Unsatisfied patient's rights: A survey on the views of patients, nurses and physicians.

Neglecting patients' rights in a health care system can give rise to a challenging situation between health care providers and patients. The purpose of this study was to compare the views of patients as recipients of healthcare services and physicians and nurses, as healthcare providers, regarding the unsatisfied demands of different aspects of patients' rights in 3 hospitals representing three types of settings (teaching, private, and public). This was a cross-sectional descriptive analytical study. Data were gathered using a questionnaire which was filled out by an interviewer for the patients and self administered for nurses and physicians. The research venues were one general teaching hospital, one first class private hospital, and one non-teaching public hospital, and all 3 were in Tehran. The questionnaire consisted of some general questions about respondents' demographics, and 21 questions concerning the importance of patients' rights, and how well patients' rights were observed. Overall, 143 patients, 143 nurses (response rate: 61%) and 82 physicians (response rate: 27.5%) completed the questionnaire. The degrees of unsatisfied demands were different depending on the various views within each group regarding the degree of importance and observance of each right, which was measured by the Likert's scale ranging from 0.0 (no importance, no observance) to 10.0 (absolutely important, full observance). Concerning the non-normal distribution, the collected data were analyzed by non-parametric tests using the SPSS software (ver. 11.5). Results showed that the studied groups had significantly different views. The most prominent issue concerned patients' to make an informed decision, which was particularly unsatisfactory in the teaching hospital. The results of this research indicate that healthcare providers, especially physicians, need to be informed to show more respect for patients' rights in terms of access to clinical information and making decisions. The results demonstrated that there was a significant difference between the opinions of patients and health care providers regarding the extent of unsatisfied demands of patients' rights. According to the patients, the level of unsatisfied demands of these rights is far higher than that expressed by physicians.

Introduction

Following great advances in biomedical sciences and technologies in the recent decades in Iran, considerable research has been carried out in biomedical ethics with a focus on policy making, medical education, and research [1, 2]. The field of patients’ rights can be considered one of the most important aspects of medical ethics research, and respecting patients’ rights can be claimed to be one of its most important facets in healthcare provision [3, 4].

Although assessment of observance of patient’s rights in health care provision systems provides a framework for managers, it cannot depict a clear picture of the neglected rights. This could happen because patients have different opinions regarding the priority of different rights over one another [5].

On the other hand, comparing the views of healthcare providers and patients about the extent of adherence to patients’ right can notify the hospital management system about neglected rights.

The current study was designed and carried out from 2007 to 2009 in order to shed some light on the issue of respecting patients’ rights in Iran. In this study, the difference between the “importance” and “observance” of each right was used as an indicator for in-depth assessment of how well patients’ right are satisfied.

A comprehensive literature review showed that several studies have been carried out on the awareness of various groups regarding different aspects of patient’s rights and the impacts of demographic, environmental and cultural factors on this awareness [6-12]. Since various factors affect peoples’ perception of the importance and observance of different aspects of patient’s rights, in this study, the views of all involved groups including patients, physicians, and nurses towards the services provided in hospitals were compared. It is worth noting that none of the indexes used in this study regarding the unsatisfied demands of patient’s rights was based on the methods and findings of previous studies.

Method

The protocol of this study was approved by the Research Ethics Committee of Tehran University of Medical Sciences.

The current study was a cross-sectional descriptive and analytic one. Data collection was performed using a questionnaire which was filled out by an interviewer for the patients, and personally by physicians and nurses. In order to determine the validity of the questionnaire, its content was prepared based on a comprehensive literature review and the questions were modified through formal consultation with a group of experts in the field. To ensure reliability, differences in the mean scores were assessed using test-retest analysis. To increase the reliability of data collection, all interviews were completed by a single interviewer.

This field study included three differently funded and managed hospitals which were selected based on feasibility and cooperation of their directors; a teaching general hospital, a private hospital and a public general hospital, all located in Tehran, Iran. Detailed information of the study groups is tabulated in Table 1.

Table 1:

Number (response rate percentage) of respondents in each study group.

