Hospitalized Patients Awareness of Their Rights in Saudi Governmental Hospital

Middle-East Journal of Scientific Research 11 (3): 329-335, 2012 ISSN 1990-9233 IDOSI Publications, 2012 Hospitalized Patients Awareness of Their Rights in Saudi Governmental Hospital Alyah M. Almoajel Department of Community Health Sciences, Applied Medical Sciences College, King Saud University, Riyadh, Saudi Arabia Abstract: Aim: To determine the level of awareness of patients rights among hospitalized patients. Methods: A questionnaire survey was conducted among patients at a governmental hospital. Results: Most patients did not know about the patients bill of rights, even though they are spontaneously practicing their rights. Conclusion: In the studied Saudi hospital, there was a lack of patients' awareness regarding the patients' rights. Key words: Patient s Rights Awareness of patients' rights Human Rights INTRODUCTION participate in decision-making. Proposed procedures or treatments and their various alternatives. General Patients rights, is recently introduced term in health awareness of human rights has been on the rise [14]. sciences literature and practice and has become an Many countries have guaranteed patients' rights to important part of modern health care practice. Patients process for resolving dissatisfactions with health care now are much more aware of what they expect from health providers. The United States, for example, since care professionals, when they enter the health care November 1997 have included an aspiration statement in environment. the Consumer Bill of Rights regarding this issue Global developments impacting on social, economic, (President's Advisory Commission on Consumer cultural, political and ethical affairs have also affected our Protection ). Other countries, such as Sweden, the United understanding of what is meant by human rights. Kingdom, Italy, Spain and New Zealand also have a However, the fundamental reason for the importance specific legislation regarding patient's protection and attached to patients rights and the corresponding safety [15-16]. increase in legislation, is that respecting patients rights In Iran; the quality of care is very important, such as is an essential part of providing good healthcare [1-6]. patient's satisfaction, patient's empowerment and patient's There have been many declarations defining the treatment, also the access to health personnel and to importance of the right to lead a healthy life [7-9]. such as regular sources of care and convenient services are The Lisbon Declaration of World Doctors important in medical care services [17-19]. Association[10], was the first study to look specifically at To provide ethical health care, it is important to patients rights. The World Health Organization consider patients rights as mentioned in different published a detailed document (A Declaration on the patients bills of rights or charters published in each Promotion of Patients Rights in Europe) stating the country. Cultural differences, however, play an important principles and strategies of patients rights in Amsterdam role in individual attitudes and perceptions of rights in (28-29 March1994). Finland(1992), The Netherlands, general and patients rights in particular. As culture and Lithuania (1996), Denmark (1998), Norway (2000) and socio-economic contexts create different barriers and France (2002) have all drawn up legislation covering facilitators to respecting patients rights, a World Health patients rights [5-6, 11-13]. Organization research group on patients rights and Today, concerns about the patients choice, respect citizens empowerment suggested that each country for their values and preferences and access to health care should articulate its concerns and priorities according to are becoming more complex. Patients expectations are its own cultural and social needs to promote and protect higher and they want the best. They want to actively patients rights [20]. Corresponding Author: Alyah M Almoajel, Department of Community Health Sciences, Applied Medical Sciences College, King Saud University, Riyadh, Saudi Arabia. 329

