Original Manuscript
Nurses’ knowledge and performance of the patients’ bill of rights
Nursing Ethics 1–11 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015584967 nej.sagepub.com
Abbas Sheikhtaheri Iran University of Medical Sciences, Islamic Republic of Iran
Monireh Sadeqi Jabali Isfahan University of Medical Sciences, Islamic Republic of Iran
Zahra Hashemi Dehaghi Islamic Azad University, Islamic Republic of Iran; Tehran University of Medical Sciences, Islamic Republic of Iran
Abstract Background: Observance of the patients’ bill of rights is one of the main features of moral codes in hospitals. In this regard, nurses bear great responsibility because they spend a long time with patients. Therefore, the continuous evaluation of the nurses’ performance and assessing their knowledge about the patients’ bill of rights are a need. Objectives: We aimed to determine the nurses’ awareness of the patients’ rights and measure their performance in this regard. Research design and participants: This cross-sectional study was carried out in 2013. To measure the nurses’ knowledge and performance, 250 nurses and 300 patients were surveyed. The participants were selected randomly from five teaching hospitals in Tehran, Iran. Two questionnaires, one for nurses (17 questions) and the other for patients (11 questions), were applied. The data were analyzed in SPSS software using descriptive and inferential statistics. Ethical consideration: The research protocol was submitted and approved by the research and ethics committees of the participating hospitals. Additionally, the consents of all of the participants were obtained before the study. Findings: The mean score of the nurses’ knowledge regarding the patients’ rights was acceptable (69.85 + 11.7 of 85). Furthermore, the mean score of nurses’ performance in observing the patients’ rights was relatively acceptable (11.2 + 4.6 of 22). More experienced and educated nurses had higher knowledge regarding the patients’ rights, and patients with higher education level or experience of being hospitalized were less satisfied with the nurses’ performance. Conclusion: Nurses’ knowledge of the patients’ bill of rights was acceptable; however, observance of the patients’ rights was not. It seems that notification of the patients’ bill of rights has increased the nurses’ awareness of the patients’ rights, although improvement of the nurses’ performance needs more extensive measures.
Corresponding author: Abbas Sheikhtaheri, Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Yasemi St., Near Niayesh Highway, Valey-e-Asr St., Tehran, Islamic Republic of Iran. Email: [email protected]
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Keywords Iran, knowledge, nurse, patients’ rights, patients’ bill of rights, performance
Introduction The World Health Organization (WHO) defines patients’ rights as a set of rights that an individual have in healthcare settings.1 In other words, the patients’ bill of rights refers to a set of privileges regarding legitimate and rational needs of patients designed in the form of standards, laws, and regulations, and the healthcare providers are required to observe them.2,3 In Iran, the patients’ bill of rights was first developed and notified to healthcare organizations by the Office of the Health Affairs of the Ministry of Health in 2002. Afterward, the revised version of the bill was approved by the Health Policy Council of the Ministry in 2009 and notified to all of the healthcare organizations of the country in the end of 2009.2,4 The final bill of rights has been developed based on five key axes including ‘‘right to receive proper services,’’ ‘‘right to be informed properly and adequately,’’ ‘‘right to have free choice regarding health services,’’ ‘‘right to be treated respectfully and observation of confidentiality of patients’ information,’’ and ‘‘right to have access to an effective patients’ complaint service.’’ Each of these axes has several requirements.3,4 According to previous studies, observance of patients’ rights lead to improvement in healthcare quality and satisfaction of patients, and healthcare providers,5,6 as well as improvement in patient and provider relationship.5,7 On the other hand, negligence of these rights ends up breaking patients’ trust in healthcare providers and other unwanted consequences such as legal prosecution.6,7 However, several studies have indicated that some parts of the patients’ bill of rights may not be completely observed by healthcare providers. For instance, Kuzu et al.8 showed that the majority of patients noted that they did not have access to complaint services to claim their rights. Studies in Iran have revealed different performance of providers in this regard.9,10 Some researchers believe that observing patients’ rights is more critical in the case of nurses as they spend more time with patients and more intimate relationship is formed between the nurse and the patient.11 Parts of the supports that can be provided by nurses to patients are recognition of needs, informing patients of their rights, and protecting the patients’ rights.12 Many factors may influence nurses’ performance in observing patients’ rights, one of which is their knowledge about these rights.6,12 Studies in different countries have shown poor or moderate knowledge of nurses regarding patients’ rights.13 Iranian studies have found different results so that some have reported good6 and some poor5 knowledge of patients’ rights among the nurses. However, different studies have reported different results regarding performance of nurses as to observance of the patients’ rights. In a study, 80% of the patients were satisfied with observance of their rights by the nurses;14 this figure was 53% in another Iranian study.15 Non-Iranian studies have reported inconsistent results so that a study reported good satisfaction16 and another one reported poor satisfaction17 with observance of the patients’ rights. Moreover, nurses’ estimate of their performance in observance of the patients’ rights was higher than that of the patients.18,19 In addition, it seems that the relationship between knowledge and performance of the nurses regarding the patients’ bill of right is not clear, so some studies20 reported that better nurses’ knowledge significantly results in a better performance; however, some studies19 did not show such relationship. Although there are many studies about patients’ rights in the field of nursing, because of the discrepancies in literature and also the need for ongoing evaluation of this issue, researchers should continue to conduct research in this regard. In light of this, this study is an attempt to evaluate Iranian nurses’ knowledge of the patients’ bill of rights and to measure their performance.
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Methods Settings and study population This cross-sectional study was carried out in spring 2013 in Tehran, Iran. At first, five teaching hospitals affiliated with medical science universities in Tehran were randomly selected. The study population for assessing knowledge comprised the nurses working in these hospitals. To measure nurses’ performance, the hospitalized patients were surveyed. One of the hospitals did not allow surveying the patients, and thus, patients in four hospitals constituted the study population. The sample size of the nurses and the patients were 250 and 300, respectively. The same number of patients and also nurses from each hospital were selected. To this end, 75 patients from each of the four hospitals and 50 nurses from each of the five hospitals were selected. For recruiting nurses, we obtained a list of the nurses and sample selection was done randomly. As for patients, a systematic random sampling method was applied through which patients were selected at the time of their discharge at different working shifts.
