The Nursing Students' Views About the Patient's Rights at the West Black Sea Universities in Turkey.

BACKGROUND: The members of healthcare team have an important role in implementation and protection of patient's rights. Contemporary nursing entails an ethical responsibility to advocate and protect the patients' rights.
OBJECTIVES: This study was designed to evaluate how ready nursing students, at the end of their education, were to play the role of patient's rights advocates and to discuss ethics education in nursing.
MATERIALS AND METHODS: This descriptive study was performed on nursing students at Black Sea Universities in the academic year 2010-2011. Data were collected using a structured questionnaire about students' attitudes regarding patients' rights including patient's rights regulations. The association between gender and students' attitudes was analyzed using Chi-square test.
RESULTS: The mean age of the 238 participants was 22.11 ± 1.21 years and 82.8% of them were female. The majority of the nursing students held desirable attitudes toward patient information, truth telling, and protection of patients' privacy and medical records. However, the students' views about the rights of patients to refuse treatment, children's active participation in treatment, prioritization of the quality of life in treatment, and respect for the rights of dying patients were less satisfactory.
CONCLUSIONS: The results of this study was concerning with regard to nursing students' readiness for duties such as patient's rights advocacy. Therefore, it proposes ethics education that covers both patient's rights and the obligations of nurses to defend these rights.

1. Background

Generally, patient’s rights refer to the human rights to which patients are entitled while they are in the care of health services (1). It refers to rights that are secured by international agreements, laws, and other legislation, which are granted entirely on the basis of the humanity of individuals who require health services (2). It is based on international documents such as the Universal Declaration of Human Rights and the World Medical Association Declaration and legal requirements based on these documents (3).

In Turkey, the first legislation related to patient’s rights, “The Regulation of Patients’ Rights” (RPR), was enacted in 1998. Although there is clear knowledge about what the patient’s rights are, the responsibilities of health institutions and professionals regarding this subject as well as the way of implementing these rights are not clear. Thus, “the directive for practice of patient’s rights” (4) was issued in 2005 to practice, enhance, and standardize patient’s rights. The RPR was recently updated on May 8, 2014 (5), which stated that the rights of vulnerable patient groups would be further protected in our country by future legislation (2).

Health team members play an important role in the implementation and the protection of patient’s rights, a topic dealt with great care in medical ethics (6). In this sense, nurses are expected to provide patients with safe, sufficient, and ethical care (7). However, the role of patient’s rights advocacy assigned to nurses in particular gives patients the right to make decisions about themselves, whereas the same role requires the nurses to advocate the patients’ rights on behalf of them when they cannot use (8). This role, defined for the first time in 1976 by The American Nurses Association Code of Ethics, prohibits nurses from acting unethically and breaking the law (9). The Turkish Nurses Association gives Turkish nurses a similar responsibility and wants them to support patients so that the individuals the nurses serve would be competent to defend their own rights. Nursing schools, professional organizations, and health institutions have an important responsibility to ensure that both nurses and student nurses are prepared for this role (10).

It is necessary for nurses to observe and even to protect the moral integrity of patients in order to speak about quality of patient care. Therefore, the aim of ethics education in nursing is to train responsible nurses in every respect who know the ethical issues related to their branches and to provide ethical care (11). During this educational period, the target is not only to equip the students with knowledge about patient’s rights, but also to enable them to do patient’s rights advocacy because patient’s rights advocacy obligations are the foundation of nursing ethics. Thus, it is very important that candidate nurses should be educated on ethics that would prepare them for this role (12). Gorgulu and Dinc (11) conducted a study in Turkey and reported that nursing education often covered the basic concepts of ethics, ethical theories and principles, dilemmas in healthcare, patient’s rights, and nursing ethical codes. Lectures, class discussions, and case studies were generally used for this education. However, the depth and the precise content of this education remained unclear. There are numerous studies that have assessed the knowledge levels and attitudes of patients (13-17) and nurses (15, 18, 19) toward patient’s rights in our country. Yet, there are few studies that have assessed the attitudes of students, trained in nursing, toward patient’s rights (10).

2. Objectives

This study aimed to assess the curriculum of ethics education related to patient’s rights in nursing in order to learn how ready the students were for patient’s rights advocacy. This study was conducted on undergraduate students at the end of their education.

3. Materials and Methods

3.1. Study Design and Population

A self-administered, structured questionnaire that included five questions and 15 items was used in this descriptive study. The study population consisted of fourth year nursing students at seven health schools in the Black Sea Universities Association, where 10% of Turkey’s undergraduate nursing students study (Abant Izzet Baysal University, Bartin University, Bulent Ecevit University, Duzce University, Karabuk University, Kocaeli University, and Sakarya University) in 2010-2011. This study was conducted at five universities because one of the universities did not have nursing department, and the other did not have a final semester (seven academic semester).

3.2. Data Collection

Permissions were obtained from the universities chosen for the study. Information about the study was given by visiting the nursing schools. The data were collected from three universities between October 2010 and February 2011 by two researchers and from the other two universities by a volunteer nursing lecturer who had previously agreed to assist with data collection. The students completed and left the questionnaires in their classroom when not affected their schedule. This process took approximately twenty minutes.

