1. Background
The novel coronavirus disease 2019 is the third common coronavirus disease between humans and animals after severe acute respiratory syndrome and middle east respiratory syndrome, but its spread rate is much higher than the two previous viruses (1).
It caused common mental disorders in nurses working with COVID-19 patients, including post-traumatic stress disorder, depression, anger, fear, and sleep disorders (2, 3). Mental disorders can result in refusal to take care of patients, quitting the job (4), reduction of work efficiency, increase in absenteeism, relocation of staff, and service quality reduction, which, in turn, cause patient dissatisfaction with the quality of nursing care (5).
Satisfaction with the quality of nursing care is an important aspect of patient-centered care in COVID-19 patients (6), which is affected by several factors such as the nurse’s sufficient knowledge of how to respond to patients, their up-to-date care information, their skills in providing nursing care, their attempt to provide the patients with safe and timely care, their familiarity with nursing responsibilities, their abilities to understand the patients’ needs and expectations, and their confidentiality in providing nursing care as well as the patient education, patient participation in treatment and care decisions, and patients’ right of self-determination (7).
Nursing care, according to the ethical codes of the International Council of Nurses (ICN), should be delivered based on respect for human values, and the discrimination by age, gender, language, nationality, religion, beliefs, social situation, and type of illness should not affect its delivery (8). Considering the patients’ views on health and disease status as well as understanding their social, political, and, particularly, cultural differences is in line with the goals of patient-centered care (9).
Ethical nursing care is a measure taken to meet the needs of the patient in accordance with the profession. The American Nurses Association (ANA) announced 2015 as the Year of Ethics, and specified the quality care and ethical performance as the main elements the nurses should focus on (10).
Respecting the rights of patients with COVID-19 is an essential part of efforts to improve the quality of health care. Patients’ rights are respected in order to guarantee the ethical and equal treatment for all patients. Patients’ rights are defined based on patients’ satisfaction with the quality and process of treatment, privacy, confidentiality, and informed consent (11). Patients with COVID-19, compared to other patients, have more psychosocial and physical needs due to their special conditions and vulnerability; however, they may fail to express all their needs (12). Thus, it is necessary to consider patients’ rights. In most countries, health organizations announce and implement the Charter of Patients’ Rights to gain patient satisfaction (13). In Iran, the Charter of Patients’ Rights was drawn up by the Ministry of Health and Medical Education (MOHME) in 2001. The second edition was drafted based on the feedback provided by experts from 2007 to 2009. After the approval of the patient’s rights charter, an official order was issued by the Ministry of Health and Medicine, according to which the universities were obliged to implement the charter. It was later revised in order to comply with the charter of hospital accreditation standards (14).
Observing the justice when delivering care, providing appropriate care, carrying out professional responsibilities, exercising supervision, controlling, and performing follow-up are the standards set for care, according to which fair decisions should be made in critical situations in terms of allocating resources, triage, care, and treatment for patients (15). Developing crisis standards of care is an effective measure that can help nurses and other health care providers choose the most beneficial and the least harmful care for the patients and community (16). The approaches to the care and treatment of COVID-19 patients should be supportive and unique to each patient, and be accompanied by evaluation of interventions (17). Proper communication with COVID-19 patients and their participation in care decision-making processes are two of the most important principles of care (16). One of the most important care challenges in patients with emerging diseases is the lack of respect for their independence by, for example, depriving them of participation in decision-making process, which is exercised due to the adoption of traditional approach to care by health care providers alone (18).
There are specific guidelines that should be followed by both patients and health care provider when a disease epidemic emerges (19-23). Due to the nature of emerging diseases, one of the most important challenges in these cases is the quality of nursing care (20), and attention to patients’ rights (24). Since nurses, as the largest group of health care provider, spend more time with patients than other members of health care team, they play a pivotal role in providing care and treatment for patients with these diseases (3). The unknown nature of emerging diseases can affect the quality of nurses’ daily care and patients’ satisfaction with offered services (25). Patient satisfaction is considered as one of the main components of health service quality, and its accurate evaluation helps improve the quality of care. In addition to ignorance of prevention, diagnosis, and treatment of COVID-19, it has created many gaps in patients’ satisfaction and observance of their rights in providing services (6). The quality and customer satisfaction play particular role in the success or failure of organizations, and only those organizations attempting to meet the needs of customers with the minimum price and maximum quality and satisfaction can survive in the competitive market. Following the outbreak of COVID-19 disease and emergence of up-to-date treatment methods to deal with this disease, new ethical challenges arose in terms of respecting patients’ rights and satisfaction. Addressing the given challenges can increase the quality of provided services and, as a result, increased patient satisfaction.