Instruments and data gathering We developed two questionnaires in which the questions were designed based on Iranian.6,14 To measure the nurses’ knowledge, 17 questions were designed and the participants were asked to determine whether they found the items as a right of patients or not. They should answer the questions based on Likert’s scale (completely agree to completely disagree). The validity of the questionnaire was confirmed by 10 experts in nursing and medical ethics fields. The experts were asked to rate the necessity and clarity of each question from 1 to 4 (1 ¼ low necessity/clarity to 4 ¼ high necessity/clarity). They found all the questions necessary (mean score above 3) and recommended minor changes to improve the clarity of some questions. Furthermore, we used the test–retest methods to ensure the reliability of the questionnaire. Ten nurses (excluded from the main study) were asked to fill out the questionnaire in a 10-day interval (r ¼ 0.85). In addition, the reliability of the questionnaire was tested by Cronbach’s alpha (a ¼ 0.93). According to the experts’ opinion who participated in the validity study, 11 out of the 17 questions were found to be more relevant to the nursing activities. Therefore, we considered these questions to develop our questionnaire for evaluation of nurses’ performance. In this questionnaire, the patients were asked to determine the extent to which the nurses have observed their rights. The validity of the questionnaire was ascertained by the experts using the same methods mentioned above. The reliability of the questionnaire was examined by the test–retest method in a 10-day interval (with participation of 10 patients who excluded from the main study). The correlation was 0.79. Moreover, the reliability of the questionnaire was checked by Cronbach’s alpha (a ¼ 0.75). We distributed the questionnaires and collected them in spring 2013. Eventually, 193 nurses and 240 patients answered the questionnaires. In some cases (patients below statutory legal age), parents of the patients completed the questionnaire on behalf of their children.
Ethical consideration First, the research protocol was submitted to research and ethics committees of the hospitals. All of the hospitals authorized us to conduct the research; however, one of them did not allow to survey patients. Therefore, we excluded this hospital from the study (evaluation of nurses’ performance). In addition, the participants were volunteers and signed a letter of consent before being admitted in the study. Furthermore, confidentiality of the patients’ and nurses’ information was observed throughout the study.
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Table 1. Demographic data of the patients.a Characteristics
Number (%)
Sex Male Female Marital status Single Married Age (years) 20 20–29 30–39 40–49 50–59 60 Level of education Illiterate Less than high school diploma Diploma Technician Bachelor’s degree Master’s degree Previous admission Yes No
71 (29.6) 167 (69.6) 21 (8.8) 99 (41.2) 14 (5.8) 50 (20.8) 40 (16.7) 45 (18.8) 31 (12.9) 60 (25) 59 (24.6) 30 (12.5) 60 (25) 18 (7.5) 12 (5) 2 (0.8) 66 (27.5) 174 (72.5)
a
As not all questions were filled out completely, sum of some variables is less than 100%.
Data analysis For data analysis, the answers were scored. In the knowledge questionnaire, scores were as follows: 5 ¼ completely agree to 1 ¼ completely disagree. In addition, in the performance questionnaire, we used scores 0, 1, and 2 for answers ‘‘did not observe,’’ ‘‘somewhat observed,’’ and ‘‘completely observed,’’ respectively. Afterward, the data were analyzed in SPSS using descriptive statistics (e.g. frequency and mean of scores) and inferential statistics (e.g. t-test, and analysis of variance (ANOVA) for data with normal distribution and the equivalent nonparametric tests for data without normal distribution). The level of knowledge and performance was categorized as follows: scores less than 50% of the total points (for total questions and for each question) were considered ‘‘unacceptable,’’ between 50% and 75% were considered ‘‘relatively acceptable,’’ and more than 75% were considered ‘‘acceptable.’’
Results Demographic data of the participating patients and nurses are listed in Tables 1 and 2. The majority of the patients were female, married, and had a high school diploma or below. Average age of the patients was 44.5 + 1.7 years. Moreover, the majority of the nurses were female and belonged to age group 10
64 (33.2) 129 (66.8) 82 (42.5) 87 (45.1) 24 (12.4) 10 (5.2) 175 (90.7) 8 (4.1) 123 (63.7) 70 (36.3)
a
As not all questions were filled out completely, sum of some variables is less than 100%.
participants obtained more than 75% of total knowledge score. The findings showed that the knowledge was acceptable for all of the rights except for ‘‘patients’ access to their medical record’’ (3.4 + 0.3 out of 5). We found that knowledge of the nurses with a master’s degree ( p ¼ 0.047) and those with more than 10 years’ experience (p ¼ 0.001) was significantly higher than others’. There was not any other significant relationship between the nurses’ knowledge and other demographic variables. Table 4 shows the patients’ perceptions regarding the performance of the nurses in observing their rights. In short, the mean score of the patients’ perception was 11.2 + 4.6 (50.8% out of 22 points). From the patients’ viewpoint, the nurses had unacceptable performance in ‘‘allowing patients to access their information and medical records,’’ ‘‘informing the patients about the patients’ bill of rights,’’ ‘‘informing names and specialty of the providers in the medical team,’’ ‘‘confidentiality of patients’ information,’’ ‘‘explaining the possible side effects of treatment,’’ and ‘‘allowing the patient to refuse treatment.’’ Moreover, many patients were not sure whether confidentiality of their information is observed or not (about 64%). In addition, patients with a previous hospitalization experience ( p ¼ 0.005) and also more educated patients ( p ¼ 0.001) were less satisfied with the nurses’ performance.