The questionnaire was created by the researchers based on other relevant research (3, 10). The first section consisted of questions regarding demographic data (five questions), and the second section evaluated students’ views about the patient’s rights guaranteed by the Turkish RPR (5). The students were asked to respond as “agree”, “neither agree nor disagree” or “disagree” to the items in the second section. A few minor changes were made after pilot testing for content and clarity with 15 nursing students.

3.3. Ethical Considerations

Ethical approval for the study was obtained from the Kocaeli University Ethics Committee (21 February 2011, 6/5/2011). An anonymous self-administered questionnaire was used. The first page of the questionnaire included information about the aim and content of this study. It was also added that participation in the study was voluntary, and the participants were assured that the confidentiality of their answers would be respected. In addition, the data were not used for any purpose other than this research.

3.4. Data Analysis

SPSS 13 (SPSS Inc, Chicago, IL, USA) was used for data analysis. Descriptive statistics (frequency distributions, percentage, mean and standard deviation) were calculated for the obtained data. A chi-square test was used to determine the association between opinions about patient’s rights and demographic variables.

4. Results

Of 321 students, 238 participated in this study (74.1%). The students’ mean age was 22.11 ± 1.21 years (range, 17-28 years). The majority of the students (82.8%) were female (Table 1). Students’ opinions about patient’s rights are shown in Table 2. In total, 98.7% of the students agreed that healthcare is a right, that patients have the right to identify, choose, and change their healthcare providers (84.9%), and that patients have the right to see and copy their own medical records (84.5%). In addition, 89.5% agreed about respecting the privacy of the patient before and after death.

Table 1.

Characteristics of Nursing Students (n =238)

Characteristic	Value [a]
University
Abantizzet Baysal (42 [b])	37 (15.5)
Bulent Ecevit (83)	67 (28.2)
Duzce (42)	38 (16.0)
Kocaeli (68)	46 (19.3)
Sakarya (86)	50 (21.0)
Gender
Female	197 (82.8)
Male	41 (17.2)

a Data are presented as No. (%).

b The numbers in parentheses indicates the total number of nursing students at the university.

Table 2.

Preferences of Nursing Students to Patient’s Rights (n =238)

Patient’s Right Which I Agree	Value [a, b]
Health care is a right	235 (98.7)
Before any treatment or intervention patients should be informed and give their consent	231 (97.1)
The patient has right to permit the use of body organs after death	219 (92.0)
The patient’ information can be shared with relatives with the permission of the patient	213 (89.5)
The patient’s information should remain confidential after death	204 (85.7)
Patients have the right to identify, choose and change their healthcare personnel	202 (84.9)
Patients have a right to see their own laboratory results and medical records	201 (84.5)
“Quality of life” standards should be used to determine if treatment continues	149 (62.6)
Patients should be fully informed about their status (including bad news)	140 (58.8)
After your death, you will donate your organs	122 (51.3)
Even if it causes death, a conscious patient has the right to refuse treatment	112 (47.1)
Children should agree with decisions about their treatment after seven years of age	70 (29.4)
Patients have the right to die	55 (23.1)
Upon the terminally ill patient’s request, nurses and physicians should be allowed to end life	36 (15.1)
Newborns with severe disabilities should be allowed to die	28 (11.8)

a Data are presented as No. (%).

b These preferences were listed in order of ranking so the table can read easily.

Students had positive opinions about providing information to the patients since almost all of students (97.1%) agreed that patients should be informed of their disease, its treatment, and the benefits and harms of treatment. More than half of the students (58.8%) believed that the truth must be told to the patients. Nearly half of students (49.2%) agreed that the patient has right to refuse treatment. The item “children should participate in decisions related to treatment” was agreed by nearly one quarter of the students (29.4%). One quarter of nursing students (23.1%) believed that patients have the right to die. Most students (92.0%) agreed with the patients’ right to donate their organs after death, but consenting to the use of their own organs falls to half (51.3%). Moreover, 62.6% of the students agreed that the criterion for continuing treatment is the patient’s quality of life (QoL), and 11.8% shared the belief that newborns whose QoL would never improve should be allowed to die (Table 2).

There were statistically significant differences in the students’ opinions about patient’s rights by sex of participants. For instance, in comparison to female students, fewer male students agreed that patients have the right to donate organ after their death (χ2 = 9.028; P = 0.011), and that the newborn with disability should be allowed to die (χ2 = 6.020; P = 0.049) (Table 3).

Table 3.

