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URL: http://journal.zums.ac.ir/article-1-6078-en.html
2- Food Safety Research Center (salt), Semnan University of Medical Sciences, Semnan, Iran. ,
3- Tabriz Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
4- Dept. of Medical Library and Information Sciences, Faculty of Health Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran.
✅ An education-based program plays an important role in promotion of the respect to patient’s rights. This suggests health care systems to have a practical and ethical (not merely legal and official) perspective to patient’s rights which in turn would optimize service quality delivered by health care providers.
Patients are a vulnerable and assist-required group who rely on health settings and care providers to meet their health needs. In this interaction, patients have the right to receive their required health and have basic rights, such as choice, dignity, and privacy, which should be considered along with their cultural, psychosocial, and spiritual values. On the other hand, health settings and care providers need to be responsible for these rights and considerations based on the acceptable national and international rules declared in the patient’s rights charters (1).
The charter of the patients’ rights implies that the respect and dignity of patients are maintained and that patients should be properly managed regardless of gender, age, and financial status. Furthermore, according to the patients' rights, the care for patients requires to be provided with high quality and respect (2).
Patient’s rights and generally medical ethics principles integrate the health care services with the needs, expectations, preferences, and values of patients. They are aimed to protect and improve health by reflecting human rights on provided care (3). Respect for patient’s rights by health care providers may optimize health outcomes and the quality of life along with creating a perfect connection between health care services and patients’ needs and expectations (4).
Compliance with the charter of the patient’s rights in health care settings leads to improved patients care, health outcomes, and caregiver satisfaction (2). Although the patient’s rights seem to be accepted theoretically, this subject is often neglected in practice. Despite passing acts and regulations concerning respect for patient’s rights, relative infringement of the rights has been reported in some health settings around the world (5). A notable point is that the compliance of patient’s rights by health facilities and staff has an effective impact on patients satisfaction, rather than direct effects on health outcomes (6).
Based on the results of a study conducted in the educational hospitals in Iran, the health staff believed that their provided care had a consistence of 84.4%with Iranian patient’s rights charter. They believed that the highest agreement was between their provided care and respecting patients' privacy and confidentiality principles with almost 100% compliance. On the other hand, the lowest compliance of 48.1% was with presenting appropriate and adequate information for patients (2).
The reported rates were not similar to those released by caregivers. Therefore, it seemed that the status of patient’s rights compliance was overestimated from the healthcare providers' perspective in Iran. The conducted studies showed that the compliance rate of patient’s rights charter in Iran's healthcare setting was in the range of 52-56% (4).
Other countries, especially the developing countries have reported facing principle challenges in this regard. For example, a study in Turkey revealed that 92% of patients were not aware of their rights and 95.2% declared they did not receive any training on patient’s rights from health care providers (7). Various studies concluded that patients were not usually aware of their rights and the knowledge, attitude, and practice of health workers regarding patient’s rights was 30-60% ranked as low to moderate (8).
Only 9% of patients in Turkey were aware of their rights (7) and 9.5% of patients in China knew their rights regarding accepting or refusing the care offered by health workers (9). Another study showed that 63% of physicians had limited knowledge of the patient’s rights and legal consequences (10). It was demonstrated that 52% of medical staff in Shanghai had not been educated regarding patient’s rights (11). Furthermore, a systematic review and meta-analysis revealed the awareness and compliance of patient’s rights by Iranian patients as 54.2% (12).
Under the most world-wide rules, Iranian new and revised patient’s rights were formulated based on a comprehensive approach and clear declaration of Patient’s Rights and Moral Values in 2009 by Iran Ministry of Health and Medical Education. Next, the legislation called “Patient’s Rights Charter” was immediately passed. This charter includes five main sections, including the rights of 1) receiving optimal health services, 2) access to optimal and sufficient information, 3) making decisions to use health services, 4) privacy and secrecy protection, and 5) access to an effective complaint procedure. These sections are composed of 14, 4, 7, 9, and 3 subsections, respectively (13).
Physiotherapy is an integral part of medical fields in the tertiary level of the healthcare system which provides pre- and post-op care for patients with neuromusculoskeletal diseases (6). Adequate implementation of patient’s rights sections and standards is essential in these health fields, especially due to the previously identified dissatisfactions and shortcomings in surveyed physiotherapy clinics (14, 15). However, establishing a perfect patient’s rights charter does not guarantee respect for patients’ rights.
