Observance of Patient's Rights: A Survey on the Views of Patients, Nurses, and Physicians.

Assessment of patients' views about the observance of patients' rights in the health system is of great importance for evaluation of such systems. Comparing views of patients (recipients of health services) and physicians and nurses (health care providers) regarding the observance of various aspects of patients' rights at three hospitals representing three models of medical service provision (teaching, private, and public) is the main objective of this study. This was a cross-sectional descriptive and analytical study, and the information needed was gathered through questionnaires. They were filled out by an interviewer for patients, but self administered by physicians and nurses. The field of study consisted of three hospitals including a general teaching hospital, a private hospital, and a public hospital, all located in Tehran. The questionnaires contained some general questions regarding demographic information and 21 questions concerning the necessity of observing patient's rights. The questionnaires were initially filled out by a total of 143 patients, and then consigned to 143 nurses (response rate = 61.3%) and 82 physicians (response rate = 27.5%) to be completed. The rate of observance of each right was measured on a Likert scale ranging from zero (non-observance) to 10 (full observance). Considering abnormal distribution of the information, it was analyzed with non-parametrical tests using SPSS 11.5 software package. The results of this study showed that the study groups had different views about how well different aspects of patients' rights were observed. The highest level of disagreement was related to the right of choosing and deciding by the patients, which was not satisfactory in the teaching hospital. According to the results, it seems that healthcare providers, especially physicians, should be better informed of patients' right of access to information and right of choosing and deciding. Based on the observed disagreement between the views of the patients and those of the physicians in the present study, it can be asserted that the patients thought that the level of observance of these rights was lower in comparison with what the physicians thought.

Introduction

Surveying the rate of observance of patients’ rights in medical services provides a suitable guide for health system management to ensure an appropriate relationship between service providers and service recipients.

Literature contains numerous studies concerning the degree of observance of various aspects of patients’ rights from the viewpoint of different stakeholders and effects of demographic, environmental and cultural factors on their awareness (1–6).

Considering various determinants of stakeholders’ views in regard to observing different aspects of patients’ rights, the main objective of the present study was to compare views of major stakeholders including patients, physicians and nurses at hospitals representing three models of medical service provision, including teaching, private, and public hospitals.

The aspects presented in this study regarding the opinions of various groups had not been observed in previous studies.

Methods

This was a cross-sectional descriptive and analytical study, and the information was gathered through questionnaires which were filled out by an interviewer for patients, and self administered by physicians and nurses. The questionnaire content was modified after expert consultation was performed to ensure validity. To increase reliability, interviews were performed by the same interviewer at all three hospitals. Using the test-retest, the mean differences in responses were studied at two stages, which confirmed the reliability of the questionnaire.

The research venue was three hospitals including a general teaching hospital, a private hospital, and a public hospital, all located in Tehran. The questionnaire comprised of a series of general questions with regard to demographic information and 21 questions concerning the observance of patients’ rights. Patients were selected from those hospitalized in the surgery and internal medicine wards of the mentioned hospitals. The exclusion criteria for patients in the study were:

1) Patients who had been hospitalized for less than 24 hours; 2) patients suffering from moderate and severe cognitive problems; and 3) patients with moderate to severe pain.

Interviews were conducted with patients after being informed of the objective of the study. The only inclusion criterion for physicians and nurses was clinical activity in any of the above-mentioned hospitals. Before the interview, it was emphasized that interviewees should restrict their judgment to the respective hospital only. Questionnaires were distributed, completed, and collected over a three-month period. The information related to 143 patients was gathered through interview, and was then sent to the other two groups. Respondents were 143 nurses (response rate = 61.3%) and 82 physicians (response rate = 27.5%).

The rate of observance of each right was measured on a Likert scale ranging from zero (non-observance) to 10 (full observance). To describe results, the mean, median, and standard deviation (SD) were used for quantitative variables, while the number and percentages were determined to describe qualitative variables.

Non-parametrical tests were used for comparing the three groups in terms of their views about the rate of observance of each right and other independent variables. As the variable of observing rights had been measured on a scale from zero (non-observance) to 10 (full observance) and had no normal distribution, non-parametrical tests were applied.