Discussion Knowledge The results showed that the nurses had an acceptable knowledge regarding the patients’ rights (82% of total score). In this regard, only the knowledge about ‘‘patients’ access to their medical record’’ was relatively acceptable. Before enactment of the patients’ bill of rights in Iran, few studies had been conducted on this topic and inconsistent results had been reported, including good awareness of the nurses (95%)12 and weak awareness of the nurses as to patients’ rights (22%).21 The enactment of the bill surged the number of studies in this field, which showed an increasing trend of awareness among the nurses regarding the patients’ rights. For instance, studies in 2010 reported that nurses’ knowledge regarding the patients’ rights was at mean level5 and studies in 2011 and 2012 reported that most nurses (54.5%,7 58.3%,22 and 68.2%23) had a good level of
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Table 3. Nurses’ knowledge of patients’ rights. Agree/ Disagree/ completely agree Neutral completely disagree
Questions Providing healthcare services without any discrimination Providing all essential utilities for patients Providing emergency care regardless of costs Providing services in the shortest feasible time Right to be aware of the content of the patients’ bill of rights Providing information about the names and specialties of the healthcare team Informing about the advantages and disadvantages of diagnostic and therapeutic methods Authorizing patients to access their medical record Providing information about the costs of diagnostic and therapeutic services, insurance regulations, and support systems Consulting with other physicians without affecting the treatment process Explaining the possible side effects of treatment before treatment Patient’s right to refuse treatment Allowing patients to choose his or her physician Ensuring confidentiality of medical records and preventing access of other people without the consent of the patient Allowing patient to have a trusted person at all stages of hospitalization In case of violation of patients’ rights, allowing complaints to the competent authorities without affecting the treatment process Compensating medical errors
185 (95.9)
2 (1)
Mean + SD
6 (3.1)
4.5 + 0.72
189 (97.9) 183 (94.8) 189 (97.9) 129 (66.9)
2 (1) 2 (1) 4 (2.1) 30 (15.5)
2 (1) 6 (3.1) – 34 (17.6)
4.6 + 0.6 4.6 + 0.72 4.7 + 0.5 3.8 + 1.2
137 (71)
24 (12.4)
30 (15.5)
3.9 + 1.2
155 (80.3)
16 (8.3)
20 (10.4)
4.1 + 0.9
99 (51.3) 137 (71)
28 (14.5) 34 (17.6)
64 (33.2) 20 (10.4)
3.4 + 0.3 4.0 + 1.0
139 (72)
48 (24.9)
6 (3.1)
4.1 + 0.9
171 (88.6)
8 (4.1)
10 (5.2)
4.4 + 0.8
131 (67.9) 138 (71.5) 123 (63.7)
20 (10.4) 29 (15) 42 (21.8)
42 (21.8) 26 (13.5) 28 (14.5)
3.8 + 1.2 3.9 + 1.1 3.9 + 1.1
169 (87.6)
8 (4.1)
12 (6.2)
4.3 + 0.9
137 (71)
44 (22.8)
12 (6.2)
4.1 + 1
147 (76.2)
38 (19.7)
8 (4.1)
4.2 + 0.9
SD: standard deviation.
awareness. The nurses’ awareness of the patients’ rights increased to 67%20 and 87%19 in 2014. These results are consistent with this study. Similar studies have been conducted in other countries. A study in Yemen showed that 95.5% of the nurses had good knowledge as to mothers’ and infants’ rights,17 while 84% of nurses in Spain had good knowledge in this regard.24 These studies are consistent with this study. It is notable that studies in the developing countries have reported a lower level of awareness among the nurses in this regard. Studies in India indicated that many of the participating nurses had poor or moderate knowledge of the patients’ rights.25 A study in Uganda26 showed that 69% of the nurses and physicians did not have considerable awareness of the patients’ bill of rights; this figure in Turkey and Egypt was about the half of the nurses.11,27 However, studies in developed countries have shown that awareness as to some aspects of the bill was good among the nurses.28,29 For instance, awareness about confidentiality of patients’ information in Canada was reported 84%.30 These reports generally show a good knowledge of Iranian nurses of the patients’ rights comparing with other developing countries. This indicates that after approval of the patients’ bill of rights in Iran, good measures have been taken to inform the nurses in this regard.
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Table 4. Respect to the bill of patients’ rights by nurses from patients’ view points. Completely Somewhat observed observed
Questions Proving healthcare services without any discrimination Providing all essential utilities for patients Providing services in the shortest feasible time Explaining the content of the patients’ bill of rights Providing information about the names and specialties of healthcare team Describing the advantages and disadvantages of diagnostic and therapeutic methods Authorizing patients to access their medical records Explaining the possible side effects of treatment before the treatment Allowing the patient to refuse of treatment if patients disagree with the treatment Ensuring the confidentiality of medical records and preventing access of other people without the consent of the patient Allowing the patient to have a trusted person at all stages of hospitalization
Did not observe
Not applicable Mean + SD
193 (80.4) 137 (57.1) 142 (59.2) 80 (33.3) 70 (29.2)
35 (14.6) 12 (5) 63 (26.2) 40 (16.7) 62 (25.8) 35 (14.6) 18 (7.5) 129 (53.8) 49 (20.4) 115 (47.9)
– – – 8 (3.3) 3 (1.2)
1.75 + 0.53 1.4 + 0.76 1.4 + 0.74 0.78 + 0.9 0.8 + 0.9
108 (45)
47 (19.6)
4 (1.7)
1.11 + 0.8
80 (33.3)
15 (6.2) 90 (37.5)
28 (11.7) 137 (57.1) 57 (23.8) 0.32 + 0.6 25 (10.4) 99 (41.2) 26 (10.8) 0.95 + 0.9
58 (24.2)
21 (8.8)
63 (26.2) 96 (40)
0.96 + 0.9
70 (29.2)
57 (23.8)
96 (40)
15 (6.2)
0.88 + 0.8
161 (67.1)
29 (12.1)
47 (19.6)
3 (1.2)
1.48 + 0.8
SD: standard deviation.
We found that the nurses with higher education and those with more experience were more knowledgeable than other nurses. Some studies have reported that there was no relationship between education level of nurses and awareness regarding the patients’ bill of rights.17,20 Additionally, a study, inconsistent with this study, showed a negative relationship between nurses’ knowledge regarding the patients’ bill of rights and education level of the nurses.21 As to relationship between work experience of the nurses and their knowledge of the patients’ bill of rights, some studies showed a positive relationship,5,21 which is consistent with our study. However, there are some studies that did not confirm the relationship between these two variables,7,17 which hints the need for more studies in this regard.
Performance Our results showed that the nurses observed the patients’ rights relatively acceptable (51% of the total score). Studies before 2010 revealed that patients’ satisfaction with observation of their rights was about 53% (mean level) in Tehran city.31 In addition, 53% of the nurses agreed with the patients in this regard.15 Studies in 2010 showed that about 45% of the patients in Ielam (a city of Iran)18 and 80% of patients in Tehran14 were satisfied with the nurses’ performance. Studies in 2013 indicated that 67% of the patients and 67% of the nurses in Kerman city found observance of the patients’ bill of right satisfactory.19 The studies on nurses in 2014 reported that the average point of observation of the patients’ bill of right was 4.09 out of 5 (good level) from the nurses’ point of view.20 These studies have shown that observation of the patients’ rights after the enactment of the bill has changed over time and remained on average and good levels. Studies in India,16 Yemen,17 and Uganda26 have reported problems in this regard. For instance, the study in Uganda showed that none of the health staff observed all of the rights and 80% of the staff only observed two-thirds of the rights.26 These results are consistent with our work, which indicate that the observation of patients’ rights in the developing countries should be improved.