The health care system, professions, service providers, patients, and information are all significant factors in terms of respecting patient’s rights and preventing the flaws, which normally vary among countries and health care institutions (16). Therefore, it is necessary to recognize the error flaws and non-compliance with the patient’s rights to overcome the problems with the right strategy and plan.
With this background in mind, this study aimed to identify the deficits and problems of patients in the physiotherapy clinic following the Iranian patient’s rights. In addition, the present investigation attempted to promote respect for patient’s rights using an education-based program targeted to the providers of physiotherapy treatment and patients. We hypothesized that an education-based program obviates deficit in health care institutions could improve respect for patient’s rights and the quality of physiotherapy treatments.
Participants and Study Design
This interventional (quasi-experimental) study was conducted in two phases at the Clinic of Physiotherapy, Faculty of Rehabilitation, Tabriz University of Medical Sciences, Iran. The patient’s and their coadjutors' perspectives were assessed qualitatively. The sample size of 204 participants was calculated based on the previous similar studies in rehabilitation settings, specifically in physiotherapy clinics (4, 14).
The inclusion criteria entailed having an experience of at least two physiotherapy treatment sessions and a willingness to participate in the study. The research was performed in three phases as follow: 1) assessing, categorizing, and analyzing the problems in the clinic as pre-test phase, 2) designing and conducting the intervention toward enhancing patent’s rights compliance in presence of the stakeholders, and 3) evaluating the efficacy of intervention as a post-test phase by comparing the number of identified problems and shortcomings with those in the pre-test phase. Finally, the identified problems and shortcomings in the pre-test and post-test phases were compared with Iran’s patient’s rights charter.
Study Tools and Data Collection
In the first phase of the study, a semi-structured face-to-face interview consisting of some open-ended questions was conducted to collect data. Due to qualitative data collection, the routine research instrument of quantitative studies (17) was not used. Instead, the primary interview questions were assessed and approved by 20 experts and patients in a preliminary study (18). The questions were categorized as deficit observation, deficit type, disrespect to patients' rights, and factors associated with choosing the clinic for physiotherapy care.
Afterwards, the stated answers were evaluated and classified using the so-called “6MP pattern”. The 6MP is a simple, effective, and practical tool, which categorizes the identified problems and shortcomings in organizational performance and processes. The 6MP pattern helps managers and policymakers to determine the root cause analysis (RCA) of problems and choose an appropriate intervention to improve the improper status (15). The 6MP categories encompass management, methods, manpower, materials, money, machinery, and plant, which are presented as the frequency of the deficits. Next, the classified responses were compared with the Iranian patient’s rights so that the corresponding sections were determined and presented as the frequency and percentage of the deficits.
Interventions
In the intervention phase, an education-based program was designed by the researchers and was conducted for 18 months for physiotherapy treatment providers. A total of 120 patients participated in the first phase of the study due to diseases condition. The education-based program included the following items:
- Familiarizing with the concepts and executive outcomes of patient’s rights and the manifestation of patients’ rights. This procedure targeted both physiotherapy and health care providers and patients. It was implemented by seminars, educational packages, and pamphlets.
- Administrative and executive attempts to obviate the deficits and problems mentioned by the patients. This package included diverse strategies and was only presented to physiotherapy and health care providers. One of these strategies was improving the medical record system by developing medical files, patient treatment cards, and clinic archives system. Other strategies entailed engaging participants actively in the treatment process, establishing a complaint management system and providing an adequate answer to patient’s complaints, organizing proper physiotherapy treatment appointments for the patients, and involving senior physiotherapy students to obviate possible problems caused by health care providers shortage.
Data Analysis
Descriptive analysis, including the frequency and percentage, and the Chi-Squire test were used to analyze the data before and after the education-based program by SPSS software version 16 (SPSS Inc., Chicago, Ill., USA). The difference in the participant numbers between before and after the education-based program was taken into account in statistical analysis. P-value<0.05 was considered significant for all tests.
Ethical Considerations
This study was approved by the Research Ethics Committee of Tabriz University of Medical Sciences with the code of “IR.TBZMED.REC.1396.137”. The participants were informed by the researchers regarding the study purposes and written informed consents were obtained from them. Freedom of participation, privacy and confidentiality, anonymity, and right to withdraw from participation during the study were all explained and assured.
The majority of study participants in the pre- and post-test phases were patients aged older than 32 years and with no academic education. The number of men and women in the study sample was equal. This means that data distribution was normal and the demographic and background characteristics had no significant effects on the impacts of interventions as intervening or moderating variables (P>0.05).