The Association Between Opinions About Patient’s Rights and the Sex of Nursing Students (n =238)

Patient’s Rights	Sex of Nursing Students, %		X2	P Value
	Female	Male
Patients have the right to permit the use of body organs after death			9.028	0.011
Agree	94.4	80.5
Neither agree nor disagree	3.1	9.7
Disagree	2.5	9.8
Newborns with severe disabilities should be allowed to die			6.020	0.049
Agree	13.2	4.9
Neither agree nor disagree	31.5	19.5
Disagree	55.3	75.6

5. Discussion

Health professionals are expected to know patient’s rights, to put these rights into practice, and even to advocate for their patients’ rights. Although it is possible to acquire this knowledge with training after graduation, medical education and nursing education intends that students should be made aware of ethical responsibilities by education before graduation. In the present study, it was noted that most of the students thought that patients’ informed consent should be obtained prior to the treatment or intervention. Accordingly, student nurses were prone to protect and respect patient autonomy, which is very important in patient’s rights. However, the fact that only half the nursing students said that patients had the right to decline treatment created doubts whether this modern idea was understood properly or not. Another study (10) conducted with nursing students in our country reported similar results; near graduating (last year) students said, with percentages similar to those of first year students, that patients had the rights to decline the treatment, which indicated that nursing education ethics curricula should be improved.

The majority of the students said that patients had the right to access medical records that would help them make autonomous decisions and to acquire a copy of these records. Moreover, most of the students said that patient confidentiality should be respected, and that this confidentiality should be protected after death. According to these findings, students were ready for their ethical responsibilities in patient’s confidentiality and the protection of privacy.

Telling the truth reflects the trust on which the patient and nurse relationship is based. It is another important ethical responsibility of nurses (8). Yet only half of the nursing students thought that patients had the right to know the whole truth about their conditions. Another study conducted with nursing students reported that increasing number of students, especially fourth year students, agreed that patients had the right to be told the truth (10). We might suggest that the reason why nursing students had a negative view about this patient right might be resulting from their clinical experiences because some of the intern nurses noted that patients are not actually told the truth in practice. However, it has been reported that patients want to know all the side effects of the diseases including death and fatal diseases, too (20, 21). Therefore, it would be beneficial if the topic of telling the truth and its exceptions were emphasized in ethics in nursing education.

Few students believed that children older than seven years old should be included in treatment decisions. This draws attention to the fact that child patients, like other patients, should be informed about their diseases and treatment according to their knowledge capacity and should be included in treatment to the degree that they are competent to do so (22). Children should absolutely be included in treatment decisions, especially after the age of seven (23). Thus, the subject of sick children’s rights should be included in nurse’s ethical education.

Although most nursing students believe that QoL criteria should be used to determine if treatment is to be continued, the fact that they suggested that newborns at the threshold of viability should not be allowed to die makes us think that students did not sufficiently consider the interests of the newborn. Especially male students said that such newborns should be kept alive because QoL criteria plays an important role in making ethical decisions. Other studies have found that nursing students (10) and midwives (24) had difficulties making the best choices for these children. These results indicate the importance of not overlooking ethical topics related to children’s rights and maternalism/paternalism in nursing education.

Another finding was related to the right to die and euthanasia. Nearly one quarter of the nurses believed that individuals have the right to die, and even fewer said that doctors and nurses should be allowed to perform voluntary euthanasia. More than half of the students were in favor of euthanasia in a study done in 1995 (25), whereas the results of another study conducted in 2003 were similar to ours (10). A study done in Istanbul in 2005 reported that 28.1% of the students declared that they would actively take part in euthanasia (26). Another study conducted with professional nurses showed that this percentage rose to 36.4% (21). Although euthanasia is banned by the Turkish RPR (5), the fact that there are opposing tendencies means that debates about right to die and euthanasia should be initiated.

Another interesting result of the study was related to nursing students’ attitudes towards organ transplants. Most students said patients had the right to allow the transplantation of their organs, but to allow transplantation of their own organs rate was rather low. In particular, male students agreed less often than females that patients had the right to allow transplantation after they died. Other studies reported that nursing students (27, 28) and medical students (29, 30) did not consider organ transplantation with similar rate. These results indicated that nurses who assumed an important responsibility to increase public awareness about organ donation should first increase their own willingness to donate body organs and should draw attention to ethical aspects, especially the social benefit, of organ transplants.

Although this study had some limitations, it is one of the few studies that have examined the views of nursing students about patient’s rights. Educational differences related to patient’s rights (e.g. in which course were they taught, the duration of education, and lessons from an ethics expert or a nursing educator) were the limitations of this study. Collecting data at times suitable for the students (sometimes in the afternoon, sometime before noon) could affect responses the questionnaires. Personal beliefs and societies’ traditions and values can shape the students’ views related to patient’s rights, and not all these views are related to their educational program. More studies are needed to evaluate the effectiveness of education on patient’s rights in nursing to resolve patient’s rights ethical problems in health care services and to provide ethical care.

The majority of nursing students studying in five nursing schools at West Black Sea Universities in our country believed in patients’ rights such as informing patients, truth telling, and protection of patients’ privacy and medical records. However, the patient’s rights to refuse treatment, children’s active participation in treatment, the prioritization of life quality in treatment, and respect for patients’ right to die were less recognized by nursing students. Therefore, wide-ranging research on the adequacy and methodology of current ethics education, as well as discussion of ethical issues, seems to be essential.