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As illustrated by the results, observation of ‘‘the patients’ right to access their medical records’’ obtained the minimum score. Another Iranian study reported observance of patients’ right to access their medical records at the 14.2% level.32 The reason for negligence of this right might be lack of awareness or reluctance of the Iranian nurses to recognize such right, as some works have demonstrated general disagreement with this right among healthcare providers in Iran.4 This right is clearly expressed by the bill of rights; however, our finding calls for more promoting works in this regard. We found that the nurses’ practice regarding ‘‘the patient’s right to be informed about the patients’ bill of rights’’ was not acceptable. According to a study, 93.5% of the patients had received no information about their rights.33 Other studies in the developing countries have reported consistent results.34 Patients believed that informing them immediately after being hospitalized is a fruitful way to respect their rights.35 It is essential, thus, to hold courses to train the nurses how to inform the patients of their rights.11 The patients believed that the right to refuse treatment has been neglected by nurses. Failure to observe this right has been consistently reported by several studies in Iran.31,36,37 It is the patients’ right to refuse a treatment9 and the medical team is required to provide enough information to patients and enable them to make a proper decision. As indicated by other studies, participation of the nurses in this regard helps the patients to make more informed decisions.9,10 Therefore, it is recommended that nurses help physicians in this regard. The results showed poor observation of the patients’ right of being informed of the names and specialty of the healthcare team (physicians, nurses, etc.). Some studies in other developing countries reported poor observance of this right. For instance, a study indicated that only 28% of the participants were introduced to their medical team;34 another study in Turkey reported this figure to be 70%.8 Iranian studies have also obtained consistent results.31,33 It appears, however, that when the patient is introduced to the medical team, they can build better relation with the medical staff, which helps better provision of healthcare services. We also found that patients with a hospitalization history and more educated patients were less satisfied with the nurses’ performance. Some studies have found no relationship between the patient’s satisfaction with observation of the patients’ bill of rights and hospitalization experience14,36 and education level32 of the patient. However, there are studies including the present one that have shown patients with higher education level expressed less satisfaction with observance of their rights.14 On the other hand, some studies have shown direct relationship between education level and satisfaction level of the patients with observation of the bill.36 It is notable that none of these studies have been explicitly on nurses and thus no direct conclusion can be made. There is a need for further studies in this regard.
Relationship between nurses’ knowledge and performance Our results showed acceptable knowledge of nurses about different areas of the patients’ bill of rights; however, the performance of the nurses about some areas of the bill was not acceptable. Some studies have indicated that better knowledge about patients’ rights among nurses results in a significantly better performance5,20 However, some studies have reported no relationship between these two variables.19,36 Because of the design of our study, we cannot make any direct conclusion about the relationship between the nurses’ knowledge and performance; however, the authors believe that knowledge is not the only factor in predicting the performance. As recommended by different studies, insufficient staffing,1,13,35 low salaries, negligence of the nurses’ rights, burnout, long working hours, lack of performance standards in hospitals, and lack of enough equipment13 are the factors that are effective in poor observance of the patients’ rights. Therefore, reasons for unacceptable observation of the patients’ rights in the nursing domain need to be examined in more details.
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Limitations To interpret the results, limitations of the study must be taken into account. The study only focused on five teaching hospitals in Tehran. Therefore, the results cannot be generalized nationwide. Moreover, the results are based on self-reporting. More studies in this regard are recommended thus.
Conclusion The nurses’ knowledge about the patients’ rights was acceptable. Moreover, the nurses with lower education and experience were less aware of the patients’ bill of rights. Additionally, the nurses’ performance regarding observance of the patients’ rights was relatively acceptable. Patients with higher education were not satisfied with observance of their rights. It seems that over the years enactment and introduction of the patients’ bill of rights in Iran have led to an increase in knowledge about patients’ rights among nurses. However, mere notification to the hospitals and asking them to implement the bill are not enough, that is, there is a need for further evaluation and observation. Additionally, deeper studies as to the factors effective on observation of the patients’ rights by the nurses, specifically in terms of the patients’ and nurses’ level of education are recommended. Acknowledgements We would like to thank F. Arabi, S. Esmaili, S. Samiei, M. Shahabi, and M. Ghasemi for their help in data collection. Conflict of interest All authors declare that there is no conflict of interest. Funding This study is self-funded. References 1. Joolaee S and Hajibabaee F. Patient rights in Iran: a review article. Nurs Ethics 2012; 19: 45–57. 2. Hadian Jazi Z and Dehghan Nayeri N. Barriers in the performance of patient’s rights in Iran and appropriate offered solutions review article. Holist Nurs Midwifery J 2015; 24: 69–79 (in Persian). 3. Parsapoor A, Bagheri A and Larijani B. Patient’s bill of rights in Iran. Iran J Med Ethics Hist Med 2009; 3: 39–47 (in Persian). 4. Bostani Khalesi Z, Masole S and Abedinzade M. Evaluation of the patients, doctors and nurses view points about patient bill of rights in Rasht public hospitals. J Fasa Univ Med Sci 2012; 2: 91–95 (in Persian). 5. Ghaljeh M, Zakeri Z, Rezaee N, et al. Physicians and nurses awareness and function about patients right charter in Zahedan. Iran J Med Ethics Hist Med 2010; 3: 69–75 (in Persian). 6. Mohammad Nejad E and Ehsani SR. Nurses awareness of patients rights in a teaching hospital. J Med Ethics Hist Med 2011; 4: 2. 7. Vahedian Azimi A, Ghasem Kashani S, Avazeh A, et al. Awareness of nurses about patients’ rights and the extent they respect it. Prev Care Nurs Midwifery J 2011; 1: 55–63 (in Persian). 8. Kuzu N, Ergin A and Zencir M. Patients’ awareness of their rights in a developing country. Public Health 2006; 120: 290–296. 9. Farzandipour M, Sheikhtaheri A and Sadeqi Jabali M. Perceived quality of informed refusal process: a cross-sectional study from Iranian patients’ perspectives. Dev World Bioeth. Epub ahead of print 11 April 2014. DOI: 10.1111/dewb.12054.