Quality care of patients means satisfaction with understanding of the questions. The patient duration facilities given by the hospital. As health facilities, food, should have been hospitalized for at least three days, to nutrition, sanitations and clean drinking water and enable them to exercise their rights. medicine given in time by the nurse, also satisfaction of The sample was selected purposively from different the hospital environment, availability of food products wards and all the data was collected by a trained research supply, post-operative care facility and cleanliness. nurse, patients were approached in person and Which has been observed on patients satisfaction and provided with a brief description and aim of the study. quality of treatment in a governmental hospital in Pakistan Their consent was obtained before they were asked to [21]. answer the questionnaire. In Saudi Arabia, The Ministry of Health published a Each question required a yes, no, or to some extent. patients bill of rights in 2001,The patient bill of rights as The questionnaire consisted of two parts, the first part a written document is available in most Saudi health care was information regarding the patients demographics; and organizations, but many patients and their families may the second part consists information about awareness of not be aware of their rights that have been granted by the patient rights. Saudi government through policies and regulations of the Patients were asked whether they were aware of their Ministry of health [22]. rights such as autonomy, privacy, confidentiality. The social system in Saudi Arabia is very supportive All patients recruited into the study were fully for patients and their families and in most hospitals conscious and able to give a consent. Unstable patients, patients have access to free health care services. pediatric patients and patients from the intensive care However, there has been little discussion on how patients unit, coronary care unit and high dependency wards were rights are practiced in such health care systems. excluded. Most bills of rights, including the Saudi, are concerned with informed consent, autonomy, Statistical Analysis: Statistical analysis was done using confidentiality and privacy. Professionals are expected to the statistical package for social sciences version respect patients rights, but if they are not familiar with 11(SPSS). Mean and frequency were used to describe the contents of the bills of rights, or what they imply, the items of the questionnaire. Chi-Square (X2) test was problems can arise. used to compare the proportions among the various In Saudi Arabia, it was very difficult to find a research groups and a p- value of > 0.05 was taken to be study that examined the patients' rights. Only one study statistically significant. was conducted by Al Bishi in 2004. This study was performed in order to investigate the awareness of RESULTS patients rights in Saudi Arabia. A total of 250 patients were surveyed, Table 1 lists MATERIAL AND METHODS the demographic profile of the study population. The majority of participants were female, aged from 20 to 39, This was cross-sectional descriptive questionnaire Saudi, married, living in Riyadh city. Half of study survey, investigating awareness of rights among participants were with under Elementary education level. hospitalized patients. Their economic level was less than 5000SR and most of The study sample consists of 250 hospitalized them had spent more than two weeks in the hospital. patients from King Saud Medical City in the middle Table 2 shows the awareness of patient about their province in Saudi Arabia, it is the largest governmental rights; 25.2% of respondents don t know about that they hospital that is under the Saudi Ministry of health which have rights and half of them are aware about more than 6 there are 600 bed. rights (Table 3). An initial pilot study was carried with 15 patients in Table 4 shows that the source of information was the hospital, who were asked to feedback information from nurses or they read it as a poster. regarding whether the questionnaire worked well, there From Table 5, it was found that there were significant was only one negative comment related to the differences for all the expressions for the list of patient's questionnaire, which was that it was too long, which rights in the governmental hospital in Riyadh at the level showed the validity, the easy to use format and of significance (0.01). It is the highest level of significance 330

