the appropriateness and applicability of the recently issued Patient Bill of Rights.

Considering the novelty of the bill, no relevant conducted studies were found. In Iran, patients usually trust in health care teams, while in American and European countries, basic changes have been observed in behaviors and expectations of hospitalized patients since 1960. In recent years, patients have mainly asked health authorities, doctors, and nurses about the ways of treatment and care, and have criticized them for ignoring their rights⁷.

The nurses participating in the present study also believed that an increase in the patient awareness of the bill could lead to its better application, and eventually in patient satisfaction.The results of our study are consistent with those in other studies mentioning that the observance of patient rights will result in the application of care standards, which leads in turn to improvements in the quality of care and patient satisfaction. Moreover, the more a patient is aware of his or her rights, the more the rights are observed by health care providers⁹.

Woogara et al.carried out an ethnographic study in three wards with medical and surgical patients in a large NHS hospital for six months. The results of this study, in which unstructured interviews were conducted with 55 patients and 12 members of staff, showed the physicians and nurses’ low awareness of the importance of observing patients’ privacy, and recommended the necessity of integrating courses in undergraduate and postgraduate healthcare curricula¹⁰.

In order to implement the Patient Bill of Rights in Iran (approved in 2009), patients need to be informed about their rights. In this regard, training programs should be compiled and implemented in hospitals or in the media , and patients and their families should be informed of these programs through bulletin boards. The results of a descriptive, cross-sectional study by Abolarin and Oyetunde, conducted on 360 outpatients using a 45-item self-administered questionnaire, showed that most of the patients (94.2%) were aware of their rights and few patients (37.2%) denied their active involvement in making decisions on issues related to their care. Moreover, 50.8% of the patients were not completely informed of the diagnosis and treatment plans concerning their health conditions, and 75.0% reported that they would resist if their rights were limited¹¹.

Kagoya et al performed a study to investigate the level of patients and health workers’ awareness of, responsiveness to, and practice of patients’ rights in Mulago Hospital in Kampala, Uganda. Their descriptive, cross-sectional study was conducted on 211 patients, 98 health workers, and 16 key informants using a three-phase questionnaire. The results of the study showed that 36.5% of the patients encountered challenges related to their rights when they sought health care, 79% of the patients never tried to demand their rights, and 81.5% of the patients and 69.4% of the health workers had never heard of the patient bill of rights in Uganda. Since awareness of, responsiveness to, and practice of patients’ rights was limited at the hospital, they recommended that “ an integrated, multi-level, multi-channel, patient-centered approach ” be implemented promptly to incorporate social services and address the factors of health system with the aim of strengthening patients’ rights¹².

The most important barriers reported in our study included shortage of manpower; patients, attendants, nurses, doctors, and health care staff’s unawareness; patients’ unwillingness to demand their rights; lack of a bill of rights for nurses and hospital staff; and absence of structural and process standards, being consistent with other studies. In a qualitative study by Joolaee et al, two main clusters of themes emerged from the nurses and physicians’ interviews. They included the factors affecting patients’ rights negatively acting as barriers, and those affecting patients’ rights positively facilitating patients’ rights practice. Although the emerging themes are clustered distinctly, they overlap to the extent that they cannot be considered and discussed separately. Consequently, they are presented as three main subheadings of awareness of rights, resources, and accountability. Managers and policy-makers should consider healthcare professionals’ live experiences as an important source of data if they want to make changes and initiate legislations to protect and enhance patients’ rights¹³.

The solutions recommended by the nurses for a better application of the Patient Bill of Rights included provision of necessities for internalization; public and specific training in hospitals; establishment of the committee of the Patient Bill of Rights; paying attention to nurses, doctors, and hospital staff’s rights; standardization; allocation of human resources; and active participation of the health care teams with direct contact with patients. These results are consistent with the results of other studies, as Joolaee et al achieved significant results concerning patient rights in a qualitative study. The researchers extracted five themes including holistic care, awareness of rights, adequacy of resources, responsible accountability, and interconnectedness of rights of health providers and recipients. They also mentioned that designing the standards of patient rights without considering all stakeholders’ views will question the applicability of these criteria⁹. Generally, two principles have to be considered in observing patient rights. The first principle is training, so that patients and health care providers will be aware of patient rights. The second principle is related to the guarantees of application of the bill¹⁴. Numerous studies have stressed that the observance of patient rights necessitates patients’ awareness of their rights and responsibilities¹⁵, and have recommended the establishment of ethical committees and presence of staff aware of patient rights in hospitals to familiarize patients with new rules and regulations¹⁶.

The results of the present study showed that the appropriateness and applicability of the five domains of the Patient Bill of Rights from the viewpoint of nurses were high. It is hoped that the application of the bill provisions will be facilitated compared to the past through considering necessary measures including allocation of efficient human resources, training and increasing the awareness of stakeholders, and active participation of health care staff. This definitely affects health care safety and patient satisfaction. Moreover, due to different cultural contexts in Iran, it is recommended that more studies be conducted in various regions on other health and management professions.

CONCLUSION

Increasing the awareness of stakeholders and providing necessary measures by managers can help in the operationalization of the bill. In addition, it is recommended that more similar studies be conducted in various regions of the country and on other stakeholders.

ACKNOWLEDGEMENTS

We herby appreciate the Deputy Office for Research, Lorestan University of Medical Sciences, for the approval and financial support of this research.

Author Disclosures:

Authors Toulabi Tahereh, Kordestani-Moghadam P., Pournia Y. have no conflicts of interest or financial ties to disclose.

 

Corresponding author:

Toulabi Tahereh
Nursing and Midwifery Faculty,
Kamalvand Campus,
Lorestan University of Medical Sciences, Khorramabad,
Iran. Tel/Fax: 0098 66 6200140