Awareness of the Importance of and Adherence to Patients' Rights Among Physicians and Nurses in Oman: An analytical cross-sectional study across different levels of healthcare.

OBJECTIVES: This study aimed to determine the extent to which physicians and nurses in Oman were aware of the importance of and adhere to patients' rights and whether this differed according to role, nationality, position and institutional healthcare level.
METHODS: This analytical cross-sectional study was carried out between December 2015 and March 2016 at various governmental healthcare institutions in Oman. A self-administered questionnaire was distributed to 1,385 practitioners at all healthcare levels.
RESULTS: A total of 1,213 healthcare practitioners (response rate: 87.58%) completed the survey, of which 685 (56.47%) were nurses and 528 (43.53%) were physicians. Overall, awareness of the importance of patients' rights was high (91.51%), although adherence to these rights in practice was low (63.81%). The right of the patient to be informed was considered least important and was least adhered to (81.2% and 56.39%). Nationality, role and institutional level were significantly associated with awareness (P = 0.002, 0.024 and 0.034, respectively). Non-Omani staff were significantly more likely than Omani staff to be aware of (odds ratio [OR] = 1.696; P = 0.032) and adhere to (OR = 2.769; P <0.001) patient rights. Furthermore, tertiary care staff were twice as likely as primary care staff to perceive the importance of patient rights (OR = 2.076; P = 0.019). While physicians were more likely than nurses to be aware of the importance of patient rights, this difference was not significant (OR = 1.516; P = 0.126).
CONCLUSION: These findings may help inform measures to enhance awareness of and adherence to patients' rights in Oman. © Copyright 2019, Sultan Qaboos University Medical Journal, All Rights Reserved.

- This study found that while awareness of the importance of patients’ rights was high among nurses and physicians in Oman, adherence to these rights in actual practice was low.

- Non-Omani staff were significantly more likely to be aware of and adhere to patient rights in comparison to Omani staff.

- Tertiary care staff were twice as likely to be aware of the importance of patient rights compared to staff from primary healthcare institutions.

Application to Patient Care

- The findings of this study may help decision-makers formulate strategies to educate both healthcare providers and patients on this topic and ensure that such rights are observed in clinical practice. This would result in a radical improvement in the provision of healthcare in Oman and enhance patient safety and satisfaction.

The right to lead a healthy life is widely considered to be a fundamental human right.1 As such, promoting and assuring patients’ rights is an essential part of modern healthcare. In 1994, the World Health Organization (WHO) published a detailed declaration outlining the primary principles of patients’ rights in Europe.2 In Oman, Royal Decree #26/75 acknowledges patients as individuals with human rights and assures all citizens of their right to equal access to free of charge healthcare.3 By 2050, the Omani Ministry of Health (MOH) aims to have a responsive, equitable and efficient healthcare system that not only offers evidence-based care but also satisfies patients and attends to their needs.4

Previous research has revealed that awareness of patient rights by healthcare providers positively influences patient satisfaction.5,6 Moreover, a lack of observance of these rights in clinical practice erodes trust between patients and healthcare professionals and can endanger the life and safety of the patient.6,7 While physicians have been reported to have better knowledge of patient rights compared to nurses, both groups demonstrate similar levels of adherence in actual practice.6,8–10 In Saudi Arabia, healthcare professionals working at primary healthcare institutions were found to have little knowledge regarding the rights of their patients; furthermore, a lack of knowledge of patients’ rights, lack of standards and the legal system were identified as being barriers to the observance of patient rights in practice.11

Patients’ rights are best protected when healthcare workers are aware and conscious of these rights.12–14 As such, data are needed regarding current levels of awareness of the importance of patients’ rights. However, to the best of the authors’ knowledge, no study has yet been conducted in Oman on this topic. This study therefore aimed to determine levels of awareness of and adherence to patients’ rights among physicians and nurses in Oman and potential associations with role, nationality, position and institutional healthcare level. Such findings may help decision-makers to take necessary steps to improve educational measures in this regard and improve the implementation of patients’ rights in practice.