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31. Vaskooei Ashkevarii KH, Karimi M, Asna Ashari H, et al. Observation of patient rights in Tehran University of Medical Sciences hospitals. Iran J Med Ethics Hist Med 2009; 2: 47–54 (in Persian). 32. Babamahmoodi F, Meftahi M, Khdemloo M, et al. A Study of patient rights implementation from patients view points in the educational hospitals of Mazandaran University of Medical Sciences. Iran J Med Ethics Hist Med 2011; 4: 37–44 (in Persian). 33. Ansari S, Abeid P, Namvar F, et al. Respect to the bill of patients’ rights in the educational hospitals in Ahvaz, Iran. Middle East J Sci Res 2013; 13: 440–444. 34. Changole J, Bandawe C, Makanani B, et al. Patients’ satisfaction with reproductive health services at Gogo Chatinkha Maternity Unit, Queen Elizabeth Central Hospital, Blantyre, Malawi. Malawi Med J 2010; 22: 5–9. 35. Merakou K, Dalla-Vorgia P, Garanis-Papadatos T, et al. Satisfying patients’ rights: a hospital patient survey. Nurs Ethics 2001; 8: 499–509. 36. Basiri Moghadam K, Basiri Moghadam M, Moslem A, et al. Health providers and patients’ awareness on patient bill of rights and its observing rate in an educational hospital in Gonabad. Ofogh-e-Danesh 2011; 17: 45–54 (in Persian). 37. Kazemnezhad SM and Hesamzadeh A. Implementation of patients’ bills of rights by physicians and nurses from their colleagues’ points of view in educational hospitals of Mazandaran University of Medical Sciences. J Mazandaran Univ Med Sci 2013; 22: 216–223 (in Persian).
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Nurses’ knowledge and performance of the patients’ bill of rights
Nursing Ethics 1–11 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733015584967 nej.sagepub.com
Abbas Sheikhtaheri Iran University of Medical Sciences, Islamic Republic of Iran
Monireh Sadeqi Jabali Isfahan University of Medical Sciences, Islamic Republic of Iran
Zahra Hashemi Dehaghi Islamic Azad University, Islamic Republic of Iran; Tehran University of Medical Sciences, Islamic Republic of Iran
Abstract Background: Observance of the patients’ bill of rights is one of the main features of moral codes in hospitals. In this regard, nurses bear great responsibility because they spend a long time with patients. Therefore, the continuous evaluation of the nurses’ performance and assessing their knowledge about the patients’ bill of rights are a need. Objectives: We aimed to determine the nurses’ awareness of the patients’ rights and measure their performance in this regard. Research design and participants: This cross-sectional study was carried out in 2013. To measure the nurses’ knowledge and performance, 250 nurses and 300 patients were surveyed. The participants were selected randomly from five teaching hospitals in Tehran, Iran. Two questionnaires, one for nurses (17 questions) and the other for patients (11 questions), were applied. The data were analyzed in SPSS software using descriptive and inferential statistics. Ethical consideration: The research protocol was submitted and approved by the research and ethics committees of the participating hospitals. Additionally, the consents of all of the participants were obtained before the study. Findings: The mean score of the nurses’ knowledge regarding the patients’ rights was acceptable (69.85 + 11.7 of 85). Furthermore, the mean score of nurses’ performance in observing the patients’ rights was relatively acceptable (11.2 + 4.6 of 22). More experienced and educated nurses had higher knowledge regarding the patients’ rights, and patients with higher education level or experience of being hospitalized were less satisfied with the nurses’ performance. Conclusion: Nurses’ knowledge of the patients’ bill of rights was acceptable; however, observance of the patients’ rights was not. It seems that notification of the patients’ bill of rights has increased the nurses’ awareness of the patients’ rights, although improvement of the nurses’ performance needs more extensive measures.
Corresponding author: Abbas Sheikhtaheri, Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Yasemi St., Near Niayesh Highway, Valey-e-Asr St., Tehran, Islamic Republic of Iran. Email: [email protected]
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Keywords Iran, knowledge, nurse, patients’ rights, patients’ bill of rights, performance
Introduction The World Health Organization (WHO) defines patients’ rights as a set of rights that an individual have in healthcare settings.1 In other words, the patients’ bill of rights refers to a set of privileges regarding legitimate and rational needs of patients designed in the form of standards, laws, and regulations, and the healthcare providers are required to observe them.2,3 In Iran, the patients’ bill of rights was first developed and notified to healthcare organizations by the Office of the Health Affairs of the Ministry of Health in 2002. Afterward, the revised version of the bill was approved by the Health Policy Council of the Ministry in 2009 and notified to all of the healthcare organizations of the country in the end of 2009.2,4 The final bill of rights has been developed based on five key axes including ‘‘right to receive proper services,’’ ‘‘right to be informed properly and adequately,’’ ‘‘right to have free choice regarding health services,’’ ‘‘right to be treated respectfully and observation of confidentiality of patients’ information,’’ and ‘‘right to have access to an effective patients’ complaint service.’’ Each of these axes has several requirements.3,4 According to previous studies, observance of patients’ rights lead to improvement in healthcare quality and satisfaction of patients, and healthcare providers,5,6 as well as improvement in patient and provider relationship.5,7 On the other hand, negligence of these rights ends up breaking patients’ trust in healthcare providers and other unwanted consequences such as legal prosecution.6,7 However, several studies have indicated that some parts of the patients’ bill of rights may not be completely observed by healthcare providers. For instance, Kuzu et al.8 showed that the majority of patients noted that they did not have access to complaint services to claim their rights. Studies in Iran have revealed different performance of providers in this regard.9,10 Some researchers believe that observing patients’ rights is more critical in the case of nurses as they spend more time with patients and more intimate relationship is formed between the nurse and the patient.11 Parts of the supports that can be provided by nurses to patients are recognition of needs, informing patients of their rights, and protecting the patients’ rights.12 Many factors may influence nurses’ performance in observing patients’ rights, one of which is their knowledge about these rights.6,12 Studies in different countries have shown poor or moderate knowledge of nurses regarding patients’ rights.13 Iranian studies have found different results so that some have reported good6 and some poor5 knowledge of patients’ rights among the nurses. However, different studies have reported different results regarding performance of nurses as to observance of the patients’ rights. In a study, 80% of the patients were satisfied with observance of their rights by the nurses;14 this figure was 53% in another Iranian study.15 Non-Iranian studies have reported inconsistent results so that a study reported good satisfaction16 and another one reported poor satisfaction17 with observance of the patients’ rights. Moreover, nurses’ estimate of their performance in observance of the patients’ rights was higher than that of the patients.18,19 In addition, it seems that the relationship between knowledge and performance of the nurses regarding the patients’ bill of right is not clear, so some studies20 reported that better nurses’ knowledge significantly results in a better performance; however, some studies19 did not show such relationship. Although there are many studies about patients’ rights in the field of nursing, because of the discrepancies in literature and also the need for ongoing evaluation of this issue, researchers should continue to conduct research in this regard. In light of this, this study is an attempt to evaluate Iranian nurses’ knowledge of the patients’ bill of rights and to measure their performance.