Hospital model	Teaching general hospital	Private hospital	Public general hospital	Total
Health care stakeholders
Patients	41(100)	52(100)	50(100)	143(100)
Physicians	22(24)	49(32.6)	11(18.9)	82(27.5)
Nurses	28(56)	74(74)	41(43.9)	143(61.3)

The questionnaire included a number of general questions aiming at collecting the participants’ demographic information, and 21 questions were allocated to analyze their view of the importance and observance of patient’s rights. The patients were selected from the surgery and internal medicine wards of the hospitals. Patients with moderate to severe pain and moderate to severe cognitive problems as well as those who had been hospitalized for less than 24 hours were excluded from the study. An informed consent was obtained from all patients after explaining the objectives of the study and prior to the interview. Data collection and compiling took 3 months. The inclusion criteria for the physicians and nurses included being involved in clinical service delivery in any ward at one of the three above-mentioned hospitals. Furthermore, it was emphasized that their answers should be according to the type of hospital (teaching, private, or public).

The views of participants about the importance and observance of each right were assessed on a Likert’s scale from zero (no importance, no observance) to 10 (absolutely important, full observance). Finally, the differences between the importance and observance scores were calculated as the index of unsatisfied patients’ rights from the viewpoints of all three participant groups (patients, nurses and physicians).

In presenting and interpreting the results of this study, we calculated means, standard deviations (SD) and medians for describing quantitative variables, and numbers and percentages for describing qualitative ones. To compare results among hospitals, among the three groups of the study (patients, physicians and nurses), and other independent variables, non-parametric tests were used. This was mainly because of the fact that the importance and observance variables were graded using the scores from zero to ten and showed non-normal distribution. When the independent variable had two groups (such as gender), the Mann-Whitney test was used, and if the independent variable had more than two groups (such as hospital), the Kruskal-Wallis test was utilized. In analysis of the results, given the accuracy of the study, where the difference in the mean scores was more than two, statistically significant differences (P < 0/05) were considered clinically significant.

Results

This field study provided information regarding patients’, physicians’, and nurses’ views on the level of importance and observance patients’ rights in different hospitals (teaching, private, and public).

In the patients’ groups, men outnumbered women in the private hospital (35 out of the 52 patients were male), while the number of interviewed women was higher in the teaching (23 out of 41) and public (28 out of 50) hospitals. The age of the patients ranged between 14 and 80 years (mean 46.57±17.36 and median 46.00 years). The mean was 51.36 years for men and 41.29 years for the women, indicating a significant difference between two groups (P < 0.001).

Of the respondents, 120 were married and 21 were single, and there were no significant differences between men and women or among patients from different hospitals in this regard. The number of illiterate patients was significantly higher in the public hospital than in the other two hospitals (P < 0.001). Also, the number of patients with a high school diploma or a bachelor’s degree was significantly higher in the private hospital than in the other two hospitals (P < 0.001). The age of the physicians ranged between 28 and 68 years, and the mean was 45.33±10.017 years.

Distribution of working experience among the physicians of the three hospitals was not statistically significantly different. Moreover, there was no significant difference between the gender groups in this regard. The age of the nurses ranged between 23 and 58 years (33.22±7.4 years). Working duration in hospital in this group ranged between 4 and 384 months (mean 115.26 months). There was no statistically significant difference in the distribution of gender, age, marital status and service track record among the nurses in the three hospitals.

The results of this study revealed that the different groups had different views concerning unsatisfied patient’s rights in different aspects. In presenting the results of the study, the questions can be divided into four categories:

First category: patients’ right to respect, privacy, and non-discriminatory health service provision.

Second category: patients’ right to access their clinical information.

Third category: patients’ rights in terms of choosing and deciding freely.

Fourth category: patients’ right to complain and the necessity of declaring medical errors.

The first category:

The results shown in Table 2 are mainly about patients’ right to respect, privacy, and non-discriminatory health service provision. In all three hospitals, the scores on unsatisfied rights were almost zero, and even negative in some cases. However, the attitudes of physicians and nurses were relatively negative concerning the neglected rights. However, their attitudes were significantly negative in the teaching hospital in comparison with the other ones.