In cases where independent variables consisted of two groups (such as gender), the Mann-Whitney Test was used, while the Kruskal-Wallis Test was used in cases where independent variables had more than two groups (such as hospital). In assessing responses of the three groups at the three selected hospitals, cases with statistical significance were considered clinically significant provided that the difference between mean scores was more than 2.

Ethical Considerations

This study was approved by the Research Ethics Committee of Tehran University of Medical Sciences. Information was gathered after obtaining informed consents from the participants. To respect privacy and confidentiality, personal information shall not be disclosed to others without written authorization from participant(s) in the study. Also, considering the request of the officials in charge of the hospitals cooperating in this study, no mention will be made of the names of the hospitals.

Results

This study, as a field one, provides information concerning different views of three groups including patients, physicians and nurses concerning how patients’ rights are observed, and views of each group at three types of healthcare centers.

In the patients’ group, in terms of gender, men outnumbered women at the private hospital (35 out of 50 persons), while there were more participating women at the teaching hospital (23 out of 41) and the public hospital (28 out of 50). The age range of patients was between 14 and 80 years (46.57±17.36 years and a median of 46.00 for the whole patients). The mean age was 51.36 and 41.29 years for men and women, respectively; the difference was statistically significant (P < 0.001). One hundred and twenty patients were married and 21 were single. Marital status in two groups of men and women had similar distributions, and there were no statistically significant differences among hospitals in this regard. The number of illiterate patients was significantly higher in the teaching government-run hospital, and patients holding a high school diploma or bachelor’s degrees constituted a greater proportion in the private hospital (P < 0.001).

The minimum age of physicians was 28 years and the maximum stood at 68 years (45.33±10.017). Distribution of work experience showed no statistically significant difference between physicians working at the three hospitals. No statistically significant inter-gender difference was noted in this regard.

In the nurses group, the minimum and maximum age was 23 and 58 years, respectively (33.22±7.4). The duration of work experience ranged from 4 months to 384 months (115.26). There were no significant differences among the nurses of the three hospitals in terms of the distribution of gender, age, and work experience.

The results of this study demonstrated that the study groups had different views about how well various aspects of patients’ rights were observed. The highest level of disagreement between recipients and providers concerned patients’ right to choosing and deciding, and the situation was not satisfactory in the teaching hospital. Results suggest that healthcare providers, especially physicians, should be better informed of patients’ right to access information and right to participate in decision making.

To present results, questions can be grouped into four categories:

First category: The results shown in Table 1 mainly concern respecting the patient and his/her privacy and non-discriminatory treatment. Patients have agreed unanimously, at each of the three hospitals, on full observance of this right (mean score > 9) while physicians and nurses’ views regarding non-discriminatory treatment shows a significantly lower level of observance compared with the views of patients. In regards to refraining from disrespectful behavior, although statistically significant differences were observed, they were not of any clinical importance. On the other hand, according to the physicians and nurses’ responses, adherence to non-discrimination was significantly lower at the teaching hospital in comparison with the other two hospitals.

Table 1:

Results on the observance of the right of patients to receive respectful and non-discriminatory service

Inquired aspect	Stakeholder	Type of hospital			P value	Total
		Teaching	Private	Public
Non-discriminatory health service	Patients	9.95±1.64	9.94±0.41	10±00	0.03*	9.86±0.93
	Physicians	6.86±2.55	8.42±1.66	8.89±1.61	0.01*	8.03±2.07
	Nurses	6.42±2.67	8.74±1.80	8.26±2.22	0.00*	8.14±2.28
	P value	0.00*	0.00*	0.00*	-	0.00*
Respect for religious, national, ethnic, & cultural believes	Patients	10±00	9.81±1.38	9.96±0.28	0.67	9.92±85.0
	Physicians	7.62±2.50	9.03±1.15	9.38±0.91	0.08	8.95±183
	Nurses	7.72±1.83	9.45±1.11	9.61±0.71	0.00*	9.16±1.36
	P value	0.00*	0.02*	0.00*	---	0.00*
Observing patients’ privacy	Patients	9.20±2.42	9.71±1.46	9.59±1.23	0.44	9.351±1.72
	Physicians	6.23±3.30	8.82±1.50	7.75±2.76	0.02*	7.78±2.68
	Nurses	7.15±2.69	8.75±1.66	8.92±1.77	0.00*	8.84±2.03
	P value	0.00*	0.00*	0.00*	--	0.00*

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

The second category: In Table 2, the results on observing patients’ right to access information regarding their disease are shown.