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Methods Settings and study population This cross-sectional study was carried out in spring 2013 in Tehran, Iran. At first, five teaching hospitals affiliated with medical science universities in Tehran were randomly selected. The study population for assessing knowledge comprised the nurses working in these hospitals. To measure nurses’ performance, the hospitalized patients were surveyed. One of the hospitals did not allow surveying the patients, and thus, patients in four hospitals constituted the study population. The sample size of the nurses and the patients were 250 and 300, respectively. The same number of patients and also nurses from each hospital were selected. To this end, 75 patients from each of the four hospitals and 50 nurses from each of the five hospitals were selected. For recruiting nurses, we obtained a list of the nurses and sample selection was done randomly. As for patients, a systematic random sampling method was applied through which patients were selected at the time of their discharge at different working shifts.
Instruments and data gathering We developed two questionnaires in which the questions were designed based on Iranian.6,14 To measure the nurses’ knowledge, 17 questions were designed and the participants were asked to determine whether they found the items as a right of patients or not. They should answer the questions based on Likert’s scale (completely agree to completely disagree). The validity of the questionnaire was confirmed by 10 experts in nursing and medical ethics fields. The experts were asked to rate the necessity and clarity of each question from 1 to 4 (1 ¼ low necessity/clarity to 4 ¼ high necessity/clarity). They found all the questions necessary (mean score above 3) and recommended minor changes to improve the clarity of some questions. Furthermore, we used the test–retest methods to ensure the reliability of the questionnaire. Ten nurses (excluded from the main study) were asked to fill out the questionnaire in a 10-day interval (r ¼ 0.85). In addition, the reliability of the questionnaire was tested by Cronbach’s alpha (a ¼ 0.93). According to the experts’ opinion who participated in the validity study, 11 out of the 17 questions were found to be more relevant to the nursing activities. Therefore, we considered these questions to develop our questionnaire for evaluation of nurses’ performance. In this questionnaire, the patients were asked to determine the extent to which the nurses have observed their rights. The validity of the questionnaire was ascertained by the experts using the same methods mentioned above. The reliability of the questionnaire was examined by the test–retest method in a 10-day interval (with participation of 10 patients who excluded from the main study). The correlation was 0.79. Moreover, the reliability of the questionnaire was checked by Cronbach’s alpha (a ¼ 0.75). We distributed the questionnaires and collected them in spring 2013. Eventually, 193 nurses and 240 patients answered the questionnaires. In some cases (patients below statutory legal age), parents of the patients completed the questionnaire on behalf of their children.
Ethical consideration First, the research protocol was submitted to research and ethics committees of the hospitals. All of the hospitals authorized us to conduct the research; however, one of them did not allow to survey patients. Therefore, we excluded this hospital from the study (evaluation of nurses’ performance). In addition, the participants were volunteers and signed a letter of consent before being admitted in the study. Furthermore, confidentiality of the patients’ and nurses’ information was observed throughout the study.
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Table 1. Demographic data of the patients.a Characteristics
Number (%)
Sex Male Female Marital status Single Married Age (years) 20 20–29 30–39 40–49 50–59 60 Level of education Illiterate Less than high school diploma Diploma Technician Bachelor’s degree Master’s degree Previous admission Yes No
71 (29.6) 167 (69.6) 21 (8.8) 99 (41.2) 14 (5.8) 50 (20.8) 40 (16.7) 45 (18.8) 31 (12.9) 60 (25) 59 (24.6) 30 (12.5) 60 (25) 18 (7.5) 12 (5) 2 (0.8) 66 (27.5) 174 (72.5)
a
As not all questions were filled out completely, sum of some variables is less than 100%.
Data analysis For data analysis, the answers were scored. In the knowledge questionnaire, scores were as follows: 5 ¼ completely agree to 1 ¼ completely disagree. In addition, in the performance questionnaire, we used scores 0, 1, and 2 for answers ‘‘did not observe,’’ ‘‘somewhat observed,’’ and ‘‘completely observed,’’ respectively. Afterward, the data were analyzed in SPSS using descriptive statistics (e.g. frequency and mean of scores) and inferential statistics (e.g. t-test, and analysis of variance (ANOVA) for data with normal distribution and the equivalent nonparametric tests for data without normal distribution). The level of knowledge and performance was categorized as follows: scores less than 50% of the total points (for total questions and for each question) were considered ‘‘unacceptable,’’ between 50% and 75% were considered ‘‘relatively acceptable,’’ and more than 75% were considered ‘‘acceptable.’’
Results Demographic data of the participating patients and nurses are listed in Tables 1 and 2. The majority of the patients were female, married, and had a high school diploma or below. Average age of the patients was 44.5 + 1.7 years. Moreover, the majority of the nurses were female and belonged to age group 10
64 (33.2) 129 (66.8) 82 (42.5) 87 (45.1) 24 (12.4) 10 (5.2) 175 (90.7) 8 (4.1) 123 (63.7) 70 (36.3)
a
As not all questions were filled out completely, sum of some variables is less than 100%.
participants obtained more than 75% of total knowledge score. The findings showed that the knowledge was acceptable for all of the rights except for ‘‘patients’ access to their medical record’’ (3.4 + 0.3 out of 5). We found that knowledge of the nurses with a master’s degree ( p ¼ 0.047) and those with more than 10 years’ experience (p ¼ 0.001) was significantly higher than others’. There was not any other significant relationship between the nurses’ knowledge and other demographic variables. Table 4 shows the patients’ perceptions regarding the performance of the nurses in observing their rights. In short, the mean score of the patients’ perception was 11.2 + 4.6 (50.8% out of 22 points). From the patients’ viewpoint, the nurses had unacceptable performance in ‘‘allowing patients to access their information and medical records,’’ ‘‘informing the patients about the patients’ bill of rights,’’ ‘‘informing names and specialty of the providers in the medical team,’’ ‘‘confidentiality of patients’ information,’’ ‘‘explaining the possible side effects of treatment,’’ and ‘‘allowing the patient to refuse treatment.’’ Moreover, many patients were not sure whether confidentiality of their information is observed or not (about 64%). In addition, patients with a previous hospitalization experience ( p ¼ 0.005) and also more educated patients ( p ¼ 0.001) were less satisfied with the nurses’ performance.
