Respecting to patients' autonomy in viewpoint of nurses and patients in medical-surgical wards.

BACKGROUND: Respect to patients' autonomy is a cornerstone of medical ethics and nurses have a key role in respecting patients' autonomy. In review of Iranian literature, there is no study investigating the respect to patients' autonomy during nursing cares. The aim of the present study was to compare nurses and patients' perceptions regarding respecting to patients' autonomy during nursing care.
METHODS: This study had a comparative descriptive design and conducted in 2008. The study population was consisted of all nursing staff (n = 79) working in three related hospitals of Tabriz University of Medical Science using census sampling. Also, 187 hospitalized patients in these hospitals participated with convenience sampling. To assess the respecting to patients' autonomy, two parallel questionnaires were prepared. Data analysis was done in SPSS using Mann-Whitney and Kruskal-Wallis tests and Spearman correlation coefficient.
RESULTS: Nurses reported that they respected to patients' autonomy, but patients believed that their autonomy was not respected. Also, there was a significant statistical relation between perception of health status, need for nursing care, and age of patient and their report of respect to their autonomy.
CONCLUSIONS: There is an exiting difference in viewpoint of nurses and patients regarding respecting to patient autonomy. But, because of insufficient evidence more studies are recommended.

The history of patients’ autonomy importance comes back to Nuremberg codes of ethics and Helsinki declaration.1 The concept of autonomy acquires many attentions during the last decades. For example, International Medical Association (IMA) believed that patients not only have a right to receive necessary medical information, but they have right to select suitable treatment between all available methods.2

Nurses have responsibility to respect patients’ autonomy while enhancing their health. In nursing care, there are several situations that the nurse may invade this basic need. Therefore, nurses should respect patients’ autonomy via giving necessary information and encourage them to participate in decision making process.3 The concept of autonomy derived from Greek words “autos” and “nomos” meaning “self” and “authority” respectively.4 Today, autonomy is defined as a deliberate decision making and act according to it.5 Contrary to introduction of many theories regarding the concept of autonomy in the last decades, there is no agreement regarding the nature of autonomy.6 In general, many of authorities believed that two main prerequisite to respect patients’ autonomy are giving information about the disease and its′ treatment and engagement of patient in decision making process.7–9

Ruhnke et al reported that patients and physicians in United States have believed that the patients’ autonomy should be respected. In another hand, patients and physicians in Japan did not agree with this.10 However, Eden et al showed that many of patients in United States believed that it is better that the health care providers make decisions for them and only inform them about these decisions.11 Mattiasson reported that Swedish nurses believed that it is necessary to respect patients’ autonomy.12 Another study reported that nurses in five European countries believed that they provided enough information for their patients and engaged them in their care decision making.13 Another study showed that there is difference between viewpoints of patients and nurses regarding respecting to patients’ autonomy. Nurses believed that they gave information to their patients and engaged them in decision making process but the patients did not believe it.9

There are few studies about the effect of different factors on respecting to patients’ autonomy. For example, McKinstry reported that patients younger than 61 years were more interested in participating in their decision making process.14 Biley found that patients intended to participate in decision making regarding routing matters and patients with acute problems had fewer tendencies to engage in decision making process.15

There are few studies assessing the respect to patient's autonomy during nursing care. In the other hand, respecting to patients’ autonomy has important role in nursing care and nurses have important role in respecting patient's autonomy. Therefore, the aim of the present study was to compare nurses and patients’ perceptions regarding respecting to patients’ autonomy during nursing care.

Methods

This comparative descriptive study conducted in three separate non-teaching hospitals related to Tabriz University of Medical Sciences in 2008. The study population was consisted of all nurses and patients in selected hospitals during the time of study. Because of low number of nurses, all of them were selected for the study using census sampling. All of these nurses (n = 78) willed to participate in the study and had at least six month experience of working in medicalsurgical wards. Inclusion criteria for patients were being hospitalized in a medical surgical or coronary care unit wards, having at least 18 years of age, at least three days of hospitalization, and the ability to communicate, and satisfying to participate in the study. Because all enrolled patients were illiterate, their data was collected by interview. Finally, 178 patients were interviewed during study period.