2. Objectives
This study aimed to investigate the correlation between the satisfaction of COVID-19 patients and patients’ bill of rights.
3. Methods
This descriptive, correlational study was conducted in 2021 in the selected hospitals treating COVID-19 in Khoy city, Iran. All COVID-19 patients admitted to hospital and meeting the inclusion criteria were included in the study. Available sampling method was adopted to select patients and the STROBE cross-sectional reporting guidelines (26).
Taking into account the previous study (27) and the correlation coefficient between observance of patients’ rights charter and patient satisfaction (r = 0.3), the first type error (α = 0.05), and the second type error (β = 0.2), the study sample size was determined to be 147 individuals. The number of samples was obtained by using the following formula:
Inclusion criteria were all patients aged 18 - 60 years with COVID-19 and positive PCR test results, hospitalized for at least 2 nights, having SpO2 > 90%., being conscious and oriented, admitted to the ward of COVID-19, having no history of mental disorder or use of psychotic drugs, working in medical professions, having the ability to read and write, and willingness to participate in the study.
Three questionnaires were used for gathering data in this study which included “demographic characteristics”, “observing patient’s bill of rights” and “La Monica Oberst Patient Satisfaction Scale (LOPSS)” (28, 29).
Demographic characteristics questionnaire included age, gender, marital status, education level, employment status, the ratio of income to spend, health insurance, underlying disease, type of underlying disease, smoking, residential status, and duration of hospitalization.
Observing patient’s bill of rights questionnaire was designed by Mokhtari and Khorami Markani in 2017 in Iran (28). This questionnaire consists of three sections and 40 items. The first section includes 10 items on demographic characteristics (i.e., age, sex, marital status, level of education, income, employment status, hospitalization history, health insurance, smoking, and underlying disease), and the second one analyzes two areas: observance of patients’ rights in the psychological realm (12 items) and observance of patients’ rights in the physical realm (18 items). A 5-point Likert scale (never: 1, rarely: 2, sometimes: 3, often: 4, and always: 5) was used to score the responses. The total scores in psychological filed vary from 12 to 60. It is divided into 12 - 27 (undesirable), 28 - 43 (relatively desirable), and 44 - 60 (desirable). The total score in the physical realm varies from 18 to 90 (i.e., 8 - 42 (undesirable), 43 - 66 (relatively desirable), and 67 - 90 (desirable)). The final score is between 30 - 150, which is designated as undesirable observance (30 - 70), moderate observance (71 - 111), and desirable observance (112 - 150) (28).
La Monica Oberst Patient Satisfaction Scale was developed by La Monica et al. (29). This questionnaire has 41 items that measure the level of satisfaction with nursing services. La Monica Oberst Patient Satisfaction Scale has three subscales which include good impression with 11 questions, dissatisfaction with 17 questions, and interpersonal support with 13 questions. Each item offers seven answer options graded based on a Likert scale from “strongly disagree: 1” to 7 “strongly agree: 7”. The questionnaire score varies from 41 to 287, where a higher score indicates greater satisfaction with nursing services (29).
Face and content validity of the observing patient’s bill of rights questionnaire was determined by applying the corrective opinions of ten faculty members in Iran in such a way that the content validity ratio (CVR) was 0.8 and the average content validity index (CVI) was 0.92, which was acceptable.
The reliability of the questionnaires was determined after conducting a pilot study on 20 patients with COVID-19 by using Cronbach’s alpha method. Cronbach’s alpha coefficients for the observing patient’s bill of rights questionnaire and the LOPSS were 0.88 and 0.89, respectively.
In order to conduct our study, the approval of ethics committee of Khoy University of Medical Sciences (IR.KHOY.REC.1399.021) was obtained. Then, one of the researchers visited the sampling site three times a week during the sampling period and identified the eligible patients. After explaining the objectives of the study to the patients, an informed consent was obtained from them to participate in the study and to keep their names confidential. Then they were given the questionnaires to complete after providing them with a short training on how to complete the questionnaires.