Table 2:

Results on the unsatisfied patients’ rights to receive respectful and non-discriminatory service

Hospital model		Public general hospital	Private hospital	Teaching general hospital	P value	Total
Health care providers
Non-discriminatory health service	Patients	0.00±0.00	0.06±0.42	0.37±1.70	0.152	0.013±0.9
	Physicians	0.56±0.73	0.58±1.87	2.67±2.56	0.001*	1.18±2.19
	Nurses	1.44±1.79	0.82±2.03	2.48±3.12	0.008*	1.34±2.29
	P	0.00*	0.045*	0.000*	----	0.000*
Respect for religious, national, ethnic, cultural background of the patients	Patients	0.04±0.28	0.96±3.42	−0.60±2.27	0.108	0.51±0.42
	Physicians	0.25±0.89	0.72±1.40	2.33±2.42	0.003*	1.21±1.93
	Nurses	−0.26±1.89	0.39±0.814	1.88±1.51	0.000*	1.76±2.58
	P	0.431	0.001*	0.000*	---	0.000*
Observance of patients’ privacy	Patients	0.38±1.32	−1.42±3.48	−0.03±3.27	0.005*	−0.39±0.93
	Physicians	1.88±2.70	0.88±1.83	3.55±3.333	0.002*	1.94±2.79
	Nurses	0.68±2.31	1.19±1.73	2.50±2.66	0.004*	1.63±4.31
	P	0.120	0.000 *	0.000*	---	0.000*

Shows a significant P value. All data are demonstrated as mean±SD.

The second category:

Table 3 shows the results about the rights of patients to access their own information regarding their disease.

Table 3:

Results on the unsatisfied patients’ rights to access their own information

Hospital model		Public general hospital	Private hospital	Teaching general hospital	P value	Total
Stake Holder Group
Informing patients of their rights	Patients	5.98±4.13	3.65±4.63	6.38±3.77	0.004*	5.23±4.37
	Physicians	1.33±3.16	0.41±2.63	4.80±2.93	0.000*	1.73±3.34
	Nurses	4.47±3.33	2.20±2.14	3.63±3.44	0.001*	3.18±2.97
	P	0.300	0.000*	0.011*	---	0.000*
Providing sufficient information about the disease and its prognosis	Patients	1.86±3.76	2.12±3.88	3.98±5.46	0.49	2.56±4.41
	Physicians	0.11±0.60	0.58±2.17	3.27±2.66	0.000*	1.30±2.53
	Nurses	1.82±2.46	1/75±2/17	3.50±3.24	0.011*	2.10±2.56
	P	0.289	0.024*	0.809	---	0.038*
Informing the patients about their disease by health care providers	Patients	0.14±2.24	−0/04±3/53	1.13±3.72	0.192	0.35±3.20
	Physicians	0.00±1.00	0.60±2.05	2.95±2.63	0.000*	1.5±2.42
	Nurses	1.97±1.80	1.14±1.80	3.32±2.84	0.000*	1.83±2.19
	P	0.000*	0.052	0.016*	---	0.000*
Informing patients of the responsibility of different members of the health care provision team	Patients	4.48±4.84	2.31±5.66	6.27±5.08	0.002*	4.20±5.42
	Physicians	0.56±1.67	−0.74±3.09	3.14±3.08	0.000*	0.57±3.39
	Nurses	1.74±2.28	0.67±3.09	2.77±3.12	0.000*	1.42±2.37
	P	0.001*	0.001*	0.001*	----	0.000*
Introducing health care provision team to the patients	patients	2.92±5.19	0.79±6.16	2.74±5.77	0.127	2.07±5.76
	Physicians	0.22±1.30	−0.45±3.58	2.41±3.00	0.005*	0.52±3.42
	Nurses	0.97±3.41	0.59±2.49	2.00±3.51	0.144	0.98±3.03
	P	0.056	0.352	0.822	---	0.032
Providing sufficient information about the therapeutic plan for competent patients	Patients	2.80±3.97	1.77±4.60	5.15±5.10	0.002*	3.10±4.72
	Physicians	0.56±1.01	0.49±1.94	2.95±2.40	0.000*	1.23±4.72
	Nurses	1.41±1.83	0.13±10.22	3.58±2.79	0.135	-
	P	0.040*	0.443	0.083	---	0.009*
Explaining common risks and side effects to patients	Patients	6.54±4.50	4.13±488	7.85±3.95	0.000*	6.04±4.72
	Physicians	0.67±0.87	0.40±2.32	2.73±2.27	0.001*	1.12±2.40
	Nurses	1.62±2.10	1.95±2.31	3.15±2.46	0.025*	1.23±7.40
	P	0.000*	0.000*	0.000*	---	0.000*
Provision of information about less common side effects	Patients	5.68±4.83	4.12±5.19	6.65±4.68	0.046*	5.38v4.99
	Physicians	0.43±2.23	−0.71±2.71	1.50±3.50	0.030*	0.19±3.10
	Nurses	1.03±3.22	1.45±2.98	3.58±2.94	0.003*	2.09±2.32
	P	0.000*	0.000*	0.000*	---	0.000*
Patients’ access to content of their medical records	Patients	0.78±5.35	0.62±5.71	−0.13±4.10	0.465	-
	Physicians	−0.57±2.57	−001±2.90	0.10±4.21	0.903	-
	Nurses	0.78±5.35	−0.62±5.71	−0.13±4.10	0.018*	1.92±3.60
	P	0.723	0.723	0.221	----	0.985
Necessity of informing the patients about their rights upon admission	Patients	---	---	----	---	---
	Physicians	0.50±2.27	1.35±3.00	3.62±3.90	0.021*	2.00±3.42
	Nurses	3.16±3.89	1.81±2.22	4.69±3.21	0.00*	2.84±3.21
	P	0.070	0.400	0.306	---	0.101