To assess the viewpoints of nurses and patients regarding respecting to patients’ autonomy, two parallel questionnaires were designed based on the study of Lemonidou et al.9 The questionnaire was consisted of two sections. The demographic data of patients and nurses was registered in first section. In addition, in this section, the health status of patients was evaluated using a 5point Likert scale (1, very bad; 2, bad; 3, average; 4, good; 5, very good). Also, the need for nursing care was assessed using a 5-point scale based on following items; need for intravenous drugs, need for nutrition, need for defecation, need for self hygiene. Second section was composed of 22 questions with a 5-point Likert scale (4, always; 3, frequently; 2, occasionally; 1, never; 0, not applicable). This section evaluated the perception of nurses and patients regarding two main parts of autonomy; presenting information (11 questions) and engagement in decision making process (11 questions).

In each part, score ranged 0 to 44. Validity of questionnaire determined with content validity by sending it to experienced academic members in nursing and medical ethics. Therefore, questionnaire was sent for 8 nursing educators and 2 academic members of medical ethics. Questionnaires changed according to their recommendations. The reliability of questionnaires was determined by Cronbach's alpha coefficient. Therefore, the questionnaires tested on a sample of nurses and patients and Cronbach's coefficient was 0.82 for patients’ questionnaire and 0.78 for nurses’ questionnaire.

For data gathering, the list of nurses was obtained from nursing office of each hospital. Researchers sanded study questionnaires and informed consent in an envelope for nurses who meet inclusion criteria. A recall letter was sent to nurses who did not return the questionnaire after two weeks. A total of 95 questionnaires were distributed and 89 were completed and returned. Five questionnaires were not completed appropriately and 5 nurses did not sign informed consent. Finally, we analyzed 79 questionnaires. Regarding patients, two research assistances identified the patients who met inclusion criteria and informed main researchers to collect data from these patients. As many of our participants were illiterate, the information of patients was collected via interview. In the period of study, 182 patients identified who met the inclusion criteria and 178 of them gave their oral consent to participate in the study and were interviewed.

This study was approved by regional ethics committee of Bonab Branch, Islamic Azad University. All participants informed about aims and method of the study, confidentiality of their data and their right to participate and withdrawal in any time of the study.

Collected data was analyzed using SPSS13 software. Analysis of gathered data was done using Mann-Whitney and Kruskal-Wallis tests and spearman correlation coefficient. P-value less than 0.05 considered statistically significant.

Results

The mean (SD) age of patients was 46.93 (18.21) years and 49.1% of them were men. Majorities of patients were illiterate (43.3%) and admitted to internal wards (48.1%). Regarding nurses, the mean age was 29.75 (6.49) years and 93.7% of them were female. Majorities of nurses (92.4%) had bachelor in nursing and others have diploma degree in nursing.

Data analysis showed that the overall mean score of patients regarding giving information was 2.01 (0.36) and in decision making dimension was 2.00 (0.35). One hundred three patients (55.1%) stated that nurses respected weakly to their autonomy in giving information and 110 (58.8%) patients stated that nurses respected weakly their autonomy in decision making. patients’ data regarding each question is summarized in table 1 and table 2.

Table 1

Comparison of nurses’ and patients’ viewpoint regarding respecting patients’ autonomy in decision making dimension

Table 2

Comparison of nurses’ and patients’ viewpoint regarding respecting patients’ autonomy in giving information dimension

Result showed that the overall mean score of nurses regarding giving information was 2.88 (0.34) and in decision making dimension was 2.75 (0.38). Fifty nine nurses (74.7%) stated that they respect moderately to patients’ autonomy in giving information and 58 (73.4%) nurses stated that they respect moderately to patients’ autonomy in decision making. Nurses’ data regarding each question is summarized in table 1 and table 2.

Mann-Whitney test showed a significant difference between nurses and patients viewpoint about presentation of information (p < 0.001). Mann-Whitney test showed a significant difference between nurses and patients viewpoint about decision making (p < 0.001). Comparison of patients and nurses viewpoints is shown in table 1and table 2.

Mann-Whitney test showed that there is no significant statistical difference in viewpoint of male and female nurses regarding respecting to patient's autonomy in giving information (p = 0.20) and in decision making (p = 0.20). Also, Kruskal-Wallis test showed that there is no significant statistical differences in viewpoint of nurses in different wards regarding respecting to patient's autonomy in giving information (p = 0.60) and in decision making (p = 0.60). In addition, the nurses′ experience in nursing had no significant statistical correlation with their respect to patient's autonomy in giving information dimension (r = - 0.04, p = 0.60) and in decision making dimension (r = - 0.18, p = 0.09).

