1. Background
Patients’ rights are a part of human rights and an important part of medical ethics (1). Complying with patients’ rights, especially in vulnerable groups such as pregnant women has particular importance in scientific communities and professionalism (2). The concept of patients’ rights has been confirmed by the Ministry of Health and Medical Education in Iran. Iranian patient's rights charter has clarified the rights of clients about Islamic jurisprudence as well as observing ethical standards in medicine. The patients’ rights charter outlines five rights, including access to desirable services, access to sufficient information, respect and privacy, informed decision-making, and complaint handling (3, 4).
In the previous study, the relationship between complying patients’ rights and patient satisfaction has been documented (5). Satisfaction has also been recognized as an important principle for measuring health care quality (6). Patient satisfaction is associated with age, education, occupation, marriage, and costs (7). Also, maternal satisfaction and attitude had a relationship with socioeconomic status, education, and emotional support during and after childbirth, gravida, labor length, and type of delivery (8). Besides, most of the midwifery students had poor to moderate knowledge about patients' rights (9). Also, some studies have shown that the implementation of educational interventions for healthcare workers and hospital staff (midwives) significantly increases compliance with patients’ rights and patients’ satisfaction (10, 11).
In maternity hospitals, midwives have a closer relationship with the mother during labor and delivery (2). Therefore, teaching the patient rights charter will enable them to comply with patients’ rights, thereby increasing their client satisfaction. In the curriculum of midwifery education in Iran, insufficient attention is paid to teach the patients' rights charter, as well as insufficient attention to patients’ rights in most hospitals in Iran. Furthermore, ethical value is one of the pillars of professionalism.
2. Objectives
This study aimed to investigate the effect of educating patients’ rights charter to midwifery students on their patients’ rights practice and pregnant women's satisfaction in Fatemiyeh Maternity Hospital in Hamadan.
3. Methods
This quasi-experimental study was carried out at Fatemiyeh Hospital in Hamadan, a city in the west of Iran, in 2018. The statistical population consists of two groups: 1-All final year students of midwifery studying in the School of Nursing and Midwifery of Hamadan. 2-Pregnant women who were referred to this hospital for normal childbirth. The study period was from October 2018 to February 2018. The exclusion criterion for midwifery students was to be a student, and the exclusion criteria were reluctance to participate in research and to leave the faculty for reasons such as transfer. In this study, all final year students (20 people) were included in the study by census. The group of pregnant mothers was also included in the study by the available method. Inclusion criteria were individuals whose deliveries were performed normally by a midwifery student, were literate, did not receive formal education for physiological deliveries, and did not have a known mental illness. Exclusion criteria were people who were sent to a better-equipped center after being admitted to the delivery ward for various reasons, as well as failure to have a normal delivery. Samples of pregnant women were included in the study according to the following formula:
Formulas of means and information of Bayrami et al.'s article (10) in which σ1 = 6.54 , σ2 = 10.4, and d = 3 have been used and considering the first type error 5% and test power 80% and considering 15% sample drop, the number of samples at each stage (before and after training) was equal to 150 people. In this regard, a total of 300 women who intended to give birth normally entered the research. Because pregnant women were under the direct supervision of a midwifery student as soon as they entered the labor and delivery ward, they were excluded from the study if they talked to other patients about patients' rights. Data collection tools in this study included a questionnaire of demographic characteristics, a checklist of performance of midwives, and a questionnaire of satisfaction with the rights of pregnant women.
A researcher-made checklist was used to observe the midwifery students’ compliance with patients’ rights. The compliance with patients’ rights checklist was made based on four dimensions of patients’ rights. The patient rights charter implies five rights, including the right to access to desirable services, access to sufficient information, respect and privacy, informed decision-making, and complaint handling. We did not consider the decision-making dimension because our patients were hospitalized, and they had decided before hospitalization. The checklist consisted of 26 questions with a three-point Likert scale, including yes, somewhat, and no that pointed to 2, 1, and zero scores, respectively. The content validity of the checklist was confirmed by an expert panel, including 10 specialists in midwifery and medical ethics. Also, the checklist reliability was measured by Cronbach's alpha coefficient that was 0.909. Compliance with the patients’ rights checklist was completed by a trained midwifery supervisor who was unaware of the groups’ allocation.