Discussion Knowledge The results showed that the nurses had an acceptable knowledge regarding the patients’ rights (82% of total score). In this regard, only the knowledge about ‘‘patients’ access to their medical record’’ was relatively acceptable. Before enactment of the patients’ bill of rights in Iran, few studies had been conducted on this topic and inconsistent results had been reported, including good awareness of the nurses (95%)12 and weak awareness of the nurses as to patients’ rights (22%).21 The enactment of the bill surged the number of studies in this field, which showed an increasing trend of awareness among the nurses regarding the patients’ rights. For instance, studies in 2010 reported that nurses’ knowledge regarding the patients’ rights was at mean level5 and studies in 2011 and 2012 reported that most nurses (54.5%,7 58.3%,22 and 68.2%23) had a good level of
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Table 3. Nurses’ knowledge of patients’ rights. Agree/ Disagree/ completely agree Neutral completely disagree
Questions Providing healthcare services without any discrimination Providing all essential utilities for patients Providing emergency care regardless of costs Providing services in the shortest feasible time Right to be aware of the content of the patients’ bill of rights Providing information about the names and specialties of the healthcare team Informing about the advantages and disadvantages of diagnostic and therapeutic methods Authorizing patients to access their medical record Providing information about the costs of diagnostic and therapeutic services, insurance regulations, and support systems Consulting with other physicians without affecting the treatment process Explaining the possible side effects of treatment before treatment Patient’s right to refuse treatment Allowing patients to choose his or her physician Ensuring confidentiality of medical records and preventing access of other people without the consent of the patient Allowing patient to have a trusted person at all stages of hospitalization In case of violation of patients’ rights, allowing complaints to the competent authorities without affecting the treatment process Compensating medical errors
185 (95.9)
2 (1)
Mean + SD
6 (3.1)
4.5 + 0.72
189 (97.9) 183 (94.8) 189 (97.9) 129 (66.9)
2 (1) 2 (1) 4 (2.1) 30 (15.5)
2 (1) 6 (3.1) – 34 (17.6)
4.6 + 0.6 4.6 + 0.72 4.7 + 0.5 3.8 + 1.2
137 (71)
24 (12.4)
30 (15.5)
3.9 + 1.2
155 (80.3)
16 (8.3)
20 (10.4)
4.1 + 0.9
99 (51.3) 137 (71)
28 (14.5) 34 (17.6)
64 (33.2) 20 (10.4)
3.4 + 0.3 4.0 + 1.0
139 (72)
48 (24.9)
6 (3.1)
4.1 + 0.9
171 (88.6)
8 (4.1)
10 (5.2)
4.4 + 0.8
131 (67.9) 138 (71.5) 123 (63.7)
20 (10.4) 29 (15) 42 (21.8)
42 (21.8) 26 (13.5) 28 (14.5)
3.8 + 1.2 3.9 + 1.1 3.9 + 1.1
169 (87.6)
8 (4.1)
12 (6.2)
4.3 + 0.9
137 (71)
44 (22.8)
12 (6.2)
4.1 + 1
147 (76.2)
38 (19.7)
8 (4.1)
4.2 + 0.9
SD: standard deviation.
awareness. The nurses’ awareness of the patients’ rights increased to 67%20 and 87%19 in 2014. These results are consistent with this study. Similar studies have been conducted in other countries. A study in Yemen showed that 95.5% of the nurses had good knowledge as to mothers’ and infants’ rights,17 while 84% of nurses in Spain had good knowledge in this regard.24 These studies are consistent with this study. It is notable that studies in the developing countries have reported a lower level of awareness among the nurses in this regard. Studies in India indicated that many of the participating nurses had poor or moderate knowledge of the patients’ rights.25 A study in Uganda26 showed that 69% of the nurses and physicians did not have considerable awareness of the patients’ bill of rights; this figure in Turkey and Egypt was about the half of the nurses.11,27 However, studies in developed countries have shown that awareness as to some aspects of the bill was good among the nurses.28,29 For instance, awareness about confidentiality of patients’ information in Canada was reported 84%.30 These reports generally show a good knowledge of Iranian nurses of the patients’ rights comparing with other developing countries. This indicates that after approval of the patients’ bill of rights in Iran, good measures have been taken to inform the nurses in this regard.
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Table 4. Respect to the bill of patients’ rights by nurses from patients’ view points. Completely Somewhat observed observed
Questions Proving healthcare services without any discrimination Providing all essential utilities for patients Providing services in the shortest feasible time Explaining the content of the patients’ bill of rights Providing information about the names and specialties of healthcare team Describing the advantages and disadvantages of diagnostic and therapeutic methods Authorizing patients to access their medical records Explaining the possible side effects of treatment before the treatment Allowing the patient to refuse of treatment if patients disagree with the treatment Ensuring the confidentiality of medical records and preventing access of other people without the consent of the patient Allowing the patient to have a trusted person at all stages of hospitalization
Did not observe
Not applicable Mean + SD
193 (80.4) 137 (57.1) 142 (59.2) 80 (33.3) 70 (29.2)
35 (14.6) 12 (5) 63 (26.2) 40 (16.7) 62 (25.8) 35 (14.6) 18 (7.5) 129 (53.8) 49 (20.4) 115 (47.9)
– – – 8 (3.3) 3 (1.2)
1.75 + 0.53 1.4 + 0.76 1.4 + 0.74 0.78 + 0.9 0.8 + 0.9
108 (45)
47 (19.6)
4 (1.7)
1.11 + 0.8
80 (33.3)
15 (6.2) 90 (37.5)
28 (11.7) 137 (57.1) 57 (23.8) 0.32 + 0.6 25 (10.4) 99 (41.2) 26 (10.8) 0.95 + 0.9
58 (24.2)
21 (8.8)
63 (26.2) 96 (40)
0.96 + 0.9
70 (29.2)
57 (23.8)
96 (40)
15 (6.2)
0.88 + 0.8
161 (67.1)
29 (12.1)
47 (19.6)
3 (1.2)
1.48 + 0.8
SD: standard deviation.
We found that the nurses with higher education and those with more experience were more knowledgeable than other nurses. Some studies have reported that there was no relationship between education level of nurses and awareness regarding the patients’ bill of rights.17,20 Additionally, a study, inconsistent with this study, showed a negative relationship between nurses’ knowledge regarding the patients’ bill of rights and education level of the nurses.21 As to relationship between work experience of the nurses and their knowledge of the patients’ bill of rights, some studies showed a positive relationship,5,21 which is consistent with our study. However, there are some studies that did not confirm the relationship between these two variables,7,17 which hints the need for more studies in this regard.
Performance Our results showed that the nurses observed the patients’ rights relatively acceptable (51% of the total score). Studies before 2010 revealed that patients’ satisfaction with observation of their rights was about 53% (mean level) in Tehran city.31 In addition, 53% of the nurses agreed with the patients in this regard.15 Studies in 2010 showed that about 45% of the patients in Ielam (a city of Iran)18 and 80% of patients in Tehran14 were satisfied with the nurses’ performance. Studies in 2013 indicated that 67% of the patients and 67% of the nurses in Kerman city found observance of the patients’ bill of right satisfactory.19 The studies on nurses in 2014 reported that the average point of observation of the patients’ bill of right was 4.09 out of 5 (good level) from the nurses’ point of view.20 These studies have shown that observation of the patients’ rights after the enactment of the bill has changed over time and remained on average and good levels. Studies in India,16 Yemen,17 and Uganda26 have reported problems in this regard. For instance, the study in Uganda showed that none of the health staff observed all of the rights and 80% of the staff only observed two-thirds of the rights.26 These results are consistent with our work, which indicate that the observation of patients’ rights in the developing countries should be improved.