Table 2

Results on the observance of the right of patients to access their own information

Inquired aspect	Stakeholder	Type of hospital			P value	Total
		Teaching	Private	Public
Informing patients of the regulations on access to clinical and general services	Patients	2.69±3.67	5.00±4.51	3.10±3.97	0.01*	3.69±4.14
	Physicians	4.85±2.81	8.30±1.66	6.67±2.69	0.00*	7.15±2.61
	Nurses	5.16±2.92	7.11±2.11	4.71±2.94	0.00*	5.98±2.78
	P value	0.00*	0.00*	0.00*	--	0.00*
Providing sufficient information about the disease and its prognosis	Patients	5.15±4.77	7.77±3.88	7.34±3.66	0.01*	6.87±4.21
	Physicians	5.95±2.66	8.29±1.59	8.89±1.26	0.00*	7.93±2.21
	Nurses	5.92±2.69	7.86±1.99	7.74±2.37	0.00*	7.45±2.36
	P value	0.62	0.56	0.36	-	0.14
Responding to patients questions about their disease	Patients	8.05±3.46	8.98±2.42	9.34±1.69	0.20	8.85±2.95
	Physicians	6.41±2.72	8.60±1.61	8.68±1.22	0.00*	7.93±2.21
	Nurses	6.08±2.49	8.31±1.64	7.97±1.78	0.00*	7.76±2.04
	P value	0.02*	0.17	0.00*	--	0.00*
Informing patients of the professional duties of the health care provision team	Patients	2.37±4.10	6.21±4.74	2.82±4.07	0.00*	3.92±4.64
	Physicians	5.55±3.00	8.21±1.74	6.10±2.51	0.00*	7.15±2.57
	Nurses	6.30±2.77	8.76±1.57	7.72±2.44	0.00*	7.95±2.32
	P value	0.00*	0.00*	0.00*	-	0.00*
Introducing health care provision team	Patients	1.71±3.05	4.04±4.46	2.06±3.34	0.01*	2.72±3.95
	Physicians	5.68±2.73	7.98±2.08	6.22±3.45	0.00*	7.04±2.68
	Nurses	6.00±2.91	8.23±2.30	6.05±3.08	0.00*	7.17±2.78
	P value	0.00*	0.00*	0.04*	--	0.00*
Providing sufficient information about treatment options	Patients	4.15±4.53	7.2±4.24	5.61±4.48	0.00*	5.70±4.53
	Physicians	6.36±2.23	8.53±1.42	7.89±2.93	0.00*	7.81±2.11
	Nurses	5.96±2.66	9.44±10.28	8.13±2.05	0.00*	8.32±7.46
	P value	0.03*	0.18	0.00*	--	0.00*
Explaining common risks and side effects	Patients	2.02±3.92	5.23±4.70	2.50±3.98	0.00*	3.36±4.45
	Physicians	6.36±2.36	8.49±1.62	7.80±1.93	0.00*	7.77±2.10
	Nurses	6.15±2.11	7.48±2.27	7.64±2.43	0.01*	7.26±2.34
	P value	0.00*	0.00*	0.00*	--	0.00*
Providing information about less common side effects in an understandable language	patients	1.10±2.99	2.29±4.07	1.12±2.91	0.17	1.54±3.43
	Physicians	5.32±0.04	7.06±2.13	6.88±3.04	0.08	6.344±2.67
	Nurses	4.31±2.83	6.38±2.72	6.22±3.35	0.01*	5.90±3.03
	P value	0.00*	0.00*	0.00*	--	0.00*
Providing patient access to their medical records and their contents	Patients	8.79±3.20	7.58±4.23	7.30±4.50	0.23	7.88±4.04
	Physicians	6.19±3.02	7.79±2.26	6.22±3.30	0.15	7.03±2.76
	Nurses	5.342±2.41	6.74±3.04	6.85±2.65	0.04*	6.51±2.85
	P value	0.00*	0.24	0.70	--	0.00*
Necessity of informing patients about their rights upon admission	Patients	--	--	--	--	--
	Physicians	4.67±2.68	7.32±2.63	6.67±2.00	0.00*	6.36±2.81
	Nurses	4.62±2.65	7.62±2.35	5.95±3.12	0.00*	6.49±2.91
	P value	0.94	0.55	0.51	--	0.77