Demographic information included age, education, insurance, gravida, para, and obstetric history. Besides, the patient satisfaction questionnaire was used to assess pregnant women’s satisfaction. The patient’s satisfaction questionnaire was a researcher-made questionnaire based on the literature review (3, 10, 12). This questionnaire included 16 questions. Each item was measured using a 5-point Likert scale that ranged from completely satisfied (5 points) to completely dissatisfied (1 point). There were 13 questions about satisfaction in the psychological field (establishing proper communication with the client, respect for his privacy) and three questions about satisfaction in the physical field (observing the patient's rights and physical needs such as adequate anesthesia while suturing and so on). The face validity and content validity of the questionnaire were assessed by ten experts in midwifery and medical ethics (CVI = 0.91). The reliability of the questionnaire was assessed by Cronbach's alpha. Cronbach's alpha coefficient was 0.844 for the desired services, 0.656 for the sufficient information, 0.684 for respect and privacy, and 0.699 for the complaints handling, and 0.798 overall for all questions. Informed consent was obtained from all participants and they entered the study voluntarily. The method of work in this study was that in the first step before the educational intervention, pregnant women referred to the delivery ward for normal childbirth who met the inclusion criteria, were included in the study by the available method, and the satisfaction questionnaire was given to them. As a result, 150 pregnant mothers were surveyed before midwifery training. In the second step, a two-day workshop in four hours by the researcher, in April 2019, was held for midwifery students through lectures and questions and answers. The content of the meetings was presented using the proposed text of the charter of patients' rights in Iran, which was approved by the Policy Council of the Ministry of Health and Medical Education in October 2009 and communicated to the affiliated units (Table 1). Scenarios were then designed for students, and possible mistakes were discussed. In the end, the questions were answered.
Table 1.Educational Content in the Two Days’ Workshop for the Intervention Group
| Session | Educational Content |
|---|---|
| First | Stating the goals and playing a clip about patients’ rights |
| Explaining the right to freedom, independence, and the right to participate in decision-making, free from any coercion or threat | |
| Explaining the right to receive desirable services through proper care and being free from any physical or psychological harm | |
| Explaining the right to equality for services and to be free from any discrimination | |
| Explaining the client's right to access adequate information about illness and hospital costs | |
| Second | Reviewing previous session content |
| Explaining privacy and respect (privacy observing is compulsory unless stated in regulations, respect and privacy at all times, access to information only for patient or people authorized by the patient, law and medical team, and patients are entitled to enjoy the companionship of a person they wish during diagnostic procedures such as a physical examination. Parents can accompany their child during all treatment stages unless there is a medical restriction). | |
| Declaring the right to access the appropriate health service (Coordination of all aspects of care, including prevention, diagnosis, treatment and rehabilitation, avoidance of causing unnecessary pain, suffering and limitation | |
| Explaining the right to obtain informed consent and to respect the client's preferences and decisions | |
| Explaining the right to respectful conduct and to preserve human dignity | |
| Explaining patients' rights regarding the information and follow-up of complaints |
Then, during two weeks, the students sent a total of seven text messages regarding the observance of the rights of pregnant women. Two weeks after the workshop, the satisfaction questionnaires were completed again by 150 pregnant women who were referred to the delivery ward for normal childbirth. Therefore, the group before the workshop was considered the control group and the group after the workshop as the intervention. Also, the performance of midwifery students at this stage was re-evaluated by a checklist by the researcher. It is necessary to explain that the performance of midwives was assessed by the researcher by directly observing their performance in the delivery ward. Data were analyzed using SPSS 16 software. Chi-square and independent sample T-test were used to analyze the data.
4. Results
The mean age of the women was 26.16 ± 6.20 and 26.66 ± 6.04 years in the intervention and control groups, respectively. Also, the mean gestational was 38.93 ± 1.74 and 38.39 ± 2.10 weeks in the intervention and control groups, respectively. The mean number of gravida in the intervention group was 2.23 ± 1.13 and in the control group was 2.29 ± 1.09. There was no significant difference in the history of obstetric and demographic variables between the control and intervention groups (Table 2).