Table 1: Demographic profile of all participated patients in the study Characteristics NO % of patients Gender Male 38 15.2 Female 212 84.8 Age Less than 20 47 18.8 From 20-39 78 31.2 From 40-59 69 27.6 Over 60 59 22.4 Nationality Saudi 176 70.4 Non Saudi 74 29.6 Social Status Married 144 57.6 Unmarried 71 28.4 Widow 33 13.2 Diverse 2 0.8 Place of residency Inside Riyadh 202 80.8 Outside Riyadh 48 19.2 Educational level Literacy 112 44.8 Elementary 40 16 Intermediate 31 12.4 High school 50 20 University and above 17 6.8 Economic level Less than 5000 178 71.2 From 5000-10000 48 19.2 more than 10000-15000 11 4.4 more than 15000 2 0.8 not mentioned 11 4.4 Table 1: Continue Characteristics NO % of patients Length of stay in the hospital Less than one week 45 18 Week to two weeks 80 32 2 weeks to one month 59 23 More than one month 66 26 Number of hospitalization admission Non 104 41.6 Once 50 20 Twice 39 15.6 3 times 32 12.8 More than 3 times 25 10 Table 2: Awareness of patient about their rights Are you aware that there is special bill of patients rights in the hospital Number % Yes 63 25.2 No 187 74.8 Table 3: Distribution for those who are aware of patients rights How many rights you are aware of Number % 1-3 20 31.75 4-6 24 38.1 7-10 19 30.16 Total number of patients who are aware of patients rights 63 100% Table 4: Distribution for those who are aware of patients rights according to the source of awareness of patients rights Source of awareness of patients rights Number % The nurse explained it to me 21 33.33 My doctor explained it to me 15 23.81 I read it as a poster 20 31.75 My relative read it to me 7 11.11 Total number of patients who are aware of patients rights 63 100% Table 5: Patients awareness of their rights Yes to some extent No -------------- ------------------- -------------- Chi- Square The patient has the right for the following: F % F % F % Mean and Sig. Arrange 1. To receive compassionate and respectful care. 754 75.4 144 14.4 102 10.2 2.65 799** 3 2. To be cared for by qualified competent staff and to be seen by specialized consultant. 1468 73.4 294 14.7 238 11.9 2.62 1447.2** 4 3. To be kept fully informed of his \ her diagnosis and treatment plan. 261 26.1 105 10.5 634 63.4 1.63 443.3** 10 4. To receive all necessary information to allow informed consent to be given for all medical interventions. 1117 74.47 201 13.4 182 12.13 2.62 1142.4** 4 5. To be informed of the effects on his\ her health if he\ she refuse treatment. 203 81.2 20 8 27 10.8 2.70 258.1** 2 6. To be able to comment on and discuss the care and service he\she is receiving. 352 70.4 71 14.2 77 15.4 2.55 309.2** 6 7. To be assured of privacy and confidentiality with regard to medical and social information. 803 80.3 112 11.2 85 8.5 2.72 993.7** 1 8. To be able to refuse to take part in any proposed research. such refusal or withdrawal will have no effect on care delivered. 370 29.6 734 58.72 146 11.68 2.18 422.7** 9 9. To be discharged as recommended by the doctor with appropriate medications, follow up appointment and required educations\ information. 532 53.2 349 34.9 119 11.9 2.41 257** 8 10. To be provided with a medical report summarizing his\her medical condition and course during admission. 266 53.2 192 38.4 42 8.4 2.45 156.3** 7 The Total 6126 61.26 2222 22.22 1652 16.52 2.45 * P- Value (0.05), ** P- Value (0.01). 331

and the researcher found that most of these differences To be discharged as recommended by the doctor for the benefit of choice (Yes) except two statements, with appropriate medications, follow up appointment firstly (To be kept fully informed of his \ her diagnosis and and required educations \information. treatment plan) differences then for the choice (No) and To be able to refuse to take part in any proposed the second statement (To be able to refuse to take part in research such refusal or withdrawal will have no any proposed research, such refusal or withdrawal will effect on care delivered. have no effect on care delivered) differences then in favor To be kept fully informed of his \ her diagnosis and of choice (to some extent). treatment plan. This means that most of the sample of patients agreed with most of the expressions for the patient's rights in the DISCUSSION governmental hospital in Riyadh, except as the previous two terms are explained. Implementation of patients rights should not be It is clear from the above table that the arithmetic something that restricts the practice of medicine. Rather, mean of the expressions for the bill of patient rights it can both contribute to the improvement of healthcare confined between (1.63, 2.72), mostly located opposite the practices and achieve an equal distribution of degree (Yes), that is the respondents agree with most responsibility between patient, physician and nurse. of the expressions for the list of patient's rights, except the However, this study found that, most patients did not two