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

In this study, all three groups, regardless of study venue, agreed that the level of observing patients rights was low to average. In most cases, the level was least at the teaching hospital.

In all three hospitals, physicians reported more observance of this right compared to what the patients did; the difference was significant. As far as nurses were concerned, in most cases scores were in-between those of the other two groups. All three groups at each of the three hospitals admitted to an intermediate level of observance of patients’ right to access their medical records; nurses, especially in the teaching and public hospitals, gave lower scores than the other two groups.

The third category:Table 3 shows the results of the study on observing patients right to choose and decide freely.

Table 3

Results concerning the observance of patients’ right for choosing and deciding freely

Inquired aspect	Stakeholder	Type of hospital			P value	Total
		Teaching	Private	Public
Right to choose care-provider (original physician) by patients	Patients	4.91±4.89	8.51±3.36	4.58±5.03	0.00*	6.15±4.77
	Physicians	3.79±2.65	8.33±1.65	6.33±3.00	0.00*	6.90±2.88
	Nurses	3.92±3.22	7.64±2.77	5.54±2.91	0.00*	6.27±3.24
	P value	0.51	0.19	0.37	--	0.38
Seeking the opinion and involving the competent patient in diagnostic and treatment measures	patients	2.13±3.84	5.96±4.85	5.20±4.37	0.00*	4.63±4.67
	Physicians	6.00±2.30	7.94±1.72	7.50±2.00	0.00*	7.22±2.14
	Nurses	5.35±2.72	7.44±2.21	7.19±2.62	0.00*	6.94±2.56
	P value	0.00*	0.01*	0.02*		0.00*
Possibility of leaving the hospital with personal consent against the advice of the treatment team	Patients	---	--	--	--	--
	Physicians	8.36±1.96	9.75±3.86	8.55±2.20	0.00*	9.81±1.60
	Nurses	7.40±2.36	9.18±1.34	8.82±2.43	0.00*	8.71±2.05
	P value	0.13	1.01	0.73	--	0.08
Right to consult physicians other than the treating physician by the patient	Patients	--	--	--	--	--
	Physicians	5.00±2.58	8.25±1.62	7.75±2.49	0.00*	7.30±2.58
	Nurses	5.52±2.75	7.97±2.14	6.24±3.05	0.00*	6.91±2.76
	P value	0.50	0.51	0.20	--	0.57

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

Regarding the observance of the patients’ right to choose their healthcare provider (the main physician), the private hospital showed considerably higher scores. Observance of this right, in the view of all three groups, showed lower rates at the teaching hospital, but a high rate was seen in the private hospital.

With regard to seeking the participation of the competent patients for diagnosis and treatment, scores given by patients were lower than that of the other two groups, especially at the teaching hospital.

In the patients’ group, the observance rate was significantly lower at the teaching hospital compared to the other two hospitals. It should be noted that the disparity between the other two hospitals was not considerably high. It seems that the possibility of consulting with other physicians was better observed in the private hospital.

The fourth category: The results shown in Table 4 concern the existence of a complaint system and the necessity of revealing medical errors.

