Occupational therapists and patients' rights: their level of Clinical knowledge.

Addressing patients' rights issues brings occupational therapists ethical and political responsibilities that involve patients' privileges and new facilitating factors which influence their needs. The goal of this study was to determine the level of occupational therapists' knowledge about patients' rights. The present research was a cross-sectional study which involved 125 occupational therapists chosen by a convenience sampling strategy in Tehran during the year of 2012. A four-part questionnaire was used for data collection, and the degree of the subjects' self-assessment of their knowledge was measured based on the obtained numbers of correct answers in the third part. The validity and reliability of this questionnaire were assessed prior to its being distributed among participants. The results demonstrated no significant association between the level of occupational therapists' knowledge about patients' rights and their existing experiences within their areas of occupational therapy (P>0.05). Based on the result, 53.6% of the respondents had high level of knowledge about patients' rights. Facilitating factors which influence the attainment of patients' rights were classified into three groups: organizations, therapists and clients. The results of the present research demonstrated that the level of occupational therapists' knowledge about patients' rights were high. Furthermore, this study showed that for optimal result, there is a need to provide milieu for observing the patients' rights in clinical occupational therapy services.

Introduction

The patients’ rights movement have promoted patient involvement in health care for 50 years (1). Patients’ rights encompass legal and ethical issues in the provider-patient relationship, including a person’s right to privacy, the right to quality medical care without prejudice, the right to make informed decisions about care and treatment options, and the right to refuse treatment.

The Patients’ Rights Charter of Iran was approved by Health Policy Council with a new and comprehensive viewpoint which aimed to clarify the rights of the health service recipients and ensure observance of moral standards in the treatment and medical fields on November 26, 2009, and on December 1st of the same year, it was corresponded to all relevant centers (2, 3).

One of the health services which patients may get involved in is occupational therapy (OT). According to the World Federation of Occupational Therapy (WFOT), OT is a client-centered health profession which concerns promoting the health and well-being of patients through their occupation. Professional ethics and standards for regulating ethical conduct will reinforce level of confidence between patients and health professionals in OT, which in turn will result in protection of community (4). Galheigo reported in 2011 that occupational therapists and scientists need to be attentive of human rights issues (5) and they must provide a supportive environment which facilitates patients’ efforts in getting involved in their own health care services (6). Nowadays, people’s public health information and awareness of patients’ rights has increased. Furthermore, observing patients’ rights may help to achieve more satisfaction among patients and the medical team, while not observing these rights would lead to distrust, damages and losses in the patients and the medical team. Hence, OT professionals must be aware of patients’ rights and try to observe them.

Up to the present time, no descriptive study has been reported in Iran in regard to the relationship between occupational therapists’ work experience, their educational level and level of their knowledge about patients’ rights in all areas of their clinical practice. Therefore, this study was conducted to examine the level of occupational therapists’ knowledge about patients’ rights in this effective health care professional service.

Method

The present research was a descriptive, analytic, and cross-sectional study. The study samples consisted of 125 occupational therapists that were chosen by convenience sampling strategy from rehabilitation clinics under the supervision of the University of Social Welfare Rehabilitation Sciences (USWR) and departments of OT in the School of Rehabilitation of USWR, Tehran University of Medical Sciences and Shahid Baheshti University of Medical Sciences. The sample size determined for the current study was five participants per variable (7). Occupational therapists with more than six months’ work experience were included. The study was approved by the ethical committee of USWR, and all participants were informed about study objectives and their written and signed informed consents were obtained. Questionnaires were anonymized and the information got collected privately by the researchers.

The data collection instrument was a questionnaire designed by the researchers and consisted of four-parts: the first part included demographic information (age, gender, work experience, educational level); the second part consisted of five questions about participants’ self-assessment of their knowledge about deputy police of the medical council Medical Council of Islamic Republic of Iran, legal rules and regulations, ethics committee of medical council, OT code of ethics and Patients’ Rights Charter of Iran; the third part consisted of 20 questions based on ten sections of the Patients’ Rights Charter of Iran (8) and the last part included an open question about facilitating factors involved in patients’ rights.

The participants’ answers to the questions of the third part were quantified based on a four-score scale: “high” (4 scores), “moderate” (3 scores), “low” (2 scores) and “none” (1 score). The validity was assessed using content validity. The questionnaire was given to 10 faculty members of USWR and their comments were applied accordingly. The reliability was examined using a test-retest method in which the questionnaire was given to 10 eligible participants twice with a 10-day interval, and the respective interclass correlation coefficient (ICC) of the first and second answers obtained was 0.82 (95% CI, 0.146 – 0.951). These eligible participants were excluded from the main study population.