Shows a significant P value. All are presented as mean±SD.

In this study, apart from service location, all the groups of participants had consensus on the high level of unsatisfied rights; this was highest and lowest in the teaching hospital and private hospital, respectively. Also physicians reported lower unsatisfied rights in comparison with the patients in all the three hospitals; differences between these two groups were statistically significant in some cases. The calculated indexes for nurses were between these two groups. However, as for answering patients’ questions about their disease, the lowest and highest values pertained to the patients and nurses, respectively.

The third category:

Table 4 shows the results of the assessment of patient’s rights in terms of choosing and deciding freely.

Table 4:

Results the unsatisfied patients’ rights regarding their freedom to choose their health care provider

Hospital model		Public general hospital	Private hospital	Teaching general hospital	P value	Total
Stake holder group
Having the option to choose care-providers (Management consultant) by patients	Patients	3.17±4.66	−0.18±4.62	2.06±5.94	0.055	1.62±5.17
	Physicians	0.89±1.83	0.31±2.11	1.74±3.54	0.126	0.75±2.57
	Nurses	3.03±3.39	1.21±3.00	3.88±4.16	0.002*	2.31±3.53
	P	0.287	0.094	0.265	---	0.036*
Seeking the opinion and involving the competent patient in diagnostic and treatment measures	Patients	3.10±4.10	3.19±5.25	5.56±5.10	0.032*	3.82±4.92
	Physicians	0.63±1.77	0.42±2.37	3.09±2.41	0.000*	1.38±2.61
	Nurses	1.78±2.41	1.06±2.27	3.38±2.89	0.000*	1.77±3.16
	P	0.068	0.001*	0.029*	---	0.00*
Possibility of leaving the hospital with personal consent against the advice of the treatment team	Patients	---	---	---	---	---
	Physicians	0.11±2.62	−1.07±1.96	0.73±1.93	0.004*	−0.39±2.17
	Nurses	−0.23±2.37	−0.93±2.60	−0.12±2.67	0.277	2.92±3.94
	P	0.703	0.769	0.224	---	0.684
Possibility of consulting with physicians other than the treating physician by the patient	Patients	---	---	---	---	---
	Physicians	0.88±1.64	0.19±2.04	2.91±2.64	0.000*	1.24±2.53
	Nurses	2.54±3.11	0.61±2.11	3.08±2.67	0.000*	1.75±2.78
	P	0.150	0.367	0.828	---	2.33

Shows a significant P value. All data are presented as mean±SD.

Overall, according to patients and nurses, the index of unsatisfied rights were significantly higher than those calculated for physicians in case of patients right to choose their care provider (the main physician) and participate diagnostic and therapeutic decision making.. However, there was a significant difference in this regard among the three different hospitals (highest in the private hospital as compared with the other two).

The fourth category:

Table 5 shows the unsatisfied rights in regards to a complaint system and revealing medical errors.

Table 5:

Results of the unsatisfied patients’ rights in regards to a complaint system and revealing medical errors.