Table 4

Results on the observance of the patient’s right to follow up their complaints and revealing medical errors

Inquired aspect	Stakeholder	Type of hospital			P value	Total
		Teaching	Private	Public
Active complaint system in the hospital	Patients	6.67±5.00	5.87±4.94	6.60±4.62	0.88	6.22±4.75
	Physicians	6.41±2.77	9.11±1.41	7.56±1.66	0.00*	8.13±2.26
	Nurses	5.80±2.53	8.93±1.51	6.81±2.68	0.00*	7.66±2.50
	P value	0.70	0.00*	0.75	--	0.00*
Revealing compensated treatment error by the responsible person	Physicians	4.76±3.13	5.48±2.47	7.00±3.60	0.13	5.42±2.97
	Nurses	4.08±2.95	6.67±2.76	5.16±3.58	0.00*	5.71±3.21
	P value	0.51	0.05*	0.017	--	0.56
Revealing compensable (uncompensated) treatment error by the responsible person	Physicians	5.62±3.15	6.45±2.47	8.50±2.27	0.01*	6.50±2.83
	Nurses	3.78±2.75	6.77±2.97	5.78±2.98	0.01*	5.86±3.31
	P value	0.03*	0.61	0.01*	--	0.18
Revealing no compensable treatment error by the responsible person	Physicians	4.75±3.68	5.82±3.23	8.00±2.05	0.04*	5.83±3.38
	Nurses	3.00±2.37	6.26±3.15	4.56±3.35	0.00*	5.06±3.13
	P value	0.05*	0.57	0.00*	--	0.16

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

The activity of the complaint-examining system at the private hospital was more tangible in the view of physicians and nurses. However, patients’ views did not demonstrate any difference.

Discussion

A review of the opinions of the three groups (patients, physicians, and nurses) in the three types of healthcare service providing centers revealed different views about the observance of patients’ rights from different standpoints. The analysis of the results of the study is presented in four categories:

The first category (Receiving respectful and non-discriminatory services):

The results of our study demonstrated that there was general consensus among patients in the three hospitals regarding complete observance of these rights (Mean score >9). However, literature review showed different results. In the study by Kuzu et al. on 166 patients in internal medicine and surgery wards of three general hospitals in Denizly, Turkey, it was shown that 91% believed that there were no fair accesses to healthcare services; and, 86.1% said that their privacy was respected (4). It needs to be mentioned that the difference in terms of fair access to healthcare services may be due to different perceptions of the interviewees regarding the concept of fairness and justice

The results shown in Table 1, which indicate differences in the reported rate of observance by the recipients and providers of healthcare, may be due to higher sensitivity of providers to this subject. Of course, there may be differences in the healthcare providers and recipients’ perceptions of these rights and their applicability. On the other hand, non-observance of these rights, despite its relatively low rate, may leave a persisting effect on the minds of the healthcare providers. Another reason for this difference may be higher sensitivity and sufficient attention of the healthcare providers to this subject. Further research in this regard is recommended.

The considerable difference in the rate of observance of these rights in the three hospitals concerned necessitates surveying the factors by the managerial authorities of teaching hospitals.

The second category (the right of patient to access information):

The low rate of observance of this right indicates the necessity of paying more attention to management of information transfer between physicians and patients. Other studies, similarly, revealed a low rate of observance of this right. In a report by the British Patients Association in 2005 which was published after a survey on 1000 persons over 18 and 333 patients with chronic diseases in order to assess the situation of patients’ rights in the British Health System, it was shown that nearly 90% of the participants believed that enough information about their treatment, risks, and benefits was given to them as they expected; however, the observance of the right to see their medical record was mentioned only by 75% of the participants. Regarding the possibility of receiving information about prescription and other therapeutic options, 90% had a positive view. About the possibility of receiving a copy of their medical records from their physician, 60% had a positive view, 10% saw it as limited by conditions and 7% had a negative view (7).