The questionnaires were completed within three months in target clinics and universities. Obtained quantitative data were expressed as mean±SD. One-way analysis was used for comparing scores of occupational therapists’ knowledge of patients’ rights according to educational level, areas of practice in occupational therapy and work experience. All statistical analyses were done using SPSS 16.0 statistical software (SPSS Inc, Chicago, IL).

Results

Demographic data of the participating occupational therapist, including their gender, educational levels, different areas of clinical practice and periods of their work experiences are shown in table 1. As it is illustrated, the majority of these participants were females (59.2%).

Table 2

Level of occupational therapists’ knowledge about general information of ethics

Variables	High	Moderate	Low	None
	N (%)	N (%)	N (%)	N (%)
How much do you know about the deputy police of the Medical Council of Islamic Republic of Iran?	7 (5.6)	18 (14.4)	19 (15.2)	81 (64.8)
How much do you know about the rules and regulations of the Ministry of Health and Medical Education?	9 (7.2)	26 (20.8)	44 (35.2)	46 (36.8)
How much do you know about the ethics committee of the Medical Council?	9 (7.2)	20 (16)	30 (24)	66 (52.8)
How much do you know about the code of ethics in OT?	9 (7.2)	24 (19.2)	20 (16)	72 (57.6)
How much do you know about the Patients’ Rights Charter of Iran?	33 (26.4)	33 (26.4)	33 (26.4)	26 (20.8)

The participants’ self-assessment of their knowledge about deputy police of the Medical Council of Islamic Republic of Iran, legal rules and regulations, ethics committee of medical council and OT code of ethics (second part of the questionnaire) are shown in table 2.

Furthermore, the sum of the scores based on answers to the questions in the third part of the questionnaire showed 67 (53.6%) of respondents had scores above the median, hence, 67 (53.6%) of occupational therapists had high level of knowledge about sections of Patients’ Rights Charter of Iran. It should be noted that the calculated median score was 62.

There was no significant difference between male and female participants’ knowledge of Patients’ Rights Charter of Iran (P>0.05). Likewise, we could not find a relationship between occupational therapists’ knowledge of Patients’ Rights Charter of Iran and their educational level, areas of practice in OT and periods of their work experience (Table 3).

Table 3:

The level of occupational therapists’ knowledge about patients’ rights

Occupational therapists’ knowledge about patients’ rights		Mean ± SD	F	P value
Educational level	Bachelor	61.81 ± 8.97	2.268	0.084*
	Master student	61.58 ± 9.02
	Master	59.33 ± 8.34
	PhD student	66.73 ± 10.05
Areas of practice in OT	Child	61.89 ± 8.38	2.348	0.102*
	Adult	63.58 ± 8.62
	Psychosocial	58.27 ± 11.31
Work experience	< 5 years	61.78 ± 9.19	1.999	0.140*
	5–10 years	58.35 ± 7.66
	>10 years	63.30 ± 9.41

P> 0.05 was considered as non significant.

In the next step, regression analysis was performed to determine the relationship between total scores of occupational therapists’ knowledge about patients’ rights and sex, educational level, areas of practice in OT and work experience. The obtained results showed that the sex, educational level, areas of practice in occupational therapy and work experience did not have any significant correlation with occupational therapists’ knowledge of patients’ rights (P>0.05).

Finally, participants’ answers to open-ended questions about facilitating factors of patients’ rights were categorized. These factors were classified in three groups of factors related to the organization, therapists and clients (Table 4).

Table 4:

Facilitating factors promotion of patients’ rights

Groups	Factors	N
Factors related to the organization	Approval of health insurance	95
	Patients’ Rights Charter installed in occupational therapy clinics	50
	Ethical committee	38
	Dealing with the welfare state of the therapist	23
	Careful monitoring of therapeutic interventions	18
	Enough staff	21
	Consultancy and social work units	9
Factors related to the therapists	Ethics curricula for undergraduates	85
	Workshops for therapists	54
	In-service training	32
	Using an evidence-based rehabilitation	16
Factors related to the clients	Increasing patients’ knowledge of their rights	89

Discussion

One of the most important components of patients’ rights is to provide an ethical and humanistic care. European regional office of the World Health Organization (WHO) states that promoting patients’ rights is a multi categorized topic, and goals should be followed through multilateral efforts. In addition, WHO has presented solutions to this issue, most of which involve active participation by both the service recipients and service providers in formulating health policy and developing training programs, specifically for service providers and the entire community (9).