Table 2.Distribution of Obstetric Variables in Intervention and Control Groups a
| Group | Values | Statistical Test Results |
|---|---|---|
| Age | T = -.533, df = 177, P = 0.595 | |
| Intervention | 26.16 ± 6.20 | |
| Control | 26.66 ± 6.04 | |
| Gestational age | T = 1.806, df = 172, P = 0.073 | |
| Intervention | 38.93 ± 1.74 | |
| Control | 38.39 ± 2.10 | |
| Newborn weight (gr) | T = -.057, df = 170, P = 0.955 | |
| Intervention | 3182.28 ± 370.03 | |
| Control | 3185.81 ± 440.90 | |
| Gravida | T = -.339, df = 156, P = 0.735 | |
| Intervention | 2.23 ± 1.13 | |
| Control | 2.29 ± 1.09 | |
| Para | ||
| Intervention | 1.33 ± 1.04 | T = -1.317, df = 156, P = 0.190 |
| Control | 1.54 ± 0.94 | |
| Abortion | ||
| Intervention | 0.24 ± 0.52 | T = -1.168, df = 156, P = 0.245 |
| Control | 0.35 ± 0.64 | |
| Education | X2 = 2.499, df = 2, P = 0.287 | |
| Intervention | ||
| < Diploma | 75 (70.1) | |
| Diploma | 26 (24.3) | |
| Academic | 6 (5.6) | |
| Control | ||
| < Diploma | 49 (66.2) | |
| Diploma | 16 (21.6) | |
| Academic | 9 (12.2) |
aValues are expressed as mean ± SD or No. (%).
The mean score of compliance with patients’ rights for midwifery students in the intervention group was 65.37 ± 5.72 and in the control group was 62.57 ± 12.25 out of 78 points. The mean score of desirable service in the control group was 34.55 ± 5.97, and it was 36.20 ± 2.56 in the intervention group, which was statistically significant (P < 0.05). Also, the mean score of the other dimensions of compliance with patients’ rights in the intervention group was higher than the control group, but these differences were not significant (Table 3).
Table 3.Comparison of the Mean Score of Compliance of Patients’ Rights and Patients Satisfaction in Before and After Training in Midwifery Students
| Domains | Mean ± SD | T | P-Value |
| Desirable service | 2.225 | 0.029 | |
| After | 36.20 ± 2.56 | ||
| Before | 34.55 ± 5.97 | ||
| Adequate information | 0.184 | 0.855 | |
| After | 15.07 ± 3.06 | ||
| Before | 14.97 ± 3.73 | ||
| Respect and privacy | 1.959 | 0.052 | |
| After | 9.79 ± 1.52 | ||
| Before | 9.26 ± 2.08 | ||
| Complaints handling | 0.476 | 0.635 | |
| After | 2.57 ± 1.13 | ||
| Before | 2.48 ± 1.28 | ||
| Compliance of patient rights (total score) | 1.835 | 0.070 | |
| After | 65.40 ± 5.72 | ||
| Before | 62.57 ± 12.25 |
The mean score of overall satisfaction in the intervention group was 71.90 ± 10.04 and in the control group was 70.68 ± 8.29. The mean score in the psychological domain of the patient satisfaction questionnaire was before training 58.30 ± 6.72 and after training 59.33 ± 8.49. There is a significant difference in this area (P < 0.05). But there was no statistically significant difference in the physical domain (P > 0.05) (Table 4).
Table 4.Comparison of the Mean Score of Satisfaction’s Questionnaire in the Intervention and Control Groups
| Domains | Mean ± SD | P-Value |
| Physical | 0.417 | |
| Intervention | 12.58 ± 2.20 | |
| Control | 12.13 ± 2.25 | |
| Psychological | 0.047 | |
| Intervention | 59.33 ± 8.49 | |
| Control | 58.30 ± 6.72 | |
| Total | 0.071 | |
| Intervention | 71.90 ± 10.04 | |
| Control | 70.68 ± 8.29 |
5. Discussion
In this study, the score of all aspects of the patients’ rights was higher in after training than before training, but this difference was not significant except for the dimension of the desired services. These findings are different from Nikbakht’s study in 2015 that nurses’ compliance with patients’ rights in the intervention group was statistically different in all aspects of the patients’ rights except complaint handling in comparison to the control group (13). His study was a quasi-experimental study with the control group. To measure the observance of patients' rights by nurses before and after the intervention, 180 patients were admitted to the emergency department. For nurses, a nursing ethics workshop has been held in a thought-provoking and conversational manner. This difference may be due to the difference in target groups in two studies. Also, nurses are more supervised by supervisors in the workplace. It can affect the results.