In a questionnaire survey, by Chan and Goh in 2000 in Singapore, on the views and performances of 475 physicians concerning physician-patient relations, 85% of the physicians paid attention to patients’ questions about their illness, and in 24% of cases, they did not explain the disease to the patient, while 32% of the physicians never concealed the patients’ conditions from them. In explaining the probable risks and adverse effects of the prescribed medication, 92% mentioned only common adverse effects, while 29% mentioned all of them, and 10% mentioned only those important to the patient. (3)

In the study by Basagaoglu and Sari on the views of patients regarding ethical considerations, with emphasis on informed consent during clinical training, it was revealed that 29% of patients stated they had signed an informed consent form after being admitted to the surgical ward, while 56% said that they had not received such a form to sign, and 15% could not recall whether they had signed one or not. The truth, however, was that most of the forms were signed by the patients’ relatives, and they were not aware of it. Interestingly, only one of the patients was not conscious when admitted. On the other hand, only 19% of the patients had read the form before signing it. In reply to the question about who had given them the form, only 23% identified the person concerned (surgeon, nurse, receptionist) (8).

In the study by Kuzu et al., 40% of the patients said that they did not ask the personnel for service. The reasons given for this included: fear of the personnel getting angry because of asking, worrying about the negative effects of such a protest on the quality of care, poverty, shyness, being an immigrant, psychological problems, illiteracy, not being aware of relevant laws and regulations, the personnel being too busy, and poor relationships between patients and care-providers. (4)

In another study in Turkey, it was demonstrated that only 36% of patients knew about the rules of the hospital (9).

In our study, the higher rate of observance stated by physicians doubles the concern because it is indicative of less importance given by physicians to patients’ need for information.

Preparing patient information packages about the hospital regulations and the process of service provision, as well as giving necessary training to healthcare providers about communicating skills, and finally, practical measures such as specific informed consent forms may help in solving some of these problems. This necessity is more visible at teaching hospitals.

The third category (patients’ right to choose and decide):

Given the nature of the teaching hospital, it seems that the low rate of observance of the patients’ right to choose their healthcare providers is not surprising. This situation is negligible only in cases where the patient has been informed of the situation on admission. One could argue that even at a teaching hospital, patients should have the right to choose their healthcare providers from each level of hierarchy. This aspect was not included in this survey. In a report by the British Patients Association, nearly 80% of patients had the right to choose their general practitioner (GP), but only 45% of them had the same right regarding their specialist physician. In cases where the patient was in doubt about the diagnosis made by the GP, only 40% of them believed that seeking another opinion in this regard was easy, while 27% saw it difficult and nearly 30% did not know (7).

Concerning the patients’ right to participate in decision making for diagnostic and therapeutic procedures, as in the second category, the rate of observance of this right was low, particularly in the teaching hospital. This calls for the same measures in this case, too. In other studies, although the nurses often hold a positive views in this regard (10), observational studies have shown that, in practice, this right is not observed. On the other hand, although the patients are interested in receiving more information about alternative treatments, they are reluctant to participate in subsequent decision-makings. Evidence indicates that more interventions by healthcare professionals are needed to encourage patients to participate in decision making (11).

The fourth category (patients’ right with respect to investigation of their complaints and revealing medical errors):

The functionality of the complaint system in the private hospital was rated higher, according to the physicians and nurses. This indicates the necessity of informing patients more appropriately regarding 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.

Limitations of the study:

The relatively low response rate of the physicians was one of the limitations of this study. However, we tried to minimize this limitation by making arrangements with hospitals directors to endorse the study and follow up the correspondence with the physicians concerning filling out the questionnaires.

To mention the study’s methodological and practical limitations, it was not possible to carry out examine some aspects of patient’s rights. For example, since no research activity was carried out in the private hospital, it was not practical to ask about adhering to research ethics. Inquiring about medical error was also not possible either, because of the possibility of worrying patients. That is why some articles of the Charter were not included in the questionnaire. Generalization of these results to various models of service provision (private, teaching, and public) requires studying on larger samples from several hospitals in each group.

Conclusion

Based on the results, it seems necessary for healthcare providers to be better informed of patients’ rights to access information and to choose and decide. This can be asserted as our results demonstrated that the extent of observance of patients’ rights was evaluated lower by the patients compared with the views of health care professionals. This indicates that further investigation is needed to establish and develop proper guidelines regarding this issue.