Data analysis was performed using SPSS software version 20, and the significance level was set at 0.05. Kolmogorov-Smirnov test was also used to determine the normal distribution of data. Statistical indicators of frequency, percentage, mean, and standard deviation were employed in order to evaluate some socio-demographic and disease-related characteristics, observance of patient rights charter, and patient satisfaction of nursing care. Pearson’s correlation test was also performed to examine the relationship between two quantitative variables. In order for evaluating the significance of the difference between two independent groups, two independent sample t test was used, and the one-way ANOVA was used to test the significance of the differences among multiple groups.
During the data collection period, the researcher implemented the safety measures such as washing and disinfecting the hands before and after visiting each patient as well as wearing N95 mask, gloves, gown, hat, and shoe cover. The researcher also received two doses of COVID-19 vaccine at the time of data collection, while the third dose was injected after completion of data collection. Sampling lasted about two months, from January 20 to March 20, 2021, and the second researcher collected the data. Due to the heavy nursing workload in the morning shift and physicians’ visits, the participants were asked to complete the questionnaires in the evening shift. Patients were requested to complete the questionnaires during evening shift; however, they were allowed to postpone the questionnaire completion until next day if they failed to complete them during the specified time.
4. Results
A total of 147 eligible patients were included in this study. The mean age of patients was (43.7 ± 12.5), and more than half of them were male (Table 1).
Table 1.Demographic Information of Patients With COVID-19 a
| Variable and Group | Value |
|---|---|
| Gender | |
| Female | 63 (42.9) |
| Male | 84 (57.1) |
| Marital status | |
| Single | 36 (24.5) |
| Married | 108 (73.5) |
| Divorced | 0 (0.0) |
| Widow | 3 (2) |
| Education level | |
| Elementary | 2 (1.5) |
| Diploma | 60 (40.6) |
| Bachelor | 71 (48.1) |
| Associate Degree | 14 (9.8) |
| Employment Status | |
| Unemployed | 38 (25.9) |
| Employee | 109 (74.1) |
| The ratio of income to spend | |
| Negative | 78 (52.9) |
| Equals | 60 (40.7) |
| Positive | 9 (6.4) |
| Health insurance | |
| Yes | 122 (83.3) |
| No | 25 (16.7) |
| Underlying disease | |
| Yes | 62 (42.1) |
| No | 85 (57.9) |
| Type of underlying disease | |
| Cardiovascular | 15 (24.2) |
| Hypertension | 27 (43.9) |
| Autoimmune | 4 (6.2) |
| Cancer | 3 (4.5) |
| Diabetes | 8 (13.6) |
| Renal disease | 5 (7.6) |
| Smoking | |
| Yes | 31 (20.9) |
| No | 116 (79.1) |
| Residential status | |
| Urban | 131 (89.1) |
| Rural | 16 (10.9) |
| Age | 43.7 ± 12.5 |
| Duration of hospitalization | 9.5 ± 5.1 |
a Values are expressed as No. (%) or mean ± standard deviation.
According to our study results, the total score of COVID-19 patient satisfaction with nursing care was 214.19 ± 52.02. The mean of patients’ responses to each domain of the questionnaire is presented in Table 2.
Table 2.Correlation Between Satisfaction from Nursing Services with Observing Patient’s Bill of Rights in COVID-19 Patients
| Variables | Mean ± Standard Deviation | Pearson Correlation |
|---|---|---|
| Patient satisfaction | r = 0.71; P < 0.001 | |
| Dissatisfaction | 92.05 ± 19.81 | |
| Interpersonal support | 66.82 ± 18.88 | |
| Good impression | 55.30 ± 14.57 | |
| Total score | 214.17 ± 52.02 | |
| Observing patient’s bill of rights | ||
| Psychological realm of patients | 48.85 ± 10.17 | |
| Collective and physical realm of patients | 69.38 ± 11.41 | |
| Total score | 118.23 ± 20.5 |
The total score of observing patient’s bill of rights was 118.23 ± 20.5, which was desirable. The mean response of patients to each domain of the questionnaire is presented in Table 2.
Pearson test result was suggestive of a direct and significant linear relationship between COVID-19 patients’ satisfaction and compliance with the patients’ bill of rights (r = 0.7, P < 0.001) (Table 2). It was found that there was a direct and significant linear relationship between the variables of age, income level, education level, insurance status, underlying disease, residential status, and length of hospitalization with patient satisfaction (P < 0.05). Furthermore, there was a direct and significant linear relationship between the variables of income level, education level, and length of hospitalization with observing patient’s bill of rights (P < 0.05) (Table 3).