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As illustrated by the results, observation of ‘‘the patients’ right to access their medical records’’ obtained the minimum score. Another Iranian study reported observance of patients’ right to access their medical records at the 14.2% level.32 The reason for negligence of this right might be lack of awareness or reluctance of the Iranian nurses to recognize such right, as some works have demonstrated general disagreement with this right among healthcare providers in Iran.4 This right is clearly expressed by the bill of rights; however, our finding calls for more promoting works in this regard. We found that the nurses’ practice regarding ‘‘the patient’s right to be informed about the patients’ bill of rights’’ was not acceptable. According to a study, 93.5% of the patients had received no information about their rights.33 Other studies in the developing countries have reported consistent results.34 Patients believed that informing them immediately after being hospitalized is a fruitful way to respect their rights.35 It is essential, thus, to hold courses to train the nurses how to inform the patients of their rights.11 The patients believed that the right to refuse treatment has been neglected by nurses. Failure to observe this right has been consistently reported by several studies in Iran.31,36,37 It is the patients’ right to refuse a treatment9 and the medical team is required to provide enough information to patients and enable them to make a proper decision. As indicated by other studies, participation of the nurses in this regard helps the patients to make more informed decisions.9,10 Therefore, it is recommended that nurses help physicians in this regard. The results showed poor observation of the patients’ right of being informed of the names and specialty of the healthcare team (physicians, nurses, etc.). Some studies in other developing countries reported poor observance of this right. For instance, a study indicated that only 28% of the participants were introduced to their medical team;34 another study in Turkey reported this figure to be 70%.8 Iranian studies have also obtained consistent results.31,33 It appears, however, that when the patient is introduced to the medical team, they can build better relation with the medical staff, which helps better provision of healthcare services. We also found that patients with a hospitalization history and more educated patients were less satisfied with the nurses’ performance. Some studies have found no relationship between the patient’s satisfaction with observation of the patients’ bill of rights and hospitalization experience14,36 and education level32 of the patient. However, there are studies including the present one that have shown patients with higher education level expressed less satisfaction with observance of their rights.14 On the other hand, some studies have shown direct relationship between education level and satisfaction level of the patients with observation of the bill.36 It is notable that none of these studies have been explicitly on nurses and thus no direct conclusion can be made. There is a need for further studies in this regard.
Relationship between nurses’ knowledge and performance Our results showed acceptable knowledge of nurses about different areas of the patients’ bill of rights; however, the performance of the nurses about some areas of the bill was not acceptable. Some studies have indicated that better knowledge about patients’ rights among nurses results in a significantly better performance5,20 However, some studies have reported no relationship between these two variables.19,36 Because of the design of our study, we cannot make any direct conclusion about the relationship between the nurses’ knowledge and performance; however, the authors believe that knowledge is not the only factor in predicting the performance. As recommended by different studies, insufficient staffing,1,13,35 low salaries, negligence of the nurses’ rights, burnout, long working hours, lack of performance standards in hospitals, and lack of enough equipment13 are the factors that are effective in poor observance of the patients’ rights. Therefore, reasons for unacceptable observation of the patients’ rights in the nursing domain need to be examined in more details.
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Limitations To interpret the results, limitations of the study must be taken into account. The study only focused on five teaching hospitals in Tehran. Therefore, the results cannot be generalized nationwide. Moreover, the results are based on self-reporting. More studies in this regard are recommended thus.
Conclusion The nurses’ knowledge about the patients’ rights was acceptable. Moreover, the nurses with lower education and experience were less aware of the patients’ bill of rights. Additionally, the nurses’ performance regarding observance of the patients’ rights was relatively acceptable. Patients with higher education were not satisfied with observance of their rights. It seems that over the years enactment and introduction of the patients’ bill of rights in Iran have led to an increase in knowledge about patients’ rights among nurses. However, mere notification to the hospitals and asking them to implement the bill are not enough, that is, there is a need for further evaluation and observation. Additionally, deeper studies as to the factors effective on observation of the patients’ rights by the nurses, specifically in terms of the patients’ and nurses’ level of education are recommended. Acknowledgements We would like to thank F. Arabi, S. Esmaili, S. Samiei, M. Shahabi, and M. Ghasemi for their help in data collection. Conflict of interest All authors declare that there is no conflict of interest. Funding This study is self-funded. References 1. Joolaee S and Hajibabaee F. Patient rights in Iran: a review article. Nurs Ethics 2012; 19: 45–57. 2. Hadian Jazi Z and Dehghan Nayeri N. Barriers in the performance of patient’s rights in Iran and appropriate offered solutions review article. Holist Nurs Midwifery J 2015; 24: 69–79 (in Persian). 3. Parsapoor A, Bagheri A and Larijani B. Patient’s bill of rights in Iran. Iran J Med Ethics Hist Med 2009; 3: 39–47 (in Persian). 4. Bostani Khalesi Z, Masole S and Abedinzade M. Evaluation of the patients, doctors and nurses view points about patient bill of rights in Rasht public hospitals. J Fasa Univ Med Sci 2012; 2: 91–95 (in Persian). 5. Ghaljeh M, Zakeri Z, Rezaee N, et al. Physicians and nurses awareness and function about patients right charter in Zahedan. Iran J Med Ethics Hist Med 2010; 3: 69–75 (in Persian). 6. Mohammad Nejad E and Ehsani SR. Nurses awareness of patients rights in a teaching hospital. J Med Ethics Hist Med 2011; 4: 2. 7. Vahedian Azimi A, Ghasem Kashani S, Avazeh A, et al. Awareness of nurses about patients’ rights and the extent they respect it. Prev Care Nurs Midwifery J 2011; 1: 55–63 (in Persian). 8. Kuzu N, Ergin A and Zencir M. Patients’ awareness of their rights in a developing country. Public Health 2006; 120: 290–296. 9. Farzandipour M, Sheikhtaheri A and Sadeqi Jabali M. Perceived quality of informed refusal process: a cross-sectional study from Iranian patients’ perspectives. Dev World Bioeth. Epub ahead of print 11 April 2014. DOI: 10.1111/dewb.12054.
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