1. Background
A human has many duties to tread the path of spiritual excellence. The perfect virtue of humanity is achieved by self-control and benevolence towards others and respect for the protection of human rights (1).
It is obvious that every human being has personal and social rights. Sometimes a humans right receives a special meaning from use, or from the special circumstances in which a man is placed, such as “sickness”. Issues of dependency and inequalities of power lead to increased vulnerability of the person with specialized needs. Under these circumstances, the physician is morally bound to provide proper physical and psychological care for every patient with respect for their inherent dignity and socio-cultural and economic status (1, 2).
Therefore, due to the importance of the patient’s rights in providing ethical healthcare, the need for definition of basic patient’s rights outlined in a charter is appreciated.
In Iran, as in most countries, the patients’ bill of rights aims to clarify the rights of health care recipients. In addition, Iran’s health policy makers in the ministry of health developed observing ethical standards in the practice of clinical medicine in 2002 (3, 4).
In fact, patient rights are those basic policies and rules that must be preserved and supported by the health care system toward the patients and their families (5).
Although paying enough attention to various aspects of patient rights charter is widely emphasized by officials of the health system, there is still a vague concept for many medical staffs as well as the patients regarding its existence and content. Several studies reported varying degrees of awareness of patients’ rights among health care providers.
The results of the limited research suggested that physicians have no desire or often have reservations to participate in the implementation of the patients’ rights laws (6).
A study done by Alghanim, in Saudi Arabia, showed poor knowledge of the doctors and nurses concerning the patients’ bill of rights and legal aspects in medical practice (7).
In Iran, the results of the studies regarding patients’ rights indicated that the level of knowledge of students and physicians was intermediate to good, however, not satisfactory (8-10). There is little data regarding knowledge of medical interns’ toward patients’ rights. In addition, collecting data regarding this issue would aid health and educational policy makers in taking up further steps and better planning for teaching and enforcing this critical subject in internships as the year of transition to a doctor.
2. Objectives
The present study was performed to evaluate the extent of the knowledge of this group of trainees regarding their ethical and professional responsibilities to patients.
3. Methods
This cross-sectional, descriptive analytical study was conducted to assess the knowledge of medical interns regarding patients’ rights in Shiraz Medical University during the academic year of 2012 and 2013.
The research population included all interns of the Shiraz Medical University. The information was collected from all participants through the census method. The main inclusion criteria was being an intern in medical school, participating with acceptance in the pre-internship comprehensive exams, being involved in hospital wards at the time of this study, as well as lack of the defense of their thesis. Interns who have not taken part in the pre-internship exam as well as those that have been dismissed from school were excluded.
For data collection, we administered a validated and reliable questionnaire that was previously used by Ranjbar et al. (r = 0.83) after obtaining permission to use the questionnaire from its authors (8).
The interviewer-administration of the questionnaire increased its accuracy of data collection.
The questionnaire consisted of 3 parts. The first part included the demographic variables (age, gender, and year of medical education) and whether participants had prior exposure to information about patient right in pre-internship period (3 questions). The second part contained a 29-item and 1 open-ended question, which tested the knowledge in the area of the patients’ right. These questions were arranged as “I agree (correct answer) = 1 point” and “I don’t agree (wrong answer) = 0” scale (no response to the question as well as the equivalent of wrong answer). The third part of questionnaire contains 3 closed-ended (yes/no) and 1 open-ended question asking for additional comments.
Based on the correct answers to the questions, the knowledge of the patients’ right was ranked in 3 categories. The average scores of correct answers were categorized as weak (less than 9), intermediate (between 10 and 19), and good (equal or more than 20).
All the data were analyzed using the SPSS version 15 (SPSS Inc., Chicago, USA). Descriptive statistics, Pearson’s Chi-square, and t-tests, were applied to evaluate significant differences between variables.
3.1. Ethical Issues
Considering ethical issues, the nature, purpose, necessity of the study, as well as the freedom of participation were explained before administration of the questionnaire and verbal consent was given by the participants. The participants had the option of refusing to answer the questionnaire. To assure the confidentiality, the questionnaires were anonymous and did not involve participants’ personal data; only age and gender were included.
