Evaluation of the Observance of the Charter of Rights of Patients with Mental Disorders from the Perspective of Nurses and Patients in Panj Azar Hospital in Gorgan in 2020

With regard to human dignity and rights of patients, the provision of health services should be fair and based on respect for the rights and dignity of patients. The basis of nursing and medical care is respect for the patient's dignity, which is becoming increasingly significant every day (1-3). Patients not only have limited physical abilities, but also they are affected by certain psychological, social, and economic stresses. Patient rights are one of the central axes in defining clinical service standards, and in recent years, the concept of patient rights has been increasingly considered by societies. Patient rights are the things that are necessary and deserving for the patient. In fact, it arises from the patient's expectations of the care and treatment process (4, 5).

In the health system of most countries, a set of patient rights has been defined that health service providers are required to comply with. Thus, the observance of patients' rights is not solely dependent on the wishes and attitudes of medical staff, but the systems of monitoring and evaluation and litigation constantly monitor and evaluate the implementation of these rights. Some of these rights include access to information, confidentiality of patients' information, informed consent, the right to vote independently, the right to health education, respect for the patient's private environment, peace of mind, and honorable death, protest, and grievances (1, 6). In 2002, the Charter of Patients' Rights was drafted for the first time in Iran, and in the winter of that year, it was announced by the Deputy Minister of Health of the Ministry of Health and Medical Education to defend human rights to honor patients dignity. In case of illness, especially in medical emergencies, without discrimination for age, sex, or financial power, the patient’s body, soul, and health will be adequately cared for; this care will be provided in an environment full of respect with a good quality (7).

Patient satisfaction is one of the principal indicators of effectiveness, efficiency, productivity, and quality of health services. Health services organizations need patient satisfaction to remain in the competitive market (8). Observance of the patient's rights leads to the patient's satisfaction and leads them to follow the instructions provided, which ultimately helps improve their condition and control their illness. Dissatisfied patients are less likely to follow treatment instructions, and subsequently, show fewer signs of improvement. They are also more likely to leave or change their treatment center despite not completing treatment. This endangers the health, life, and safety of the patient and leads to increased costs and reduced effectiveness of care services (9-11).

In the field of patient rights, one of the topics of concern in recent years for the mentally ill has been the observance of the rights of patients admitted to psychiatric health centers and the need for advanced laws to protect the severely mentally ill. Because people with mental disorders are a vulnerable part of society, defending the rights of these patients is necessary as the rights of people with mental disorders are violated in various ways. In several cases, the mentally ill are deprived of the right to a free life without supervision and in the presence of any law, in the sense that many of them are forced to be hospitalized for years in mental health institutions despite their ability to make decisions about their lives and future. They are denied access to basic health care for a variety of reasons, including low health care credits, lack of beds, and so on. Issues related to their satisfaction with the treatment process and services provided in these centers are often ignored. During hospitalization, the autonomy and freedom of these individuals are neglected due to inappropriate restrictions (12, 13).

In the numerous studies that have been performed, most studies performed among mental patients showed dissatisfaction with the observance of the Charter of Rights from the perspective of patients. Nurses do not act in accordance with international laws and have shortcomings that require further action (13-16).

In fact, the purpose of this study was to examine the observance of the Patient Bill of Rights from the perspective of patients and nurses. The findings of this study can help plan for the correction of deficiencies and improve the existing policies.

This descriptive cross-sectional study was performed among 200 nurses working in the psychiatric ward and 100 patients admitted to the psychiatric ward from April 1, 2020, to October 1, 2020, in Panj Azar Hospital of Gorgan, Iran. At the beginning of the work, a series of inclusion and exclusion criteria were set. The inclusion criteria were literacy, having full consciousness, and willingness to participate in the study, and the exclusion criterion was reluctance to participate in the study.