Methods

This analytical cross-sectional survey was carried out between December 2015 and March 2016 at various governmental institutions. Physicians and nurses were initially targeted as they constitute a large proportion of the healthcare workforce in Oman and usually spend more time performing routine daily tasks with patients compared to other health professionals. Of the 17,007 physicians and nurses working at MOH institutions, 9,750 (57.33%) are Omani nationals and 7,257 (42.67%) are expatriates.15 A proportional stratified sampling technique was used to access approximately 8% of this population, assuming a 95% confidence level and a margin of error of 3%. The final sample size was 1,385 participants, including 663 physicians (47.87%) and 722 nurses (52.13%) from all primary healthcare centres, nine secondary hospitals and three tertiary institutions in Oman. An online sample size calculator (Raosoft Inc., Seattle, Washington, USA) was initially used to calculate the sample size; subsequently, a proportional size approach was implemented to determine the precise number of healthcare professionals targeted at each institution.

Data were collected from the participants using a two-part English self-reported questionnaire designed specifically for this study. The first section of the questionnaire collected demographic information, including role, gender, years of experience, institutional level, position and nationality. The second part was designed to evaluate awareness of the importance of patients’ rights and frequency of observing these rights in clinical practice. As the official Oman Patient Rights Charter was not yet developed, 40 principles outlined in the WHO declaration on the promotion of patients’ rights in Europe were utilised.2,16 These items were divided into six domains: (1) respect and appreciation; (2) sufficient and timely information; (3) consent; (4) privacy and confidentiality; (5) care and treatment; and (6) participation in healthcare plan. Participants rated the importance of each item on a five-point Likert scale, with scores of 1–5 being unimportant, slightly important, moderately important, important and very important, respectively. Adherence to each item was similarly measured on a five-point Likert scale, with scores of 1–5 indicating never, rarely, often, daily and always, respectively.

The questionnaire was tested for content validity and relevance by a senior expert at the MOH and all necessary modifications were implemented. The internal consistency of the tool was verified, with alpha coefficients of 0.92 and 0.94 for the importance and frequency of adherence subscales, respectively. A pilot study of the survey was conducted in August 2015 with 49 healthcare professionals working in primary and secondary institutions in Al Buraimi Governorate. The final version of the questionnaire took into consideration the comments of the pilot group with regards to intelligibility, clarity and language. The questionnaires were then distributed to participants by the head of the nursing department at each healthcare institution. Completed questionnaires were returned anonymously to confidential boxes placed in the office of the head of department.

Data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 20.0 (IBM Corp, Armonk, New York, USA). Prior to analysis, the raw data were processed for incompleteness, duplication and inaccuracy before being cleaned; moreover, some variables were combined (including total importance and adherence scores) for ease of analysis. Results were presented using descriptive statistics in the form of frequencies, percentages, means and standard deviations. A Chi-squared test and logistic regression model were used to assess the association between importance and adherence scores and demographic characteristics. The level of statistical significance was set at P <0.05.

This study was approved by the Research Ethical Review & Approval Committee of the MOH. All participants filled a written informed consent form that accompanied each questionnaire along with a covering letter explaining the purpose and voluntary nature of the study and assuring the respondents’ anonymity.

Results

A total of 1,213 healthcare practitioners (response rate: 87.58%) took part in the study, of which 685 were nurses (56.47%) and 528 were physicians (43.53%). More than half were of Omani nationality (53.5%) and the majority were female (68.51%). A total of 679 healthcare practitioners were clinicians (55.98%), 141 had managerial responsibilities (11.62%) and 393 held both positions (32.4%). Participants had varying degrees of experience, ranging from ≤5 years (21.93%) to >10 years (51.03%). Overall, 40.31%, 31.82% and 27.87% worked in primary, secondary and tertiary healthcare centres, respectively [Table 1].