Table 1 shows that the main reasons for choosing the surveyed clinic by participants in the pre-test phase were the closeness to their home and advice from their relatives. However, the main reasons for choosing the same physiotherapy clinic in the post-test phase were expressed as the quality of delivered care and satisfaction from staff behavior and relationship (P<0.05).
Table 2 indicates identified deficits based on the seven dimensions of the 6MP pattern. The obtained results indicated 187 deficits in the pre-test phase, whereas this number reduced to 57 in the post-test. The number of declared deficits by participants significantly decreased (P<0.05) in all dimensions of the 6MP pattern. In other words, the identified deficits following the education-based program improved dramatically (three-fold improvement).
Table 1. Descriptive statistics of the demographic characteristics of participants
| Demographic and background variables | Characteristics | Pre education-based program responses n (%) | Post education-based program responses n (%) | P-value |
| Participants type | Patient | 133 (65.19) | 135 (66.17) | 0.675 |
| Next of kin | 71 (34.81) | 69 (33.83) | ||
| Age | ≤32 | 63 (30.88) | 59 (28.92) | 0.320 |
| 33-50 | 70 (34.31) | 71 (34.81) | ||
| ≥51 | 71 (34.80) | 74 (36.27) | ||
| Gender | Female | 98 (48.03) | 101 (49.50) | 0.466 |
| Male | 106 (51.97) | 103 (50.50) | ||
| Educational Status | Non-academic | 115 (56.38) | 118 (57.84) | 0.856 |
| Academic | 89 (43.62) | 86 (42.16) | ||
| Choice of the clinic | Quality of care | 44 (21.57) | 68 (33.33) | <0.001 |
| Satisfied from staff | 34 (16.66) | 71 (34.81) | ||
| Closeness to home | 56 (27.45) | 18 (8.82) | ||
| Relatives’ advice | 45 (22.06) | 42 (20.59) | ||
| Other causes | 25 (12.26) | 5 (2.45) |
Table 2. Frequency and percentage of deficits observed pre- and post-intervention classified by 6MP
| 6MP dimensions | Pre education-based program responses n (%) | Post education-based program responses n (%) | P-value |
| Management | 36 (19.25) | 11 (19.30) | <0.001 |
| Methods | 51 (27.27) | 18 (31.57) | <0.001 |
| Manpower | 37 (19.78) | 7 (12.28) | <0.001 |
| Materials | 18 (9.62) | 5 (8.78) | <0.001 |
| Money | 0 (0) | 0 (0) | 1 |
| Machinery | 26 (13.91) | 12 (21.05) | 0.007 |
| Plant | 19 (10.17) | 4 (7.02) | 0.002 |
| Total | 187 (100) | 57 (100) | <0.001 |
Comparison of 6MP classification with the Iranian patient’s rights indicated that 187 identified deficits in the pre-test phase significantly declined (P<0.05) to 57 in the post-test phase. It was revealed that most of the identified deficits were related to section 1 of the Iranian patient’s right charter, which is the right to receive optimal health services. Furthermore, the deficits declared by the participants significantly decreased (P<0.05) in all related sections (sections 1, 2, and 4) and overall charter (Table 3).
Table 3. Frequency and percentage of deficits observed pre- and post-intervention when matched with the patient's rights
| Patient’s rights charter area | Pre education-based program responses n (%) | Post education-based program responses n (%) | P-value |
| Section 1* | 122 (65.24) | 39 (68.42) | <0.001 |
| Section 2* | 59 (31.55) | 15 (26.31) | <0.001 |
| Section 3* | 0 (0) | 0 (0) | 1 |
| Section 4* | 6 (3.21) | 3 (5.27) | 0.047 |
| Section 5* | 0 (0) | 0 (0) | 1 |
| Total | 187 (100) | 57 (100) | <0.001 |
*Sections of Iranian patients’ rights charters; 1) the right to receive the optimal health services, 2) the right of access to optimal and sufficient information, 3) the right of decision making to use health services of own choosing, 4) the right to privacy and secrecy protection, and 5) the right of access to an effective complaint procedure
Discussion
The main reasons for choosing the surveyed clinic in the pre-test phase were the closeness to their home and advice from their relatives. However, the major reasons in the post-test phase entailed the quality of care and satisfaction with the staff of the physiotherapy clinic. A total of 187 deficits were recorded in the pre-test phase and were assessed under the 6MP pattern and the Iranian patient’s rights charters. However, the quantity of the identified deficits was reduced to 57 items in the post-test stage.