Data was collected using a demographic questionnaire including items on gender, age, religion, marriage, satisfaction with hospital services, and recommending hospital to others, and a self-made questionnaire based on the axes set by the World Health Organization (17) and the Charter of Patients' Rights in Iran (18). Assessing the realization of patient rights consisted of 70 questions in five sections, the first part was related to the optimal reception of patient rights health services and included 15 questions. The second part evaluated whether the information was provided to the patient satisfactorily and sufficiently and included 15 questions. The third part consisted of 15 questions about the patient's right to freely choose and decide on receiving health services. The fourth part was on providing health services that should be based on respect for patient privacy and the principle of confidentiality and included 15 questions. The fifth section, tapped into access to an effective patient complaints system and consisted of 10 questions. The scoring of the questionnaire was based on a 5-point Likert scale (1 = no at all, 2 = very low, 3 = more or less, 4 = somewhat, and 5 = fully scored). The total score of the questions ranged between 70 and 350, and the score of the first to the fourth part was between 15 to 75, respectively. A score of 15 to 25 was poor, a score of 26 to 50 was average, and a score of 51 to 75 was good. The score of the fifth section ranged between 10 and 50, with a score between 10 and 20 being poor, a score of 21 to 35 being average, and a score of 36 to 50 being good. The validity of the scale was established using content validity. To determine the content validity, along with the content validity indicators, eight faculty members of Aliabad Katoul School of Medical Sciences, two heads of wards, and supervisors of hospitals were asked for their corrective opinions. The reliability of the instrument was determined using the internal consistency reliability method (Cronbach's alpha coefficient) and the stability reliability method (retest). Cronbach's alpha for the 70 items was calculated to be 0.82 using a sample of 30 people, and the correlation coefficient with a two-week interval was 0.78. Data were analyzed in SPSS version 18 using descriptive statistics, Chi-square test, and independent t-test.

A total of 300 people participated in the study, of which 200 were nurses working in the psychiatric ward or had employment history in these wards, and 100 were mentally ill patients hospitalized in the ward. Overall, 210 (70%) participants were female. The mean age of the subjects was 52.7 ± 22.4 years, and the highest age group of the study participants was 21 - 30 years with 96 (32%) cases. Overall, 196 (65.3%) of the participants were married. In addition, 254 (84.7%) cases were Shia. Recommending others to visit the center was shown with and 191 (63.7%) and 109 (36.3%) “yes” and “no” answers, respectively. Moreover, satisfaction was demonstrated by points of 1 - 5 with 8 (2.7%), 6 - 10 with 38 (12.7%), 11 - 15 with 138 (46%), and 16 - 20 with 116 (38.7%) cases (Table 1).

According to the nurses, the mean scores of compliance with patient rights to freely choose and decide, access to information, receive appropriate health services, respect for patient privacy and confidentiality, efficient access to a complaint system were 59.26 ± 6.26, 54.48 ± 8.28, 53.74 ± 5.58, 53.46 ± 7.07, and 38.12 ± 7.72, respectively. From the patient's point of view, the mean scores of respect for the right to freely choose and decide, the desired receipt of health services, access to information, respect for patient privacy and observance of the principle of confidentiality, and access to an efficient grievance redressal system were 57.98 ± 8.13, 51.85 ± 7.65, 51.85 ± 7.65, 45.69 ± 9.66, and 28.74 ± 9.19, respectively (Table 2).

Also, based on the final results of the Charter of Patients' Rights from the nurse's point of view, respectively, the subgroups of respect for patient privacy and observance of the principle of confidentiality 199 (67%), respect for the right to choose and decide freely 177 (88.5%), favorable reception of health services 144 (72%), access to information 135 (67.5%), and access to an efficient grievance redressal system 116 (58%). Most of these subgroups were at a good level. Regarding the patients' point of view, respectively, the subgroups of respect for the right to freely choose and decide 90 (90%) and the optimal reception of health services 57 (57%) were at the highest level of desirability, while in the subgroups of respect for patient privacy and respect for privacy 64 (64%), access to an efficient grievance redressal system 47 (47%), and access to information 62 (62%) were at an intermediate level (Table 3). Also, there was no receiving good health services (P = 0.024) and respect for the right to choose and decide freely (P = 0.088), but there were significant relationships between the nurses' and patients' views in the subgroups of access to information (P = 0.001), patient privacy and the principle of confidentiality (P = 0.001), and access to an efficient grievance redressal system (P = 0.001).