Table 1

Demographic characteristics of physicians and nurses working at governmental healthcare institutions in Oman (N = 1,213)

Characteristic	n (%)
Gender
Male	382 (31.49)
Female	831 (68.51)
Nationality
Omani	649 (53.5)
Non-Omani	564 (46.5)
Role
Nurse	685 (56.47)
Physician	528 (43.53)
Position
Clinician	679 (55.98)
Management	141 (11.62)
Both	393 (32.4)
Years of experience
≤5	266 (21.93)
6–10	328 (27.04)
>10	619 (51.03)
Institutional level
Primary	489 (40.31)
Secondary	386 (31.82)
Tertiary	338 (27.87)

Overall, there was a high level of perception of the importance of patient rights among physicians and nurses (91.51%), although actual adherence was low (63.81%) [Figure 1]. The domain of patients’ rights perceived to be most important was respect and appreciation (97.53%), while the least important domain was the patients’ right to be informed (81.2%) [Figure 2]. Similarly, the domain of respect and appreciation reflected the highest level of adherence (85.66%), while the domain least adhered to was that of sufficient and timely information (56.39%) [Figure 3]. In terms of specific rights, 1,077 nurses and physicians (88.79%) rated a patient’s right to be treated with dignity as being very important. The provision of honest care to dying patients was the right most frequently observed in clinical practice (71.81%).

Figure 1

Overall frequency of perceived importance of and adherence to patients’ rights among physicians and nurses working at governmental healthcare institutions in Oman (N = 1,213).

Figure 2

Perceived importance of each patients’ rights domain among physicians and nurses working at governmental healthcare institutions in Oman (N = 1,213).

Figure 3

Frequency of adherence to each patients’ rights domain among physicians and nurses working at governmental healthcare institutions in Oman (N = 1,213).

Nationality, role and institutional level were significantly associated with perception of the importance of patients’ rights (P = 0.002, 0.024 and 0.034, respectively). There was also a significant relationship between adherence to patients’ rights and nationality (P <0.001) [Table 2]. In the logistic regression analysis, nationality remained a significant predictor, with non-Omani practitioners significantly more likely to be aware of the importance of patient rights (odds ratio [OR] = 1.696; P = 0.032) and more likely to adhere to these rights (OR = 2.769; P <0.001) in comparison to Omani staff. In addition, staff working at tertiary care centres were twice as likely to be aware of the importance of patient rights compared with those working in primary healthcare institutions (OR = 2.076; P = 0.019), although there was no significant difference in terms of adherence (OR = 0.848; P = 0.664). While physicians were more likely than nurses to be aware of the importance of patient rights, this difference was not significant (OR =1.516; P = 0.126) [Table 3].

Table 2

Associations between levels of awareness of the importance of and adherence to patients’ rights status and demographic characteristics among physicians and nurses working at governmental healthcare institutions in Oman (N = 1,213)

Characteristic	n (%)		P value	n (%)		P value
	Importance			Adherence
	Yes	No		Yes	No
Gender
Male	354 (92.67)	28 (7.33)	0.325	248 (64.92)	134 (35.08)	0.585
Female	756 (90.97)	75 (9.03)		526 (63.3)	305 (36.7)
Nationality
Omani	579 (89.21)	70 (10.79)	0.002	353 (54.39)	296 (45.61)	<0.001
Non-Omani	531 (94.15)	33 (5.85)		421 (74.65)	143 (25.35)
Role
Nurse	616 (89.93)	69 (10.07)	0.024	429 (62.63)	256 (37.37)	0.330
Physician	494 (93.56)	34 (6.44)		345 (65.34)	183 (34.66)
Position
Clinician	626 (92.19)	53 (7.81)	0.626	435 (64.06)	244 (35.94)	0.643
Management	128 (90.78)	13 (9.22)		94 (66.67)	47 (33.33)
Both	356 (90.59)	37 (9.41)		245 (62.34)	148 (37.66)
Years of experience
≤5	242 (90.98)	24 (9.02)	0.936	170 (63.91)	96 (36.09)	0.130
6–10	301 (91.77)	27 (8.23)		195 (59.45)	133 (40.55)
>10	567 (91.6)	52 (8.4)		409 (66.07)	210 (33.93)
Institutional level
Primary	438 (89.57)	51 (10.43)	0.034	321 (65.64)	168 (34.36)	0.279
Secondary	352 (91.19)	34 (8.81)		234 (60.62)	152 (39.38)
Tertiary	320 (94.67)	18 (5.33)		219 (64.79)	119 (35.21)