Based on the findings of the present study, more than half of the participants had a high level of knowledge in regard to patients’ rights, especially concerning issues of preserving patients’ privacy, the right to receive respectful and prompt care despite cultural and racial differences and also the right to permit the presence of those who are not directly involved in the treatment process.

The present results were more consistent with previous studies, which have shown that health care professionals have a high level of knowledge about their patients’ rights (8, 10, 11). On the other hand, the level of knowledge about patients’ rights do not correlate directly to their observance (10, 12). Liedó showed that 84% of professionals know the patients’ rights, but a mere 64.4% observe them (10). Arnetz also showed that physicians, registered nurses, and practical nurses did not differ significantly in their views of patient involvement, but did differ significantly in behavior (12).

Another study demonstrated, however, that there is a relationship between awareness of the rights of the patient and observing them (13). This may be due to the research methods and the questionnaire in the mentioned study to determine the tendency of nurses to implement their roles to advocate patients’ rights.

Despite the high knowledge of occupational therapists, there seems to be a gap between awareness of patients’ rights and their observation in practice. Hooshmand et al. suggested in 2006 that there are many other requirements that should be recognized and identified in order for patients’ rights to be observed in practice (8). Jolaee et al. showed in 2008 through a qualitative study the facilitating factors which affect patients’ rights in clinical practice. Issues categorized as barriers to patients’ rights practice and facilitators of patients’ rights practice were further classified into three subgroups: awareness, resources and accountability (14). Patients’ rights can be fully implemented only if health services identify the barriers and strategies in employment of such charters of rights (15, 16).

In this regard, another finding of the present study was related to facilitating factors of patients’ rights, which were classified in three groups (factors related to the organization, factors related to therapists, factors related to clients). The most important organizational factor was a need for approval of health insurances by the responsible organizations. In economic models, the primary function of health insurance is to alleviate the financial risk associated with unanticipated adverse health events. In general, people dislike risk and are willing to trade a small amount of money to buy insurance premium for their protection against a potentially large loss of their income (17). Health insurance improves the quality of care and introduces user entitlements known as patients’ rights (18).

The next important factor was to test patients’ knowledge level and identify responsive organizations’ roles in accomplishing their needs and rights as clients. Findings of other studies have shown only few patients knew the rules composed within their charter of rights (19). This indicates the need for extensive education of patients and healthcare professionals in related subjects.

Other important facilitating factors in the promotion of patients’ rights are ethics courses designed for undergraduate students, workshops for therapists, patients’ rights charter installations in occupational therapy clinics and the generation of ethical committees within related organizations.

A report by the Association of American Medical Colleges (AAMC) argued that medical schools “must ensure that before graduation, a student will have demonstrated knowledge of the theories and principles that govern ethical decision making and of the major ethical dilemmas in medicine…” (20). The AAMC’s statement reflects a growing consensus among medical educators that ethics education should be a core component of medical schools’ curricula. At the present time, there is no ethics curriculum for occupational therapists in Iran and this study hopes to initiate introduction of such courses in Iranian academic centers.

Our findings revealed that occupational therapists had a high knowledge of patients’ rights, but they would need to train for their implementation.

Students of occupational therapy should graduate with a baseline level of knowledge in ethics, as they do in the basic sciences. The current state of education, however, does not ensure a common standard for ethics education in occupational therapy.

Furthermore, as the client-centered approach is very important in OT, ethics are dependent on the cultural and social characteristics of societies (21), and therefore the view of the Iranian patients towards the issue urges the Ministry of Health and Medical Education of the Islamic Republic of Iran to accelerate the implementation of the Patients’ Rights Charter of Iran (22). It is suggested that a qualitative research be done to determine the views of occupational therapists and clients about observing the patients’ rights in Iran.

One of the limitations of our study was the greater number of Bachelor-level participants compared to other educational levels, due to the convenience sampling method. This may affect the results based on analyses of the relationship between the level of knowledge about patients’ rights and educational level

Conclusion

Although, the level of occupational therapists’ knowledge about the Patients’ Rights Charter are high, it is necessary to provide context for observing patients’ rights by involving related facilitating factors such as different organizations, therapists, and clients within the field of clinical occupational therapy professionalism.

Table 1.

Demographic data of the occupational therapists

Variables		n (%)
Sex	Male	51 (40.8%)
	Female	74 (59.2%)
Educational level	Bachelor	32 (25.6%)
	Master student	48 (38.4%)
	Master	30 (24%)
	PhD student	15 (12%)
Areas of practice	Child	69 (55.2%)
	Adult	34 (27.2%)
	Psychosocial	22 (17.6%)
Work experience	< 5 years	65 (52%)
	5–10 years	20 (16%)
	>10 years	40 (32%)