statements (To be able to refuse to take part in any know that the Saudi Ministry of Health had published a proposed research, such refusal or withdrawal will have patients bill of rights. Previous report from Turkey states no effect on care delivered) with average arithmetic (2.18) that only 23% of patients were able to recognize their for (to some extent) and the second (To be kept fully rights and this showed significant differences related to informed of his \ her diagnosis and treatment plan) educational level categories [23]. In a study conducted in average arithmetic (1.63) for the choice (No), meaning that Greece, the right to confidentiality was not considered as the respondents agree with the statements of the list of a right of privacy and many patients allowed their doctors patient's rights, except for the two statements on one to to make decisions; 84% of patients were not aware of some extent is (To be able to refuse to take part in any legislation. It was also stated that 60% of patients did not proposed research such refusal or withdrawal will have have any idea about their rights [24]. Another study no effect on care delivered) and the second statement found that 60% of patients were not aware of the (To be kept fully informed of his \ her diagnosis and European Convention of Human Rights [25].This also was treatment plan) do not agree with them and this is reported by Fotaki in A study resulted that many of the completely in line with the results of X2. respondents having little or no information about patient The statements for the bill of patient rights can be rights [26]. arranged, according to the arithmetic average downward Additionally, in Iran some reported studies indicated as follows: low level awareness of patients rights [27-29]. In contrast, Kuzu showed that few patients knew To be assured of privacy and confidentiality with about the regulation on patients rights in developing regard to medical and social information. countries [30]. To be informed of the effects on his\ her health if he\ Giugliani study revealed an increase with time in the she refuse treatment. number of complaints for medical issues in a university To receive compassionate and respectful care. hospital, as well as an increase in the perception of a To be cared for by qualified competent staff and to medical error after the passing of a law regarding patients' be seen by specialized consultant. rights in France [31]. To receive all necessary information to allow Many patients seem to have limited awareness of the informed consent to be given for all medical legal Implications of signing or not signing consent forms interventions. and they do not recognize written consent as primarily To be able to comment on and discuss the care and serving their interests [32]. service he\she is receiving. In Changole et al. study, half of the patients who To be provided with a medical report summarizing participated in the study had never heard of any patients his\her medical condition and course during rights anywhere. This finding may indicate how the health admission. care system has neglected such an important legal issue. 332

No single poster on patients rights was available on the Recommendations: Implementation of patients rights walls of the unit and no lesson were given to patients only seems possible when people who provide or receive concerning their rights [33]. health care and institutions where health care is provided, In Sutherland study, most of the patients who have reached the desired levels of information and participated in this study felt that they had actively consciousness. Implementation of these rights should not sought information, yet a majority preferred to relinquish be considered the responsibility of healthcare the decision making role. These results are at odds with a professionals alone. philosophy of care which advocates a consistent Information and opportunities to learn about issues unvarying dedication to the promotion of patient such as the definition and reinforcement of patients autonomy and self determination [34]. rights should be available to every- one, not just health- All previously discussed studies in the above care professionals or patients (Human Rights Education paragraphs showed that patients rights such as, Associates, 2000). Mass communication media, healthconfidentiality, legal implications of signing or not care institutions, educational institutions, medical signing consent forms indicates a need for extensive companies, political