The development of the Patient Rights Charter is the starting point for moving towards a comprehensive focus on patient rights and providing an accurate definition for the relationship between providers and recipients of services. The Patient Rights Charter presented by the Ministry of Health, consists of five axes, which include: (1) the right to receive desirable services; (2) the right to receive information in a desirable and sufficient manner; (3) the patient's right to freely choose and decide on receiving health services; (4) the right to respect patient privacy and the principle of confidentiality; and (5) the right of access to an efficient grievance redressal system (18-20).

As it is inferred from the axes of the Charter of Patients' Rights, the purpose of compiling and necessitating its implementation in medical centers is to defend the rights of human beings (especially patients) to honor and preserve their dignity and to ensure that in case of illness, especially medical emergencies, the patient’s body and soul are protected without any discrimination for race, age, sex, kinship, social status, education, etc. (20, 21). In this study, most of the participants were female, in the age group of 21 - 30 years, and married, and most of them recommended others to use this hospital and showed an appropriate level of satisfaction, which is consistent with studies of its kind (1, 22, 23), which shows the attention of hospital officials to patient satisfaction and compliance with ethical charters.

The highest level of observance of the Charter of Patients' Rights was respectively as follows: (1) respect for the right to free choice and decision-making (59.26 ± 6.26); (2) access to information (54.48 ± 8.28); (3) favorable reception of health services (53.74 ± 5.58); (4) respect for patient privacy and observance of the principle of confidentiality (53.46 ± 7.07); and (5) access to an efficient grievance redressal system (38.12 ± 7.72). In the study of Dadashi et al. (23), the highest degree of observance of patients' rights from the perspective of patients was in the first (optimal reception of health services), second (right to access information), and the third (right to choose and decide freely) axes. In the study of Sabzevari et al. (24), the rate of observance of patient rights was the highest in the fifth (access to an efficient grievance redressal system), second (the right to access information), and third (the right to freely choose and decide) axes, respectively. In the study of Sheikhbardsiri et al. (25) in Turkey, the level of patient-centered privacy showed the highest score, which is not in line with our finding. This difference may be due to geographical and cultural differences and the hospitality of the hospital.

Regarding the patient's points of view regarding the observance of the Charter of Patients' Rights, the highest scores were respectively related to respect for the right to freely choose and decide (57.98 ± 8.13), favorable reception of health services (51.85 ± 7.65), access to information, respect for patient privacy and the principle of confidentiality (45.69 ± 9.66), and access to an efficient grievance redressal system (28.74 ± 9.19). In a study conducted in a US hospital among 52 patients in the field of patient awareness, it was noted that most patients knew their rights (26). According to a report by the British Patients' Association on the assessment of patients' legal status, the right to see medical records was observed in 75% of cases, the right to access medical records in 60 cases, the right to choose a general practitioner in 80%, and the right to choose a specialist in 45% of cases (the third axis is the right to choose freely), which does not agree with our study findings (27).

The results of the study by Sookhak et al. showed that the observance of the code of ethics from the perspective of nurses was medium and fine (28). In Hui et al.'s study, the average score of awareness of compliance with the Patient Bill of Rights was good (29), which is consistent with our study. In Axworthy study, compliance with the Code of Ethics of patients was moderate (30). Finally, in Mokhtari et al. study, patient rights compliance was moderate in all the subgroups (31).

One of the strengths of this study was the lack of such a study in the province on mentally ill patients and the relatively large sample size. One of the weaknesses of this study was the lack of separation of disease type and stage in the questionnaire. The reluctance of some nurses and patients to cooperate was another limitation. However, with the cooperation of the heads of the hospital and some faculty members, an attempt was made to minimize these restrictions. Extensive measures should be taken to familiarize patients with their rights in hospitals, raise professional standards and professional aspirations, improve the treatment of patients by nurses, and provide support for poor patients.