Table 3

Logistic regression analysis of associations between awareness of the importance of and adherence to patients’ rights status among physicians and nurses working at governmental healthcare institutions in Oman (N = 1,213)

Variable	Importance		Adherence
	OR (95% CI)	P value	OR (95% CI)	P value
Gender (female versus male)	1.262 (0.734–2.171)	0.401	1.090 (0.872–1.626)	0.273
Nationality (Omani versus non-Omani)	1.696 (1.047–2.746)	0.032	2.769 (2.102–3.648)	<0.001
Role (physician versus nurse)	1.516 (0.889–2.585)	0.126	1.197 (0.885–1.619)	0.244
Position (both clinician and MGT versus MGT alone)	1.136 (0.565–2.284)	0.970	1.045 (0.674–1.617)	0.994
Position (clinician versus MGT)	1.315 (0.666–2.598)	0.372	1.089 (0.716–1.656)	0.655
Years of experience (>10 versus 1–5 years)	1.103 (0.652–1.865)	0.984	1.057 (0.771–1.451)	0.237
Years of experience (6–10 versus 1–5 years)	1.205 (0.672–2.160)	0.568	0.829 (0.587–1.171)	0.125
Institutional level (secondary versus primary)	1.178 (0.740–1.875)	0.392	0.812 (0.610–1.082)	0.349
Institutional level (tertiary versus primary)	2.076 (1.175–3.670)	0.019	0.848 (0.624–1.150)	0.664

OR = odds ratio; CI = confidence interval; MGT = management.

Discussion

From a patient’s perspective, the attitude and behaviour of their healthcare provider is the most important criterion to evaluate the quality of healthcare services rendered.10,17 Awareness of and adherence to patients’ rights therefore help to promote and sustain an effective relationship between patients and healthcare staff.2 As such, the importance of patients’ rights should be valued highly by all personnel in healthcare institutions. The current study was conducted in order to determine the extent to which physicians and nurses in Oman were aware of and adhere to various internationally accepted patient rights and potential associations with role, nationality, position and healthcare institutional level.

In the present study, nurses and physicians in Oman demonstrated a high level of awareness of the importance of patients’ rights; however, adherence to these rights in actual practice was fairly low. Ducinskiene et al. revealed similar results, in which physicians and nurses in Lithuania were well-informed regarding patients’ rights but did not always take them into consideration in practice.18 Similarly, Sheikhtaheri et al. found that nurses’ awareness of the patients’ bill of rights in Iran was acceptable, while observance in clinical practice was subpar.9 As noted by Farzianpour et al., awareness of patients’ rights does not necessarily guarantee that such rights are observed in practice.5 These findings indicate that other factors apart from staff awareness and knowledge may need to be looked at in order to promote the observation of patients’ rights in clinical practice. Moreover, these results indicate that healthcare providers do not implement all patients’ rights in practice; therefore, it is vital to devise strategies to improve adherence levels.

There was little variation in the current study in terms of the perceived importance of each of the six domains of patients’ rights, suggesting that nurses and physicians in Oman consider all domains to be important. Overall, the most important domain was respect and appreciation, particularly the patients’ right to be treated with dignity. Other studies conducted in Saudi Arabia and Iraq have reported similar results in which the most important rights were those that emanated from the care and respect domains.19,20 This could be due to the fact that patient rights included in this domain are deemed elemental human rights and constitute a fundamental part of the treatment process.

