Introduction
The concept of natural human rights has been of interest to humans for centuries, and this is evident in the heavenly teachings of all the prophets of God in various forms and is seen as an advanced scientific and human principle. Undoubtedly, every human being has individual and social rights. The patients are among the most vulnerable social groups, physically, psychologically, socially, and economically. This condition is of particular interest to international human rights organizations in the concept of patients’ rights [1, 2].
Patients’ rights are as old as medical sciences. Fundamental human rights in health care, especially the protection of a patient’s dignity, become important when the vulnerability of the patient is easily exposed to violations and considered the weak points of the health care system [3]. Patients’ rights are one of the most important ethical considerations in the hospital that need to be addressed. Attention and respect for the patients’ rights are one of the most important factors in their recovery and comfort during hospitalization [4].
According to the American Health Association, a person’s rights are based on his or her needs and is the responsibility of a health care provider. In other words, the rights of the patient are the observance of legitimate physical, mental, spiritual, and social needs. These rights are formatted in the form of standards, rules, and regulations of treatment, and the medical staff is responsible and obliged to implement them [1, 4].
The first new step in establishing the concept of patients’ rights was the Universal Declaration of Human Rights (UDHR) of the United Nations, especially Article 25, which refers to the right to health and medical care throughout the world [3]. Patients’ rights and their role in medical decisions are respected in all legal and ethical statements around the world [5, 6]. In different countries, including our country, these laws and regulations have been drafted as a charter of patients’ rights and the protection of human rights to maintain his dignity to ensure adequate care in cases of illness without any age, sexual, and financial discrimination [7].
Different studies have reported varying degrees of adherence to the charter of patients’ rights [2, 7-9]. In a study in India, Delaware estimated the level of patient’s care as moderate [10]. A study by Zarzeka et al. in Warsaw, Poland, found that most patients were satisfied with the extent to which nurses respected their rights [11]. In a study by Abu Beker et al. in Sudan, patients had a high percentage of satisfaction with patient’s rights [12]. Similar studies have been conducted in Iran before. In the study of Sharifi et al. in Kermanshah City [8] and the study of Baba Mahmoudi in Mazandaran Province [13], in most cases, the observance of the charter of rights was undesirable. While in other studies in Kerman City [7] and Ardabil City [14], the observance of the charter of patients’ rights of the studied hospitals has been reported at the desired level.
Patients’ rights are one of the key indicators in defining standards for the application of clinical governance [1]. Considering that physical, mental, spiritual and social health is one of the most important aspects of existence and its provision is one of the most important obligations of the Islamic Republic of Iran according to Article 29 of the Iranian Constitution, The Ministry of Health and Medical Education considers itself responsible for providing the desired health services to members of the community. Health care centers should be institutions for understanding and respecting the rights and responsibilities of service recipients, their families, physicians, and other caregivers [15].
In the meantime, the professionalization of the field of nursing coincides with the innovation and development of health care systems and emphasizes the promotion of health, disease prevention, and care receiver as a whole [16]. In this regard, one of the complementary roles in comprehensive care is the supportive and defensive role of the nurse [17, 18]. On the one hand, satisfaction is one of the characteristics of hospital services and, on the other hand, achieving patients’ satisfaction requires respecting their rights. Therefore this study was conducted in Rasht City educational-therapeutic centers to determine the status of observing the charter of patients’ rights from their point of view. It is hoped that the results of this study would help the medical centers to observe the charter of patient’s rights, and take more effective measures to improve the implementation of legal and ethical standards for patients.
Materials and Methods
The present study is an analytical cross-sectional study in which the status of patient observation with the Charter of patients’ rights and related factors has been determined from the perspective of hospitalized patients in Rasht City educational-therapeutic centers in 2018. The study population consisted of all patients on discharge from Rasht City educational-therapeutic centers (a total of 6 centers). The sampling method was stratified sampling and each hospital was considered as one stratify and the wards of each hospital were considered as one sabstratify. The number of samples was estimated as 342 based on 95% confidence interval, 5% margin of error, and the percentage of patient’s rights found in the study of Nekoei Moghadam et al. (66.9%) [7].
