Impact of planned teaching program on the attitude of nurses with regard to patient rights in two multispecialty teaching hospitals in India.

BACKGROUND: The attitude of nurses with regard to patients' rights bears greater influence on its practice in the health-care settings. As health-care organizations grow toward standardization, positive changes in the attitude of health-care professionals are demanding.
OBJECTIVES: The objectives of this study were to assess the attitude of nurses with regard to patient rights in two teaching hospitals, to devise a training program on patient rights for nurses, and to compare the impact of training with regard to patient rights on the attitude of nurses in two teaching hospitals.
MATERIALS AND METHODS: This quasi-experimental study with one-group pre- and post-test research design for a sample of 200 nurses was carried out during the year 2017 at two multispecialty hospitals in India. The sample size was selected based on convenience sampling method. For the pretest, attitude was measured on a 5-point Likert scale through a questionnaire containing 27 items. Small-group teaching method was used to train nurses in groups of 8-10. Posttest was done through the same attitude questionnaire 1 week after the training program.
RESULTS: In both the hospitals, the nurses had a favorable attitude toward patient rights before the training program; after training, majority of the nurses had the most favorable attitude toward patient rights. A statistically significant difference was observed in the attitude of nurses with regard to patient rights within the hospitals, before and after training nurses on patient rights (P < 0.001).
CONCLUSIONS: Health-care organizations require developing planned teaching programs for nursing care professionals in order to influence their knowledge and attitude on patient rights. Their positive attitude toward patient rights leads to improved outcomes and effective nursing care practices. Copyright:

Introduction

Patient rights are defined as the rules of conduct between people who benefit from health services and the health institutions and personnel who provide them.[12] One of the most important columns of nursing is respecting human rights and esteeming all patients' dignity, nurses are the most important health care professionals to protect patients' rights in hospitals.[3] One of the most important measures of high-quality and moral care is the recognition of patient rights.[4]

In many countries, patient rights have been standardized legally and involve a common understanding of mutual respect. Health-care providers must follow these standards and provide services of the highest possible moral and ethical level.[5] The health-care systems in many countries have compiled a patient bill of rights, which are important responsibilities of all levels of management. Hospital authorities are charged to share its bill of rights with their patients and assure that patients understand their rights.[6] Compiling a viable patient bill of rights was a strong starting; however, additional work is needed for involved parties to provide a universal application of patient rights. In addition, it is necessary to establish a correct definition for the relationship between health-care service providers and patients. This must include patients' opinion concerning their rights as well as affective factors, such as professional position and environmental differences. These have a direct effect on policymakers to create, promote, and monitor their programs to improve observance conditions of patients' rights.[7] Rights of patients can be violated from the moment of admittance. This can affect the course of their stays. In order to achieve better intent of patient bill of rights, it must be assumed that such rights are fundamental in progressive societies. This requires both active research and education of the population.[8]

Health-care professionals can provide care based on patients' rights, and their knowledge of patients' rights needs to be evaluated. Educational programs, leaflets, booklets, and posters can be helpful in this regard. In addition, professional organizations and the Ministry of Health need to be more sensitive to this issue.[910] The Ministry of Health and Family Welfare in India released the Charter for Patient rights in October 2018. The charter has focused on the patients' right to information, education, records and reports, informed consent, confidentiality, human dignity and privacy, right to choose alternative treatment options if available, and rights to seek grievance.[11] Nurses of future cannot practice in the ignorance of individual rights, neither can the nurses ignore health-care professionals' and health-care facilities' responsibility to respect rights. Nurses' first responsibility is to be aware of the clients' legal rights. Nurses' major responsibility is to follow through the clients' rights with the nursing actions that ensure the practice of patient rights.[12] It seems that nurses' characteristics such as self-concept, personal values, confidence as nurses, and personal beliefs play a main role in nurses' advocacy actions. In general, only a few quantitative studies have evaluated nursing advocacy, and the majority have been qualitative.[13]

Perhaps, the most important factor in ensuring patients' rights is the knowledge, attitude, and commitment of the mental health professionals.[14] Attitude refers to feelings, beliefs, and positive and negative reactions of an individual toward an event, phenomenon, object, or person to arise through the internalization of cognitive structures.[15] Thus, nurses' attitude toward patient rights is paramount.[16] Patients during their care process have rights, which must be acknowledged and protected. Patient rights include observance of acceptable physical, mental, spiritual, and social needs described by the current national rules and regulations. Health-care providers are responsible for establishing and maintaining patients' rights.[17]