Table 3.Correlation Between Demographic Information with La Monica Oberst Patient Satisfaction Scale and Observation of Patient’s Right Charter in Patients with COVID-19
| Variables | La Monica Oberst Patient Satisfaction Scale | Observation of Patient’s Right Charter | ||
|---|---|---|---|---|
| Statistical Analysis | P-Value | Statistical Analysis | P-Value | |
| Age | r = -0.224a | 0.006 | r = 0.030a | 0.716 |
| Gender | t = -0.075b | 0.368 | t = -0.125b | 0.132 |
| Marital status | F = 0.124 c | 0.135 | F = -0.257 c | 0.281 |
| Education level | F = -0.178 c | 0.41 | F = -0.094 c | 0.002 |
| Employment Status | F = 0.184 c | 0.025 | F = -0.010 c | 0.900 |
| The ratio of income to spend | F = -0.246 c | 0.003 | F = -0.0251 c | 0.003 |
| Health insurance | t = 0.221b | 0.008 | t = 0.189b | 0.621 |
| Underlying disease | t = 0.184b | 0.29 | t = 0.081b | 0.334 |
| Type of underlying disease | F = 0.386 c | 0.001 | F = 0.150 c | 0.230 |
| Smoking | t = -0.133b | 0.120 | t = -0.175b | 0.139 |
| Residential status | t = -0.228b | 0.005 | t = -0.071b | 0.394 |
| Duration of hospitalization | r = -0.230 a | 0.006 | r = -0.217a | 0.009 |
a Pearson correlation test
b Two independent sample t test
c ANOVA
5. Discussion
Patient’s satisfaction with nursing care is an important component that helps evaluate the nursing services provided to patients. Hospitalization of the majority of patients with COVID-19 affects nursing care and, consequently, diminishes observance of their rights (30).
Our results revealed that the mean score of patients’ satisfaction with nursing services in all three domains was desirable. These findings were consistent with the results from the studies by Gomez Martin et al. (31) and Karaca and Durna (32). The study of Farajzadeh et al., exploring the COVID-19 patients’ satisfaction with the provided services indicated that the patients’ satisfaction in the inpatient and outpatient wards were 86% and 84%, respectively (7). However, Lotfi et al. recorded a lower level of patients’ satisfaction with nursing services (33). The contradictory results found by some studies may have been due to the factors such as fatigue and lack of time or other factors contributing to a negative attitude and emotional stress in nurses that, in turn, can result in emotional and physical withdrawal of nurses from patients.
In our study, the lowest level of patients’ satisfaction, with little difference from other domains, was recorded for “good impression”, which was inconsistent with the result from the study by Ghanbari and Khalegh (34). This difference may have been attributed to the nurses’ lack of knowledge and awareness of their different roles. Nurses carry a wide range of responsibilities, such as providing counseling, protection, advocation, coordination, etc.
In the present study, the mean score of observing patients’ rights charter was desirable, and the minimum level of rights compliance was recorded for the “psychological realm of patients”. Our study results were in line with results from the studies by Vakili et al. (35) and Astaraki and Hosseini (36). Mokhtari and Khorami Markani reported that the level of observance of the patients’ right charter in the psychological realm was desirable in more than half of the cases from the patients’ point of view, but it was moderate from the companions’ point of view (28). Kamali and Mousai indicated the respect of patients’ rights by doctors and nurses was average from the COVID-19 patients’ viewpoint (11) Furthermore, Anbari et al. demonstrated that respecting patient rights in surgical departments was not satisfactory, which was inconsistence with the result from our study (37). This difference may have been due to the years of studies, types of the disease investigated, and the tools employed in the studies.
Attention to patient privacy and presenting the individual characteristics of the health care provider team were only briefly considered in this study. The first category in the study by Parsapoor et al. investigated the respect for patients, their privacy, and treatment without discrimination (38). A majority of the respondents in Humayun et al. study stated that the privacy and secrecy of patients had been fully respected in hospitals, which was not consistent with the results of our study (39). The conflicting results in our study may have been due to the crowded wards of COVID-19 patients, which caused nurses to spend all their time taking care of the medical and physical needs of patients and, therefore, neglect some of the psychological rights.
Satisfaction of COVID-19 patients was statistically different among various age groups. Azizi et al. showed that patient satisfaction is significantly associated with age, such that the satisfaction of the patients also increases as the age increases (40). Chan and Chau conducted a study in Hong Kong and found that elderly patients were highly satisfied with nursing services (41).