4. Results
In this study, out of the120 questionnaires that were distributed to the interns, 103 questionnaires were completed (response rate of 85.83%). The mean age of the study population was 22.5 years (range 23 to 40), the highest number was in an age group of 25 years. The characteristic of medical interns according to age, gender, and years of education are presented in Table 1.
Table 1.Distribution According to Characteristic of the Interns
| Characteristic Variables | No. (%) |
|---|---|
| Age, y | |
| 23 | 3 (2.9) |
| 24 | 30 (29.1) |
| 25 | 47 (45.6) |
| 26 | 13 (12.6) |
| 27 | 7 (6.8) |
| > 28 | 3 (2.9) |
| Gender | |
| Male | 54 (52) |
| Female | 49 (48) |
| Years of medical education | |
| > 8 | 4 (3.9) |
| 7 | 18 (17.5) |
| 6 | 81 (78.6) |
In the response of the question “Did you receive any information regarding patient rights?”, it was detected that the high rate of interns (57.8%) did not receive any education regarding patient rights before the internship period. the sources of information of 42.2% of interns that had received some information were showed in Table 2.
Table 2.Sources of Information
| Sources of Information | Number out of Total Participants, (%) | Out of Positive Response, % |
|---|---|---|
| Educators | 26 (25.3) | 61.9 |
| Book | 9 (8.7) | 21.4 |
| Articles | 10 (9.7) | 23.8 |
| Other | 16 (15.5) | 38.1 |
| More than one source | 15 (14.7) | 35.7 |
In this study, it was found that 51.5% of the interns realized that the content of curriculum must be included in the ethical issues to promote their awareness especially in the area of the patients’ rights. The resurvey questions revealed that 94% of interns believed their awareness of patients’ rights to be essential while 88% marked it as a “high” necessity. Furthermore, 83.9% of the interns considered their knowledge about the patients’ rights as insufficient and 16.1% considered it as adequate. Concerning the observance of patients’ rights, 40.2% responded that patients’ rights were observed in their respected teaching hospitals while only 14% rated this observance as good.
Moreover, out of the 29 questions, the highest number of correct answers was 23 (79.3%) and the lowest one was 4 (13.8 %). Results generally indicated an intermediate awareness of interns regarding patients’ rights (Table 3).
Table 3.Interns’ Knowledge rate of Different Aspects of Patients’ Rights
| Knowledge Items (Number of Related Question) | Knowledge Rate | Number of Interns, (%) | Mean Score | Percent of Correct Answer out of All Question in the Field |
|---|---|---|---|---|
| Total (29) | Low | 16 (15.5) | 14.5 ± 4.6 | 49.9 |
| Intermediate | 72 (69.9) | |||
| Good | 15 (14.6) | |||
| The right to access to health care services (4) | Low | 27 (26.2) | 2.1 ± 0.9 | 51.5 |
| Intermediate | 39 (37.9) | |||
| Good | 37 (35.9) | |||
| The right to informed consent (11) | Low | 24 (23.3) | 5.2 ± 2.2 | 52.2 |
| Intermediate | 61 (59.2) | |||
| Good | 18 (17.5) | |||
| The right to individual freedom of patients (5) | Low | 26 (25.2) | 2.2 ± 1.1 | 43.4 |
| Intermediate | 69 (67) | |||
| Good | 8 (7.8) | |||
| The right to privacy and confidentiality (4) | Low | 17 (16.5) | 2.6 ± 1.1 | 64 |
| Intermediate | 28 (27.2) | |||
| Good | 58 (56.3) | |||
| The rights to receive enough information (5) | Low | 25 (24.3) | 2.4 ± 1.2 | 48.6 |
| Intermediate | 56 (54.4) | |||
| Good | 22 (21.4) |
Pearson’s correlation revealed no significant relationships between the interns’ awareness of patients’ rights and the age, in general as well as in areas questioned. Interns’ awareness of patients’ rights and gender were also compared by the t-test, which marked a significant difference only in the area of “individual freedom of patients” (P = 0.03) (Table 4).