In 2014, an interventional study was performed in the physiotherapy clinics of Tabriz, Iran focusing on the enhancement of patient’s rights aspects, such as the choice of provider, dignity, autonomy, safety, privacy, and confidentiality based on educational programs. The study results showed that all features improved significantly (P<0.001). Therefore, the total score of compliance with patient’s rights increased significantly from 8.58 to 9.83 (19).
In another study, the implemented education-based intervention indicated an effective and positive impact on the awareness and compliance of the patent’s rights by nurses. The authors reported that the mean scores of nurses' awareness and practice pre-intervention were 15.26 and 8.82, respectively. The latter scores increased significantly to 18.6 and 11.3 post-intervention, respectively (8).
When approving the patients' rights and putting stress on the implementation of patients' right charter in every healthcare center, considerable errors occur in both patients and health provider sides. A retrospective cohort study on the health records of patients in a tertiary leading hospital during one year (2010-2011) found 50% error reports. Lack of adherence to the recommendation was recorded for patients (20) that could be prevented by respecting patient's rights implementation and education. An investigation demonstrated that the training program had a positive influence on the knowledge and attitude of hospital nurses regarding patient’s rights (21).
The present study found that the education-based program improved respecting patient’s rights as much as 4.5 times and this enhancement was associated with the elevation of service quality in the clinic (3.5 folds) and patients’ satisfaction with physiotherapy services (13.75 folds). Although patient’s rights are considered as legal and natural rights in many countries, practice and respect for patient’s rights cannot occur exclusively with passing legislation. Some actions and programs need to be taken to achieve the goal of patient’s rights. It is noteworthy that training the importance of patient’s rights to patients and health care providers plays a significant role in promoting compliance to patient’s rights charters standards.
Some studies on patients with type II diabetes showed that the most important deficit in receiving health care services was associated with insufficient knowledge about diseases and treatment options, dignity and respect of care, and timeliness and promptness of attention (22, 23), which are mostly reflected in patient’s rights. Results of the pre-intervention stage in our study are approximately consistent with those emphasizing the importance of education and information (7, 24).
Following the education-based program in the present investigation, all 6MP dimensions significantly improved. This suggests that training patients and care providers, as well as a consistent assessment of patients’ problems, resulted in the promoted quality of the service delivered as much as 4.5 times, which is remarkable from the administrative point of view. In other words, belief in the information improvement of health care providers and patients as an ethical and moral issue would cause the health system to provide care based on quality aspects (6MP), which in turn would enhance health care with regards to the patient’s rights.
Statistically significant decrease in deficits associated with sections 1 and 2 of the patient’s rights charter indicated an improvement of 4.5 and 4 times concerning respect for patient’s rights, respectively. The rights of receiving optimal health services and having access to optimal and sufficient information are the most important sections of the patient’s rights. Consequently, our intervention and programs were mainly developed based on protecting the mentioned rights. This suggests that the relevant and appropriate action would effectively augment the respect for patient’s rights. Choosing the same physiotherapy clinic by patients in the second phase of the study additionally supports the improvement of patient’s rights.
Conclusion
According to the results of the present study, passing the patient’s rights does not guarantee its respect, and actions need to be carried out to achieve suitable patient’s rights. Moreover, an education-based program might play a significant role in reducing the deficits associated with quality aspects consequently leading to greatly improved patient’s rights and optimized service quality.
Acknowledgements
Researchers are obliged to thank the sincere cooperation of all experts in developing the questionnaire as well as the collaboration of participants in answering the questionnaire of the study.
Ethical considerations
Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.
Funding and support
This study was part of an approved project funded by the Tabriz Health Services Management Research Centre affiliated with the Tabriz University of Medical Sciences particularly focusing at patient’s rights.
Implications for Practice
On the basis of the results of this study, we propose health care systems to have a practical and ethical (not legal and official) perspective to patient’s rights which in turn would optimize service quality delivered by healthcare providers.
Ethical Approval
This study was approved by the research ethics committee of the Tabriz University of Medical Sciences with the approval ID of “IR.TBZMED.REC.1396.137”.
Authors’ Contributions
AEO, FG, JST and VZG contributed to conceptualizing, writing, and revising this manuscript.
Conflicts of Interest
Authors declared no conflict of interests.
Received: 2020/06/23 | Accepted: 2020/08/12 | Published: 2020/12/4
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