In contrast, the current study found that the least important domain was related to the patient’s right to information; moreover, this domain was also least adhered to in clinical practice. Failure to observe this right is commonly reported in the international literature.21–23 In Ducinskiene et al.’s study, only half of the participating physicians agreed that informing patients of their diagnosis, medical results and treatment methods was a necessary right.18 In Singapore, a survey of medical professionals found that staff did not routinely inform patients of the benefits of their proposed treatment or of their available treatment options.24 Nekoei Moghaddam et al. and Sabzevari et al. similarly found that the patient right least adhered to was the right to receive adequate and appropriate information.25,26 Reasons for neglecting this right might include a lack of awareness or reluctance to recognise this right by healthcare providers. Accordingly, there is a need for increased educational efforts aimed at healthcare professionals, with particular emphasis on the patient’s right to the provision of sufficient and timely information.

The current study observed significant positive associations between awareness of the importance of patients’ rights and the nationality, role and institutional level of the healthcare providers. In particular, nationality remained a significant predictor during logistic regression analysis, with non-Omani staff 1.7-times more likely to perceive the importance of patients’ rights and 2.8-times more likely to adhere to these rights compared to Omani staff. The reason for this finding is unknown; however, it may be that some of the non-Omani staff had previously received additional education or training regarding patients’ rights in other countries. Awareness of the importance of patients’ rights also differed significantly according to institutional level, with patients’ rights twice as likely to be perceived as important by tertiary compared to primary healthcare workers. A previous study conducted in Oman reported patient dissatisfaction with patient-provider interactions in primary healthcare, including an unfriendly/unwelcoming tone, lack of privacy during consultation, poor attention/eye contact, lack of encouragement to ask questions and an inability to participate in medical dialogue.27

In terms of role, while physicians in the present study had significantly higher levels of awareness compared to nurses, there was no significant difference in terms of adherence; moreover, this factor was not significant during the logistic regression analysis. Previous research conducted in developing countries has indicated lower levels of awareness of patients’ rights among nurses compared to doctors, with studies conducted in Turkey, India and Egypt reporting moderate levels of awareness among the former.6,10,28–30 The current study found no significant associations between years of experience and either perception of the importance of or adherence to patients’ rights. In contrast, other researchers have reported significantly higher levels of awareness among those with longer work experience.31,32 In addition, there were no significant differences in the present study in terms of position and gender. This finding is in agreement with previous research from Iran which reported no relationship between gender and awareness of patients’ rights.33

Unfortunately, when patients feel their rights are being violated, they may seek alternative mechanisms to meet their needs, such as attending emergency departments with primary healthcare problems or relying on self-management or self-medication to treat common medical conditions.34,35 Such health-seeking behaviours can have serious implications, not only on the individual’s health, but also on the healthcare system as a whole. Therefore, healthcare professionals’ knowledge of and implementation of patients’ rights should be evaluated regularly; moreover, continuous education on this subject should be provided. Barriers to a lack of adherence to patients’ rights among physicians and nurses may include a lack of knowledge, poor attitudes and job-related factors such as low salaries, stress/burnout and long working hours.8,14 In addition, healthcare professionals may also be faced with insufficient standards and a lack of necessary hospital equipment and staff.11,36,37 It is therefore important that such barriers be identified and appropriate strategies put in place in Oman in order to ensure that patient rights are adequately observed.

This study was subject to certain limitations. Due to the lack of previous studies on this topic in Oman, the findings could not be compared with those of similar national research. Similarly, the authors could not benefit from other researchers’ experiences when designing the questionnaire. Moreover, this study was conducted prior to the development and publication of the official Patient Rights Charter by the MOH in Oman.15 Future studies are therefore recommended to evaluate healthcare providers’ awareness of and attitudes towards the rights outlined in this official charter at governmental hospitals, health centres and psychiatric hospitals in Oman. In addition, further research is necessary to determine barriers to the implementation of patients’ rights in Oman so that appropriate strategies can be developed to overcome them.

Conclusion

Nurses and physicians in Oman demonstrated a high level of awareness of the importance of patients’ rights; however, actual adherence to these rights in practice was low. Non-Omani staff were found to have significantly higher levels of awareness of and adherence to patients’ rights compared to Omani staff. Additionally, tertiary hospital staff were twice as likely to perceive patients’ rights to be important compared to primary healthcare practitioners. Strategies are needed to ensure that patient rights are adequately recognised and protected in Oman.