Table 4.Knowledge of Interns Regarding Patients’ Rights According to Gender
| Knowledge Items | Mean Score | P Value | |
|---|---|---|---|
| Male, N = 54 (52%) | Female, N = 49 (48%) | ||
| Overall questions | 14 ± 5 | 15 ± 4.2 | 0.28 |
| The right to access to health care services | 2 ± 1 | 2.1 ± 0.8 | 0.56 |
| The right to informed consent | 5.3 ± 2.2 | 5.1 ± 2.3 | 0.60 |
| The right to individual freedom of patients | 2 ± 1.2 | 2.4 ± 1 | 0.03 |
| The right to privacy and confidentiality | 2.4 ± 1.1 | 2.7 ± 1 | 0.08 |
| The rights to receive enough information | 2.3 ± 1.3 | 2.6 ± 1.2 | 0.22 |
Furthermore, it was detected that only 41% of interns received an education concerning the patients’ rights before the internship period whom were of a higher awareness than those who were not informed in advance.
On the other hand, 51.5% of interns consider the training course to be useful in promoting their awareness, however there was no significant relationship in any context that were observed between their knowledge and those who did not realize training course as effective (Table 5).
Table 5.The Relationship Between Teaching Course and Interns’ Knowledge
| Knowledge Items | Close Questions | |||||
|---|---|---|---|---|---|---|
| Yes (n = 42) mean score | No (n = 60) mean score | P value | Yes (n = 50) mean score | No (n = 47) mean score | P value | |
| Overall questions | 15.6 ± 4.5 | 13.6 ± 4. | 0.03 | 15 ± 4.7 | 14 ± 4.5 | 0.3 |
| The right to access to health care services | 2.2 ± 0.9 | 2 ± 0.9 | 0.36 | 2 ± 0.8 | 2.1 ± 1 | 0.41 |
| The right to informed consent | 5.5 ± 2.4 | 5 ± 2.2 | 0.29 | 5.5 ± 2.2 | 5.1 ± 2.3 | 0.34 |
| The right to individual freedom of patients | 2.5 ± 1 | 1.9 ± 1 | 0.01 | 2.2 ± 1 | 2.1 ± 1.2 | 0.62 |
| The right to information confidentiality | 2.9 ± 1.1 | 2.3 ± 1 | 0.01 | 2.7 ± 1 | 2.5 ± 1 | 0.33 |
| The rights to receive enough information | 2.6 ± 1.1 | 2.4 ± 1.3 | 0.32 | 2.6 ± 1.3 | 2.2 ± 1.2 | 0.14 |
5. Discussion
Issues such as the ability to receive health care services, especially disadvantaged groups, unconditional reception of patients in hospitals, special attention to the reception of emergency patients, as well as their satisfaction with emergency medical services are raised in the area of “right of access to health services”.
Our results showed that only 35.9% of the trainees ranked a good level with sufficient knowledge. Comparatively, Ranjbar et al. reported that 23% of interns were of good awareness in this area (8).
Results of another study done by Ducinskiene et al., conducted in Lithuania, Finland (10), also showed that the majority of the medical staff had heard or read about the patient’s rights, however, a small percentage of them consider nationality, language, gender, and more when providing health cares.
In the field of patients’ right to “informed consent”, some issues are brought up including the consent responsibility and the patients’ right to receive enough information regarding their illness, treatment options and its associated complications, the risks and benefits of each procedure, to access to their medical records, as well as being informed of the costs before the consent.
In present study, only 17.5% of interns were at a good level with sufficient knowledge in this field.
The research of Ranjbar et al. marked 36.3% of interns with good knowledge in this context (8). In a Malaysian study conducted by Yousuf et al., it was shown that informed consent was attained in 98% of cases by physicians (11) whereas, Ducinskiene et al. revealed that 50.2% of physicians agreed with the patients right to informed consent (10).
The present study also revealed that 21.4% of the interns had a good level of awareness regarding “the right to awareness of the treatment process”. Ranjbar et al. recorded that 42.4% of students had good knowledge in this context (8). Ozdemir et al. showed that the patients’ right to access their medical records had not been approved by physicians (12).
Interestingly, a study done by Jafarian et al. (13) determined that 4.7% of all incoming complaints to the Medical Council had resulted from lack of sufficient justification of the patients regarding treatment procedures, an issue that clarifies the need for paying more attention to this aspect of the patients’ rights.
Due to insufficient knowledge of practitioners in this area, complex legislations in the issue of informed consent, as well as the important ethical and legal consequences, more attention is needed to this topic.