Significant differences in the desirable services domain indicated that teaching the patient rights charter to midwifery students has a positive effect on their compliance with patients’ rights. Awareness of the desirable services can lead to compliance with this right. Consequently, teaching patients’ rights after training had a positive effect on midwifery students’ performance that is the cause of a significant difference.
The patient has the right to know about the treatment procedures and its side effects. The World Medical Association states that the patient's right is to receive comprehensive and complete information from health care providers. Providing information to the patient and engaging them in their care and treatment will reduce pain and anxiety, accelerate recovery, increase patient adoption, and reduce the period of hospitalization. Also, the patients’ rights include the right to be informed, to be respected as a human being, to make decisions, and to have equal access to health care regardless of their economic status, age, sex, and religion. On the other hand, patients tend to be considered a special person and they need special attention. Thus, it is essential to familiarize medical students and staff with compliance with patient rights (13). The previous study showed that nurses have not performed this role due to the lack of time, lack of teaching, and lack of staff. Patients had taken information about their rights from the internet and mass media (14).
There was no significant difference between before and after training in privacy and respect domain. The optimal privacy of patients was related to hospital facilities. Furthermore, educational regulations enforce students to respect the privacy of pregnant women. Mothers are worried about the health of their babies and themselves. Giving information can lead to reduced anxiety and worry. If students do not follow these rules, they will lose their scores. One explanation for these results may be due to the duty of midwifery students to give information to the patients and protect their privacy. Besides, respecting privacy and desirable services are also linked to hospital facilities and budget allocation.
Patients do not know who is responsible, or accountable when they are unsatisfied with healthcare services. It may be due to this fact that hospital staffs are worried about disciplinary action and legal duty. Patients’ complaints and lawsuits are increased when patients are well-informed about the quality of services and their rights (15, 16). While teaching students, they should be reminded that the contents of medical records are not easily accessible to patients in most of the hospitals due to the regulations of hospitals in Iran. Hospital managers prefer that medical records be accessed only by legal individuals. Only if the patient complains about the hospital, the medical team, or the treatment process, the patient's records will be made available to the judicial authorities or the medical system only at the request of legal authorities (17). The patient is authorized to access a copy of the information in his or her medical record by a written request (18). No significant difference was observed in the field of providing information in our research before and after the training. Lack of awareness and attitude towards patients’ rights, unavailability of workshops or training programs, lack of guidelines and direction about patients’ rights, and inadequate patients’ rights policy and procedure may lead to poor compliance with patients’ rights (4, 19, 20). Consequently, the mentioned causes are due to insufficient facilities, limited budgets, and lack of managers’ support. The reason why this area is not significant in our research may be that midwifery students have received enough information in this field while studying. Moreover, the cause in the field of complaints handling no statistically significant difference was found before and after the training in the study. This may be due to the lack of sufficient information by students about this area.
There is no independent topic for the complaints handling related to compliance with patients’ rights in the midwifery students’ curriculum in Iran. Hence, it is recommended that the medical ethics course include the curriculum. Teaching professional ethics and procedures is necessary for future health care staff (21, 22).
Regarding the study of patients' satisfaction before and after the intervention, the results showed that only in the psychological area, people's satisfaction had increased, and a statistically significant difference was observed. In a part of the findings of this study, which was published in the article of Hosseini and Fakharzadeh 2019 (23), entitling assessing mothers 'satisfaction with midwifery services based on observing the charter of pregnant mothers' rights, it is concluded that a pregnant mother's satisfaction is her assessment of the healthcare she receives. Finding aspects of services that cause dissatisfaction and intervention to eliminate them can be the most effective and the least costly way to increase the quality of services based on respect for the rights of the mother. Longer workshops or educational courses and engaging midwifery trainers as role models in teaching the patient rights charter as well as the use of active methods such as role-playing and demonstration for teaching patient rights charter is suggested for future studies. Limitations of this study were the existence of intervention and control in one hospital and different intervention and control groups, the effect of previous education for pregnant women, education of patients’ rights to students by wards.
5.1. Conclusions
In conclusion, implementation of compliance with patients’ rights workshops for midwifery students increases awareness and improves compliance with patient rights in desirable services. Thus, revising the educational curriculum of midwifery students is recommended for improving midwifery students’ awareness about patients’ rights and institutionalizing it. In this regard, it has been shown that the need to teach professional ethics and procedures is the most important need for midwifery students in the current routine educational programs. The limitation of this study was a self-reporting satisfaction questionnaire.