Nurses are the professionals who spend most of their time with patients. Nurses need to gain adequate knowledge of patient rights in order to practice these rights. Thus, it is imperative for health-care organizations to equip their nursing staff with adequate knowledge on patient rights through varied training programs. Based on the National Accreditation Board for Hospitals and Healthcare Providers (NABH) standards of nursing excellence, the researcher in this study probed on ten patient rights: right to respect and dignity, education, access, information, safety, privacy, confidentiality, informed consent, decision–making, and grievance redressal.[18] As the patient right charter was recently introduced in India,[11] there is a need to create awareness among nurses with regard to patient rights and develop a positive attitude toward these rights. Thus, it is essential to assess the attitude of nurses on patient rights and develop appropriate training program on patient rights for the nurses.

Materials and Methods

Research design

In this study, quasi-experimental one-group pretest–posttest design was used. The study was conducted in the general wards of two teaching hospitals in India. Hospital 1 was not accredited by the NABH, whereas hospital 2 was NABH accredited. The sample size consisted of a total of 200 nurses, 100 from each hospital under study. The sample size was taken considering a design effect of 0.4 and power of 0.8. Convenience sampling method was used to select the sample. A structured questionnaire was used to measure the attitude of nurses on patient rights. An attitude questionnaire, audio–visual aids, and training module on patient rights were developed for the program. To ensure content validity, the questionnaire, audio–visual aids, and the training module were submitted to eight experts in the field of nursing. As per the experts' opinion, modifications were made. The reliability of the attitude scale was 0.921. The research tool consisted of sociodemographic variables, and the attitude of nurses on patient rights was assessed. Sociodemographic variables included gender, marital status, and work experience. The structured questionnaire had 27 items. Attitude items were rated based on a 5-point Likert scale with ratings of strongly agree (5), agree (4), neutral (3), disagree (2), and strongly disagree (1). The maximum score was 135. The overall attitude score was further calculated by just summing up the correct responses and was divided into different categories.[19] Five categories were most favorable (score 81%–100%), favorable (61%–80%), neutral (41%–60%), unfavorable (21%–40%), and most unfavorable (≤20).

Ethical considerations

Ethical approval for this study was obtained from the institutional review board (FMMC/FMIEC/3008/2016). Permission to conduct the study was obtained from the administrator of the hospital prior to the survey procedure. Authorized consent was taken from the administrators of the hospitals to go on with the research study. Written consent from participants was obtained to participate in the study.

Study procedure

A sample size of 200 nurses were selected, i.e., 100 from each hospital under study. Nurses <1 year of work experience were excluded from the study. Small-group teaching method was used to train nurses on patient rights. Wherein, the nurses were trained in small groups of 8–10. Before the commencement of training, pretest was conducted on the nurses through the structured attitude questionnaire. Thereafter, the nurses were trained on patient rights through audio– visual aids, video, and training module. After a week, posttest was conducted on the nurses through the same structured attitude questionnaire.

Data analysis

Data were analyzed using IBM SPSS software version 10 IBM SPSS software version 20; descriptive analysis included frequency and percentages for all categories of variables. Patient right domain-wise mean and standard deviation scores were calculated. Wilcoxon signed-rank test was used to find the impact of the training program on nurses' attitude.

Results

Table 1 shows the baseline data of the nurses. In hospital 1, majority (94%) of the nurses were female, majority (59%) were unmarried, and majority (62%) had 1–3 years of work experience. In hospital 2, majority (97%) of the nurses were female, majority (88%) were unmarried, and majority (84%) had 1–3 years of work experience.

Table 1

Demographic data of nurses (n=100+100)

Variables	Frequency (%)*
	Hospital 1	Hospital 2
Gender
Female	94	97
Male	6	3
Marital status
Married	41	12
Unmarried	59	88
Work experience (years)
1-3	62	84
Above 3	38	16

*Percentage values are not shown as the sample size is 100, frequency is equal to (%)

Table 2 shows the level of attitude of nurses on patient rights in hospital 1. Before training nurses on patient rights, majority (65%) had a favorable attitude toward patient rights. After training, majority (76%) had the most favorable attitude toward patient rights.