The number of samples in each hospital was randomly selected taking into account the percentage of bed occupancy and the number of samples in the relevant sections. The selected samples were 60 people in hospital No. one, 41 people in hospital No. two, 64 people in hospital No. three, 60 people in hospital No. four, 67 people in hospital No. five, and 50 people in hospital No. six. 
The inclusion criteria were being hospitalized for at least 24 hours, being over 18 years of age, being completly, not having a mental disorder (based on medical records), signing the consent form, and willing to participate in the study. 
The research tool used in this study was a researcher-made questionnaire that was compiled using scientific sources (articles) and the charter of patient’s rights issued by the Ministry of Health and Medical Education to hospitals (https://behdasht.gov.ir/). The questionnaire had two sections: The first part related to personal social information about gender, age, marital status, education, place of residence, use of supplementary insurance, the reason for going to the hospital, name of the hospital, name of the ward, history, duration and the number of hospitalization, the number of hospitalizations, being under the category of vulnerable groups (including children, pregnant women, the elderly, the mentally ill, prisoners, the mentally and physically disabled, and homeless). 
The second part provided information on the status of the charter of patient’s rights, which included 48 items and 5 main domains. The areas included receiving desirable health services (11 items); the right to receive information desirably and sufficiently (15 items); the right to choose and decide freely in receiving health services (11 items); the right to respect the patient’s privacy and the principle of confidentiality (5 items); the right to have access to an efficient system of handling complaints (6 items). The choices for answers were “yes” (1 point), “no” (0 point), and “not applicable” (without a point). The total score ranged from 0 to 100. The scores from the questionnaires were classified into three levels of undesirable (0-33%), relatively desirable (34%-66%) and desirable (67%-100%).
To examine the Content Validity Index (CVI), the tool was provided to 13 faculty members of Guilan University of Medical Sciences. After collecting and applying their opinions, the Content Validity Ratio (CVR) and content validity index were calculated separately for each question. The calculated CVI and CVR of all questions were above 0.90. Only CVI values of two questions were 0.70, which were reviewed, and some minor changes implemented on the questionnaire. To determine the reliability, in a preliminary study, the questionnaire was first presented to 20 hospitalized patients, and an hour later, by changing the sequence of the questions, the same patients were tested for the second time. Due to the imminent clearance of the patients and the lack of access to them in the future, the reliability was studied simultaneously by two colleagues. Based on the information obtained, the scores of the two tools were evaluated using the interclass correlation coefficient, which was correlated in all areas (P=0.0001). 
The Cronbach alpha was used to determine the internal stability of the questions. The alpha coefficient of the first domains was 0.67, the second domains 0.83, the third domains 0.67, the fourth domains 0.69, and the fifth domains 0.79. In general, the Cronbach alpha coefficient obtained in all domains was 0.89. Data collection was performed during February and March 2018. To observe ethical considerations, the researcher referred to the samples (patients on discharge) in three different shifts; the morning, evening, and night. He first explained to the research units the purpose of the research and its importance, and how to answer the questionnaire, and assured them that the information would be confidential and that candidates would not need to write their names, and that participation in the study would be voluntary. After obtaining written consent, the questionnaire was completed by the researcher through face-to-face interviews with patients at the appropriate time and in a quiet place.
The data were examined by the Kolmogorov-Smirnov test (to determine the normal distribution of data), Friedman test (for comparison between the 5 domains), the Chi-square test (to compare the status of the charter of patients’ rights in terms of individual social variables and disease-related factors), and logistic regression model (to determine the predictors of the charter of patients’ rights) in SPSS V. 21. 
Results
The results of the study showed that the majority of the women surveyed (65.8%) were in the age group of 30-60 years with a Mean±SD age of 48.1±18.2 years and married (90.1%). Also, the majority had undergraduate education (42.4%), lived in the city (59.1%), and did not use supplementary insurance (78.7%). The majority had referred to the hospital on the recommendation of a physician (55.3%), with a history of hospitalization (71.1%), hospitalization less than 3 days (51.5%), and hospitalization more than twice (46.2%). A total of 18.1% of the samples were from the vulnerable groups of the community, of which the highest number was related to the elderly group (75.8%).