parties and religious groups should education of patients and health care professionals all have an important role to play in the reinforcement of concerning patients rights. patients rights. In the study carried out by Al Bishi (2004), he was The findings of the study suggests that appropriate concerned with this concept in a multidimensional way in measures have to be taken from a national perspective in Saudi Arabia, exploring the patients, physicians and order to enhance the quality of health care practice, nurses lived experiences with patients rights. He found control and eliminate the factors that lead to violation of that meeting the patients caring needs, is core concept patients rights and educate the public about their rights. for the meaning of patients rights in Saudi Arabia. He also found the lack of knowledge about the rights, lack REFERENCES of standard of practice among the hospitals and the impact of service pressure and subsequent lack of holistic 1. Dickens, B, L, Gostin and R. Levine, 1991. Research care, are barriers to patients rights practice in Saudi on human populations: national and international Arabia [35]. ethical guidelines. Law, Medicine& Health Care, This indicated that the process of informing 19: 157-161. healthcare providers and recipients has not been 2. Brody, B., 1992. Special ethical issues in the successfully implemented. The media plays a significant management of PVS patients. Law, Medicine & role in making people aware of their rights, but this Health Care, 20: 104-115. requires planning at a high level of healthcare 3. Fletcher, J.C., 1992. Ethics committees and management systems. Informing the public about their dueprocess. Law, Medicine & Health Care, rights as patients is part of promoting public 20: 291-293. awareness of human rights, which are important 4. Chilton, L., J.E. Berger, P. Melinkovich, R. Nelson, aspects of the Saudi Islamic culture. Using this context, P.D. Rappo and J. Stoddard, 1999. American Saudi Arabia would be more likely to adopt patients Academy of Pediatrics. Privacy protection of health rights practice. information: patient rights and pediatrician Successfully by referring to its valuable social and responsibilities. Pediatrics, 104: 973-977. cultural traditions, as well as utilizing international 5. Patients Rights Laws in Europe, 2004. /http:// experiences. Even though, most of patients are aware and home.online.no/ _wkeim/patients.htms (last accessed practicing their rights. 15.05.04). Even though, implementation and actualization of 6. Ozdemir, M.H., A.T. Ergo nen, E. So nmez, O. Can standards in hospitals require certain infrastructures such and S. Salacin, 2006. The approach taken by the as better knowledge on the part of managers regarding doctors working at Educational hospitals in Izmir quality improvement and using hospital information towards patient rights. Patient Education and system (HIS) and patient safety [36]. Counseling, 61: 87-91. One limitation of this study is that this study 7. European Convention for the Protection of Human was conducted among inpatients from a single Rights and Fundamental Freedoms, 2005. /http:// hospital; hence the results generalizability to Saudi conventions.coe. int/ treaty/ en/ Treaties/ Html/ Arabia is doubtful. 005.htmS (last accessed10. 12.05). 333

8. Universal Declaration of Human Rights, 2005. 20. WHO Regional Office for Europe, Joint consultation /http://www. un.org/ Overview/ rights.htmls (last between the Nordic Council of Ministers and accessed10.12.05). The Nordic School of Public Health. 1999. Patients 9. WHO Basic, 2006. Documents. Adopted by the Fifty- Rights and Citizens Empowerment: Through Visions first World Health Assembly, 45thedn., Supplement, to Reality. WHO, Copenhagen. October. /http:// www.who.int/governance/en/s (last 21. Bashir, T., A. Shahzad, P.A. Khilji and R. Bashir, 2011. accessed 16.11.07). Study of Patients Satisfaction and Hospital Care in 10. Lisbon Declaration, 1981. World Medical Association Pakistan: Case Study of Madina Teaching Hospital Declaration on the Rights of the Patient. Adopted by University Faisalabad. World Applied Sciences J., the 34th World Medical Assembly Lisbon, Portugal, 12(8): 1151-1155. th September/October and amended by the 47 General 22. Ministry of Health, Saudia Arabia, http:// Assembly Bali,Indonesia, September 1995. /http:// www.moh.gov.sa/ Pages/Default.aspx www.wma.net/ e/policy/ l4.htms (last 23. Zu lfikar, F. and M.F. Ulusoy, 2001. Are patients accessed16.11.07). aware of their rights? A Turkish study. Nursing 11. World Medical Association, 1991. Declaration of Ethics, 8: 487-498. Helsinki. Law, Medicine & Health Care, 19: 264-265. 