Table 2

Distribution of the nurses based on the grading of attitude scale before and after training nurses in hospital 1 (n=100)

Attitude level	Score*	Score in percentage	Frequency (%)
			Before training nurses	After training nurses
Most favorable	107-135	81-100	23	76
Favorable	82-108	61-80	65	24
Neutral	55-81	41-60	12	0
Unfavorable	28-54	21-40	0	0
Most unfavorable	≤27	≤20	0	0

*Maximum score=135

Table 3 shows the level of attitude of nurses on patient rights in hospital 2. Before training nurses on patient rights, majority (54%) had a favorable attitude toward patient rights. After training, majority (84%) had the most favorable attitude toward patient rights.

Table 3

Distribution of the nurses based on the grading of attitude scale before and after training nurses in hospital 2 (n=100)

Attitude level	Score*	Score in percentage	Frequency (%)
			Before training nurses	After training nurses
Most favorable	107-135	81-100	35	84
Favorable	82-108	61-80	54	16
Neutral	55-81	41-60	11	0
Unfavorable	28-54	21-40	0	0
Most unfavorable	≤27	≤20	0	0

*Maximum score=135

Table 4 shows that the median score of nurses' attitude regarding patient rights is higher after training compared to before training in hospital 1. The median score differs statistically significantly before training and after training in hospital 1 (P < 0.001). The median score of nurses' attitude regarding patient rights is higher after training compared to before training in hospital 2. The median score differs statistically significantly before training and after training in hospital 2 (P < 0.001).

Table 4

Attitude of nurses regarding patient rights within hospitals 1 and 2 (Wilcoxon’s signed rank test) (n=100+100)

Research setting	Pre-test and Post-test phases	Median*	Interquartile range	P
Hospital 1	Before training nurses	99	91-108	<0.001
Hospital 1	After training nurses	119	109-127
Hospital 2	Before training nurses	101.5	92-113.5	<0.001
Hospital 2	After training nurses	121	113-127

*Maximum score=135

Discussion

In the recent times, patient rights are of great concern to the health-care providers and patients. The accreditation bodies have laid higher standards to meet the demands of the patients.[18] Developing positive attitude on patient rights among the nurses is crucial to influence better practice. In this regard, a research was conducted to explore the attitude of nurses, to implement training program and to assess its impact on the attitude of nurses with regard to patient rights in NABH-accredited and non–NABH-accredited hospitals.

In both the hospitals under study, before training nurses on patient rights, majority had a favorable attitude toward patient rights. After training, majority had the most favorable attitude toward patient rights. In addition, the median score of nurses' attitude regarding patient rights was higher after training compared to that of before training. The median score differs statistically significantly before training and after training in hospital 1 (P < 0.001). Studies have shown that 82.2% of the nursing students had good perception of all 14 patient rights.[20] The findings of these studies can be attributed to the ongoing educational programs in the way toward standardization of nursing care.

Similarly, the results of another study implied that fairly positive attitudes and perception were found among the participants, and nurses' attitudes, in general, were positively correlated to their perception toward nursing advocacy. This means that with an improvement in perception, the attitude would also improve. The researcher suggested that the nurses needed more advocacy through educational programs and support from responsible employers.[21] This implies that the educational programs have shown positive results in enhancing the attitude of nurses on patient rights. In the current study, the educational intervention has shown a positive impact on the attitude of nurses, wherein after the training, the attitude was most favorable toward patient rights.

Previous research also showed that positive attitudes of health-care professionals toward ethics preparation improved beneficial outcomes of educational innovations.[22] Such findings support the belief that assessing trainees' attitudes, views, and preferences is important in developing curricular approaches attuned to their concerns and experiences.[23] The result of the current study can be interpreted on similar lines. The training program developed in the current study has shown positive outcome on the attitude of nurses on patient rights. Such innovative educational programs can be incorporated in the educational curriculum, as suggested by similar researches.

Conclusions

Patient rights are the essential elements of the total nursing care. As health-care organizations meet the standardization requirements laid by the accreditation and approval bodies, patient rights need to be given prime importance. The research concluded that the training program was efficient in bringing in the most favorable attitude among nurses in accredited and nonaccredited hospitals. Such educational programs need to be incorporated in the educational curriculum and as follow-up programs in the in-service training schedules. Quality care standards shall be greatly met through such moves.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.