Hospital model		Public general hospital	Private hospital	Teaching general hospital	P value	Total
Stake holder group
An effective Complaint Management System is in place in the hospital	Patients	2.20±6.36	3.67±5.91	3.11±5.21	0.819	3.14±5.7
	Physicians	0.38±1.30	−0.16±2.13	2.91±2.81	0.000*	0.81±2.5
	Nurses	1.32±3.54	0.56±1.88	3.68±2.64	0.000*	1.42±2.8
	P	0.630	0.000*	0.706	---	0.004*
Revealing the compensated (corrected) errors to the patients by the responsible person	Physicians	−1.43±4.43	1.70±2.63	2.48±4.01	0.041*	1.60±3.5
	Nurses	0.58±5.08	1.40±3.32	3.69±4.63	0.14	0.48±1.5
	P	0.334	0.676	0.347	---	0.965
Disclosing compensable (non-corrected) medical error to patients by the responsible person	Physicians	−1.50±3.38	1.86±2.13	2.81±3.86	0.005*	1.74±3.2
	Nurses	0.95±3.21	1.42±3.54	4.42±3.23	0.000*	1.31±2.2
	P	0.059	0.542	0.125	----	0.725
Disclosing irreversible medical errors (non-corrected) to patients by the responsible person	Physicians	−2.63±3.38	2.68±3.14	4.10±3.52	0.000*	2.40±4
	Nurses	2.69±4.27	2.14±3.69	4.48±3.43	0.011*	0.04±3.7
	P	0.002*	0.548	0.451	---	0.442

Shows a significant P value. All data are demonstrated as mean±SD.

In general, the unsatisfied rights regarding a complaint system were less pronounced in the private hospital according to the physicians and nurses, and they were similar in the two other hospitals from the viewpoints of all three participant groups.

Regarding disclosing medical errors to the patients, no significant difference was noted between the views of nurses and physicians. However, regarding the necessity of observance in terms of reversible errors, the physicians’ views were different in the public hospital compared to that in the other two hospitals.

Overall, the physicians of the public hospital reported more unsatisfied rights in comparison with the physicians of other two hospitals.

Discussion

A review of the opinions of the three groups (patients, physicians and nurses) in three types of healthcare centers revealed different views among them concerning unsatisfied patients’ rights in different respects. The results of the detailed analysis of the above-mentioned rights are as follows:

The first category (patients’ right to respect, privacy, and non-discrimination):

There existed consensus over the proper observance of patients’ rights among all the patients from three different hospitals. The different scores of unsatisfied rights by healthcare providers and recipients are demonstrated in Table 2. This could be explained by different facts, including the higher importance of the issue for health care providers, different viewpoints of health care providers compared to the patients, long lasting memory of the incidences of discrimination, and great expectations of the health care providers in selected hospitals about the necessity of non-discriminatory health care provision. It needs also to be mentioned that violating patient’s rights in this respect is a great concern from an ethical point of view. Moreover, the notable amount of unsatisfied rights in this category in teaching hospitals of Iran indicates that the issue needs to be addressed promptly.

The second category (The right of patients to access their own information):

The high scores of unsatisfied rights in terms of this category necessitate paying due attention to information transition management between physician and patient.

The report of an study conducted by British Patients Association (2005) on the views of 1000 healthy individuals (older than 18 years) and 344 patients suffering from chronic diseases demonstrated that approximately 90 percent of the participants believed that they received the required information regarding their treatment and its risks or advantages. In the same study, 60%, 10%, and 8% of patients had received a copy of their medical records from their physician, had access to limited information, and did not have any access to their clinical information, respectively [13].

In a questionnaire study carried out in Singapore on the attitude and practice of 475 physicians in regards with the interaction between physicians and patients, approximately 85% of the physicians expressed they would provide an appropriate answer to their patients’ questions about their diseases, and only 24% would not do so. In contrast, 32% of the physicians always disclosed the truth about the disease and its prognosis. As for explaining possible risks and complications, 92% of the physicians mentioned they would discuss common complications, 29% disclosed all possible complications, and 10% said they would only mention important complications to patients [9].

According to the results of a study carried out by Ducinskiene (2006), a significant discrepancy existed between healthcare physicians’ report in terms of different issues, including informing patients of the prognosis of their disease, its potential complications, and possible alternative treatment options (80% – 98%). Several other studies have demonstrated that patients were less informed of the mentioned issues [14-17]. It appears that this category of rights is less satisfied. Underestimation of physicians about such unsatisfied rights increases concerns, showing their misunderstanding of patient’s actual demands. On the other hand, the amount of unsatisfied rights was much higher in the teaching hospital than the other two, so it requires special considerations. Also for better understanding of nurses about the patients’ informative needs, their estimations could be more realistic to improve the patients’ information level.