Mann-Whitney test showed that there is no significant statistical difference in viewpoint of male and female patients regarding respecting to their autonomy in giving information dimension (p = 0.70) and in decision making dimension (p = 0.70). Also, Kruskal-Wallis test showed that there is a significant statistical difference in viewpoint of patients in different wards regarding respect to their autonomy in giving information dimension (p = 0.003) and in decision making dimension (p = 0.03).

Mann-Whitney test showed that there is a significant statistical difference in viewpoint of patients under and upper 60 years old regarding respecting to their autonomy in giving information dimension (p = 0.03) and in decision making dimension (p = 0.01).

The degree of patients’ need for nursing interventions demonstrated a significant positive correlation with respecting to their autonomy in giving information dimension (r = 0.27, p = 0.001) and in decision making dimension (r = 0.16, p = 0.02). In addition, perceived health status had a significant negative correlation with respecting to their autonomy in giving information dimension (r= -0.24, p = 0.001) and in decision making dimension (r= -0.27, p = 0.001).

Discussion

Present study suggested that there were statistical differences between viewpoints of nurses and their patients in medical-surgical wards regarding respect to patients’ autonomy during nursing care. While nurses believed that they respected sufficient to their patients’ autonomy regarding giving information and decision making dimensions, patients believed that nursing staff did not respect their autonomy in giving information and decision making.

Findings revealed that most patients believed that nurses did not give them necessary information and engage them in decision making process. None of the patients believed that nurses respect their autonomy in an acceptable level. This result is consistent with the findings of Lemonidou et al.9 They reported that patients believed that nurses did not respect their autonomy during nursing care. The result of one review article showed that the concept of autonomy is important to patients and patients expect the health care providers to respect their autonomy.16 Therefore, the results of present study denoted that the autonomy of patients was not respected during nursing care.

Findings showed that most of the nurses reported that they presented necessary information to their patients and engaged them in decision making process. This result is consistent with the findings of Suhonen et al. They reported that many of nursing staffs believed that they had respected patients’ autonomy.13 In another study, Swedish nurses reported that the autonomy of patients during nursing care was respected.12 Therefore, the results of present study indicated that nursing staff believed that they had respected the patients’ autonomy.

Findings showed that there is a meaningful difference between nurses and patients view-point regarding respecting patients’ autonomy during nursing care. In review of literature, we found only one similar article compared the viewpoint of nurses and patients regarding respecting patients’ autonomy. The results of that article is consistent with our findings and indicated that nurses more than patients believed that they respected patients’ autonomy.9 The study of LeinoKilpi et al showed that the concept of autonomy is culture dependent.17 Similarly, the finding of present study indicated the difference between nurses and patients viewpoint regarding respecting patients’ autonomy during nursing care. But, it should be noted that this finding did not clear that one of this view-points is realistic and only show the difference between their viewpoints.

There was no meaningful relationship between sex, ward, experience, and degree of nurses and their viewpoint regarding respecting patients’ autonomy. Suhonen et al reported that the viewpoint of nurses in different European countries regarding respecting patients’ autonomy were different and these viewpoints had no relationship with any character of nurse.13 Patients hospitalized in medical wards had better viewpoint regarding respecting their autonomy than patients in coronary care unit and surgical wards. Patients below 60-years old had better report of respecting to their autonomy. This finding is consistent with the findings of other studies indicating that elderly have better viewpoint regarding respecting to their autonomy.141819

Also, Patients need for nursing interventions demonstrated significant positive correlation with respecting to their autonomy and perceived health status had a significant negative correlation with respecting to their autonomy. This result showed that if patients’ health become worsen, their viewpoint about respecting to their autonomy would be better. It means that whenever contacts between patients and nurses increase, the perception of patients regarding respecting to their autonomy would be better and closer with nurse's perception. This fining does not consistent with results of Billey that reported ill patients did not want to participate in their decision making process.15

The Authors declare that have no conflict of interest in this study and ethical committee approved the study.

Result of this study indicated that there is significant difference between nurses and patients viewpoint regarding respecting patients’ autonomy during nursing care. In one hand, nurses believed that they respect patients’ autonomy perfectly. In another hand, patients did not believe it and reported that their autonomy was not respected during nursing care.

This study had some limitations in findings generalization. First, this article is based on patients and nurses viewpoints and maybe these viewpoints are not according to reality. Second, we included nurses and patient in three hospitals and did not use random sampling methods. Third, all of nurses and patients had Azeri culture. Therefore, we recommended that other studies should be conducted regarding respecting patients’ autonomy during nursing care with better sampling methods and in other Iranian cultures.