24. Merakou, K., P. Dalla-Vorgia, T. Garanis-Papadatos 12. Declaration on the Promotion of Patient s Rights in and J. Kourea-Kremastinou, 2001. satisfying patients Europe, 1994. WHO Regional Office for Europe, Rights: A hospital patient survey. Nursing ethics, Copenhagen. 8(6): 499-509. 13. Francois, P., H. Patricia, V. Scolan and M.L. Gueut, 25. Woogara, J., 2001. Human rights and patients 2002. Patients participation in medical decision- privacy in UK hospitals. Nursing Ethics, 8: 234-246. making. Change due to the Law of 4 March and 26. Fotaki Marianna, 2006. Users perceptions of health relevant jurisprudence. In: Proceedings of 3rd care reforms: Quality of care and patient rights in four European Academy of Forensic Science Meeting, regions in the Russian Federation. Social Science & 22-27 September 2003. Iÿstanbul, Turkey. Medicine, 63: 1637-1647. 14. Yousuf, R.M., A.R.M. Fauzi, S.H. How, S.F.U. Akter 27. Joolaee, S. and N. Mehrdad, 2003. An investigation and A. Shah, 2009. Hospitalized patients' awareness on patients awareness of their own rights. In of their rights: a cross- sectional survey from a Proceedings of 3rd National Congress of Bioethics, tertiary care hospital on the east coast of peninsular June 25-28 Bursa, Turkey, pp: 517-524. Malasia. Singapore Med. J., 50(5): 494-499. 28. Joolaee, S., V. Tschudin, A. Nikbakht-Nasrabadi and 15. World Health, 2007. Organization: WHO International Z. Parsa-Yekta, 2008. Factors affecting patients Digest of Health Legislation. In Edited by World rights practice: the lived experiences of Iranian nurses Health Organization World Health Organization, and physicians. International Council of Nurses, Geneva; pp: 55-61. 16. Dew Kand and M. Roorda, 2001. Institutional 29. Mosadegh-Rad, A.M. and P. Asna-Ashari, 2004. innovation and the handling of health complaints in Physicians and patients awareness of patients New Zealand: an assessment. Health Policy, 57: 27-44. rights and its observation in Shahid Beheshti 17. Nasiripour, A.A., G. Mahmoudi and P. Raeissi, 2011. Hospital, Isfahan, Iran. J. Education in Medical A survey on exploring the dimensions of acces to Sciences, 11: 45-53. medical services. World Applied Sciences J., 30. Kuzu, N., A. Ergin and M. Zencir, 2006. Patients 13(3): 424-430. awareness of their rights in a developing country. 18. Nasiripour, A.A., Siadati S.A. Maleki and Public Health, The Royal Institute of Public Health. A.N. Nasrabadi, 2011. Towards a comprehensive Published by Elsevier Ltd., 120: 290-296. model of patient empowerment through 31. Giugliani, C., N. Gault, V. Fares, J. Jegu, S.A. Trolli, nursing strategies. World Applied Sciences J., J. Biga and G. Vidal-Trecan, 2009. Evolution of 14(3): 408-413. patients' complaints in a French university hospital: 19. Taghizadeh, F. and S.J. Monfared, 2011. The Client is there a contribution of a law regarding patients' Satisfaction of Health Care in Public and Private rights?. BMC Health Services Research, 9: 141. Centers and Health Houses in Qom province. Middle doi:10.1186/1472-6963-9-141. This article is available East J. Scientific Research, 7(6): 1019-1023. from: http://www.biomedcentral.com/1472-6963/9/141 334

32. Akkad, A, C. Jackson, S. Kenyon, M. Dixon-Woods, 35. Albishi, A.A., 2004. The Saudi Patients, Physicians N. Taub and M. Habiba, 2006. Patients perceptions of and Nurses Perceptions of and Lived Experiences written consent: Questionnaire study. BMJ, with Patients Rights in Saudi Arabia: A Qualitative doi:10.1136/ bmj.38922.516204.55. Phenomenological Study. Doctoral Dissertation. 33. Changole, J., C. Bandawe, B. Makanani, George Manson University. K. Nkanaunena, F. Taulo, E. Malunga and 36. Farzianpour, F., M. Arab, S. Amoozagar, G. Kafulafula, 2010. Patients satisfaction with A.R. Fouroshani Rashidian, M.N. Moghadam and reproductive health services at Gogo chatinkha S. Hosseini, 2011. Evaluation of International Maternity unit Blantyre, Malawi: Malawi Medical J., Standards of Quality Improvement and Patient Safety 22(1): 5-6. (QPS) in Hospitals of Tehran University of Medical 34. Sutherland, H., H.A. Uewellyn-Thomas, Sciences (TUMS) from the Managers Point of View. G.A. Lockwood, D.L. Tritchler and J.E. Till, 1989. World Applied Sciences J., 15(5): 647-653. cancer patients; their desire for information and participation in treatment decisions. J. the royal society of medicine, 82: 260-263. 335