The area of “individual freedom of patients” propounds subjects such as the right to free choice in health care, including the choice of doctor and type of treatment by the patient, the right to consult with other physicians, the right to leave the hospital at any time, as well as the right to perform religious rituals. In this context, only 7.8% of interns were at a good level of knowledge. Ranjbar et al. realized that 46.8% of students had adequate knowledge. In the study of Ducinskiene et al., 90% of the medical team was aware of the patients’ rights to select a physician or nursing staff member (8, 10).
Herein, 56.3% of interns had good knowledge in the area of the “patient’s right to confidentiality of records”. Ranjbar et al. reported that 32.7% of interns and Ozdemir et al. in Turkey disclosed that 90% of physicians were aware of the right to confidentiality (8, 12).
Overall, The current survey indicated that the highest level of knowledge of interns was in the area of the “right to information confidentiality” (56.3%) and the lowest level was the right of “individual freedom of patients” (7.8 %) (Table 3). This may be due to their consideration regarding the interference of freedoms of patients in the process of therapy. Ranjbar et al. stated that the students’ knowledge in the area of “individual freedom of patients” to be greater than other areas while the least awareness was attained by the topic of the “right to access to health care” (8).
Overall, the average score of correct answers was 46.86 and the percentages of interns’ awareness of patients’ rights were as 15.5%, 69.9%, and 14.6%, respectively, for the “weak”, “intermediate”, and “good” rankings. Likewise, Ranjbar et al. reported rankings of 35.6%, 27.7%, and 36.7% for poor, intermediate, and good knowledge, respectively (8).
In general, this study showed an intermediate to weak level of knowledge of patients’ rights among the majority of interns, which was unsatisfactory.
Study of Ranjbar et al., Davati et al., and Zarei et al., respectively, evaluated the awareness of general practitioners as intermediate levels (8, 9).
The study done by Alghanim, in Saudi Arabia, recognized that the awareness of physicians and nurses regarding patients’ bill of rights was low (7).
In Turkey, Ozdemir et al. found that 40% of physicians were not aware of the legal rights of patients and 60% of them had no education in this field (12). On the contrary, Bassiri Moghaddam et al. (14) found that the levels of knowledge of physicians’ as well as medical staff are good. However, the Lithuanian study revealed that the majority of hospital staff was aware of patients’ rights but did not respect the rights (10).
In our study, no significant relationship was observed between the age and the knowledge. We found that the average score for female interns was higher than that of males, though this association was significant in only the topic of “individual freedom of the patient”. Ranjbar et al., reported a significant direct relationship between knowledge levels of participants and their age and gender (8).
In general, a slightly greater awareness of females may be due to their personal characteristics and a greater attention regarding the surroundings environment.
This survey indicated that 42.2% of interns received some information regarding the patients’ rights before the internship period majority (61.9%) by “educators”, which is consistent with study of Ranjbar et al. (8). A notable point is therefore, despite the fact that “educators” are the greatest source of information, however only 25.3% of the interns have generally used this source, which could be due to low readiness and motivation of them to obtain information or lack of teachers preparation, education, and competence required for effective teaching.
The second point to note is that book and article sources appear to have allocated the lowest percentage in this study and it seems that new generation of students are mostly seeking educators prepared materials as well as other sources of learning rather than reading a book.
This study also found that there was a significant association (P = 0.03) between the general ethical knowledge before the onset of the internship period and their awareness of patients’ rights that denotes the important role of ethical education before the start of internship period. Such significant relationships were further noticed in terms of “individual freedom of patients” and “the right to confidentiality of patients’ records” (in both cases: P = 0.01). In contrast to our study, Ranjbar et al. indicated the information source of interns had failed to provide them with enough awareness (8).
The overall results of this study indicated that the knowledge of interns was not sufficient. The important points that had been raised were: to consider the education of medical ethics and patients’ rights in theory and particularly in practice, to notify the consequences of both observance and ignoring of patients’ rights within the training program of teachers, and to train the hospital staff as part of the population affecting students’ learning (15).
5.1. Conclusion
According to the participation of clinical students in the care of patients, it should be very helpful to assign more courses to the medical ethics and increase the sessions of discussing various aspects of patients’ rights as well as to begin training in a period before the start of a clinical experiences and to offer refresher courses at all clinical levels. Moreover, holding special workshops, training courses, conferences, and supply of authentic pamphlets as well as manuals with simple expression in the early clinical course are effective in raising awareness.