The results of the present study showed that there was no statistical difference between the average scores of satisfaction with nursing care and the gender of patients. A number of studies have also reported similar findings (42, 43). However, some studies have revealed that the satisfaction level of female patients is higher than that of males (43). Comparing the results of others studies and our findings in this regard, it was found that the inconsistency between the results may have been attributed to gender; however, the patients participating in the research also had different characteristics.
The findings revealed that satisfaction level was also associated with level of education. Our findings in this regard were consistent with those from the studies by Owaidh et al., Saudi Arabia, showing that male patients and those with higher education levels were more satisfied with health care (44). This finding, however, was inconsistent with that reported by Wolf et al. (45). The correlation between satisfaction level and education level detected by the present studies may have been due to the differences in attitudes toward events associated with the increased education level of the patient.
Satisfaction of COVID-19 patients statistically differed based on insurance, place of residence, and income level of them. The study of Farzianpour et al. in Iran showed that patients’ satisfaction differed based on age group, reason for hospitalization, income level, and type of health insurance (27). However, Kol et al. reported no significant relationship among these demographic characteristics (46). The inconsistency of the findings may have been associated with cultural characteristics. This study found that there was a relationship between the length of patient hospitalization and the average scores of their satisfaction with nursing care. Similar to our studies, some recent studies had also demonstrated that patient satisfaction increased with shorter hospital stays (46, 47). In a study by Gutysz-Wojnicka et al. (48), however, no significant difference was found between the length of hospital stay and satisfaction. The results of the studies showed that the length of hospitalization was an effective factor contributing to the level of satisfaction, but the difference in the sample groups may have affected this result.
According to our study findings, there was a statistically difference between type of underlying disease and satisfaction with nursing care. Gündoğdu et al. reported a higher level of satisfaction with nursing care in patients with chronic conditions (49). However, different results were reported by other studies in this regard (44, 45). The inconsistency between the findings from other studies and ours may have been due to the fact that symptoms in COVID-19 patients can vary from mild to serious, and this disease can be fatal, especially for patients with chronic disease. Therefore, patients who require more specialized care likely have a higher level of satisfaction with nursing care. In the present study, a statistically significant relationship was discovered between income level, education, and length of hospitalization with patients’ bill of rights. Halawany et al. indicated a statistically significant association between the educational qualification of the participants and their location with patients’ rights (50). This may have been due to the fact that educated people are likely well aware of their patient rights and, therefore, more likely participate in treatment decisions and understand the explanations provided by health care providers.
The relationship between patients’ satisfaction and patients’ bill of rights was a positive and significant statistical relationship. Farzianpour et al. (27) and Vakili et al. (35) reported that the patient rights charter compliance scores and dissatisfaction scores had a negative correlation, which was consistent with our study results. Taking into account the results of studies, it can be said that the level of patient satisfaction reflects the ability of treatment staff, the level of respect for patients’ rights, and the quality of care and treatment.
5.1. Study Limitations and Strengths
This study faced some limitations. Healthcare facilities were not equally distributed in all parts of Iran, and, therefore, our results cannot be generalized. Furthermore, this work could have been further improved by collecting data from healthcare professionals if the logistical issues had been addressed.
However, one of the strengths of our study lies in the fact that a self-administered questionnaire was used to collect the data instead of observing the services in wards so that the collected data were consistent with the opinions of patients with COVID-19. It was recommended that the implementation of patients’ rights in public and private sector hospitals should be documented.
5.2. Conclusions
In sum, it was necessary to respect the patient’s rights in order to increase patient satisfaction and improve the provision of services to them. One of the main strategies to increase compliance with patients’ rights was found to be increasing patients’ awareness and health care providers about patients’ rights in clinical and health settings.
Due to the desirable satisfaction of patients with COVID-19, it was suggested that necessary measures should be taken in order to improve the services and performance, as well as to increase patient satisfaction by strengthening the positive points and analyzing the factors of patient dissatisfaction, especially in the psychological field.
Considering the importance of patients’ rights, it was recommended that the authorities develop practical solutions in a codified form and design in-service training courses for all job categories in order to increase the awareness of medical staff to respect patients’ rights. In order to increase the awareness of the people about the scope of their rights and the rights of staff, it was also recommended that notices about the patients and staff right charter should appear in different parts of the hospital.