Our findings showed that patients acquire their needed information through asking questions actively and believe that the medical team is accountable; this is not approved by healthcare providers especially in teaching hospitals.

Based on the results of this study, preparing information dissemination packages concerning the standards of patients’ access to therapeutic and non-therapeutic services, teaching communicative skills to therapeutic teams for proper transfer of information about diagnostic and therapeutic measures and introducing a proper therapeutic team to the care receiver can be greatly helpful.

The third category (Patients’ rights in terms of choosing and deciding freely):

Considering the structure and governance of teaching hospitals, it seems quite natural that patients do not necessarily have the ability to choose their physicians. In fact in teaching hospitals of Iran, patients should be examined by students and residents before physicians. This is only acceptable if patients are properly informed of the situation at the time of admission. However, it could be suggested that in an ideal situation, patients should be able to choose their intern, resident, and faculty physician through a hierarchical framework even in a teaching hospital. This aspect was not analyzed in this study. According to a study carried out by the British Patients Association [13], about 80% of the patients considered themselves capable of choosing their general practitioners, while this proportion was only 45% regarding consultant specialists. In terms of having access to a second opinion regarding the diagnosis of their disease, 40% of the participants believed that they had such access, 27% expressed that it was difficult to have such access, and 30% were completely unaware of this possibility.

The most frequently neglected patients’ right in all three hospitals concerned their contribution to diagnostic and therapeutic plans. In one study, researchers found that although nurses believed that patients should participate in clinical decision making processes, they did not practically apply this in their clinical practice [18]. Findings of another study on ethical medical issues with a focus on written informed consents conducted by Ibrahim Basagaolgu et al showed that the 29% of the patients of the general surgery ward did not recall receiving any form regarding an informed consent [19], 56% were confident that they had never received any such form, and 15% had no idea such a form existed. The reason for this was explained to be due to the fact that many written consent forms were filled in by relatives of the patients without their being informed of it. Interestingly, it was observed that only one patient was unconscious during the admission. On the other hand, only 19% of the patients who personally signed the form had read it before signing. As for the question “who collected the signed forms?”, only 23% of the patients could remember the person who collected them (surgeon, nurse or receptionist).

It has been demonstrated that although patients wish to access the information regarding alternative treatment options, they tend not to participate in the decision-making processes. Findings of several studies have demonstrated that healthcare professionals should introduce measures to encourage patients to contribute to the clinical decision making process more proactively [20]. It could be suggested that producing specifically designed informed consent forms can play an important role in improving the health care system from an ethical point of view.

The fourth category (Patient’s right regarding complaints and reporting medical errors):

According to the findings of this study, it seems that the healthcare providers are more aware of the existence of a complaint system. Thus, more effective information dissemination is needed for patients to remind them of this system. In light of the importance of such issues, public hospitals need to implement effective measures so that they can achieve patient centeredness by improving patient satisfaction.

The relatively low response rate of the physicians can be considered one of the major limitations of this study and a source of information bias. However, we endeavored to minimize this limitation by asking directors of the hospitals to demand their employees’ contribution in writing.

Furthermore, due to the executive limitations, it was not possible for us to study some aspects of patients’ rights. For example, as private hospitals in Iran are not involved in any research activity, it was not possible to investigate research related ethical issues. Furthermore, we refrained from asking patients about their views of medical errors as it was anticipated that it would induce stress. Therefore, some elements of patients’ rights were not properly investigated in our study. In order to achieve more accurate results which can be generalized to the whole health care system, conducting further studies on larger cohorts selected from different types of hospital seems necessary.

Conclusion

Based on the result of this study, it seems that healthcare providers, particularly the medical group, should receive supplementary training to observe patients’ rights to access information and their rights to choose and make decisions, because the physicians in this study had a more optimistic view about the situation in comparison with the patients.

Also, the following measures could play significant roles in improving the patient’s rights status:

Preparing proper forms for disseminating the standards and the conditions of serving at medical centers,

Expounding patient’s rights,

Preparing special informed consent forms for disseminating proper information and improving the conditions required for participation of the patients in decision-making processes,

Submitting the final revision of the questionnaire of this study to hospital authorities for internal evaluation of the different aspects of patients rights in the medical centers,

Organizing complaint systems at medical centers, and

Performing similar studies and comparing the viewpoints of providers and recipients of healthcare services.