Concerning the score of observing the charter of patient’s rights, in general, the average was equal to 68.42%±15.74% with an average of 72.32 and a minimum of 15 and a maximum of 94.6 in the range of 0-100 score. As in the case of receiving optimal health services and providing health services (78.67±16.90) based on respect for the patient’s privacy (74.93±24.76), observing the principle of confidentiality from the patients’ point of view was higher, and in terms of access to an efficient system for handling complaints (30.58±30.51) was lower (Table 1).
Regarding the condition of observing the Charter of patient’s rights based on its classification of the Charter of patient’s rights scores, the status of observing the Charter of patient’s rights in terms of receiving health services (85.1%), in terms of receiving information (69.3%), in terms of patient’s free will to select and decide on receiving health services (57.6%), in terms of providing health services based on respecting patient’s privacy and observing the principle of confidentiality (66.7%), in terms of access to an efficient system to handle complaints (19%), and in general 65.8%, was desirable.
In comparing the status of the Charter of patient’s rights with respect to individual and social variables, there was a statistically significant difference only in terms of the reason for referring to the hospital (P=0.005). Patients who went to the hospital on the recommendation of a physician were more likely to observe the Charter of patient’s rights than those who had been admitted to the hospital on an emergency basis.
The logistics regression model was used to determine the predictors of observing the Charter of patient’s rights (Table 2). In this model, the mean score below 72.3 was considered 0, and the score above the mean was considered 1. Among the variables studied, only the reason for referring to the hospital (the physician’s recommendation regarding the patient’s emergency condition) was a predictor related to the observance of Charter of patient’s rights and was statistically significant (OR=1.9, P<0.05, CI95%; 1.150-3.233)
Discussion
The study results showed that the status of observing the Charter of patient’s rights in the educational-therapeutic centers of Rasht was favorable. Different studies indicate varying degrees of patient’s rights. In the studies conducted in Qom City [19] and Kerman City [7], the status of observance of the charter of patients’ rights has been reported optimal. While in the study conducted in Tabriz City [20] and Hamedan City [21], the status of observing the Charter of patient’s rights was moderate and acceptable [20]. In the studies conducted in Mazandaran Province [13], Khorramabad City [22], and Zahedan City [23], the observance of the Charter of patient’s rights in the majority of the cases studied was desirable. It seems that a few years after the implementation of the charter of patients’ rights in our country, increasing patients’ awareness and subsequent rise in patients’ demand for their rights, as well as credit ratings in hospitals that monitor how service providers are served according to established standards, has led to an increase in observance of the provisions of Charter of patient’s rights.
The results of the studies indicate that non-compliance with the charter of patients’ rights and their dissatisfaction with the services provided has slowed down the recovery process, increased hospitalization days, irritability, and the cost of patient treatment [4, 7]. A study by Jouzi et al. states that non-compliance with patient’s rights will lead to adverse consequences and distrust of the patient to the medical staff. Besides, there may even be an unfortunate event that cannot be corrected and prosecuted [3].
The results of the present study showed no significant statistical difference in the status of the Charter of patient’s rights in any individual and social variable. It seems that the performance of the staff of the educational-therapeutic centers can affect the observance of the charter of patients’ rights without considering their demographic characteristics. However, in many similar studies, individual and social characteristics of patients have been influential factors [2, 7, 8, 24]. The cultural differences of the study population, the differences in the research environments, and the increase in patients’ awareness of their rights and judicial solutions can be among the reasons for these differences. Also, the increase in the number and activity of lawyers and legal advisors in recent years has facilitated access to legal authorities and, as a result, increased complaints of patients about the violation of their rights by health care workers, which can improve the rights of this vulnerable group. In addition, how the complaint handling units operate in the treatment center may be effective in this regard. The results of the present study showed that patients who referred to the hospital on the recommendation of the treating physician had reported a significantly more favorable status of the Charter of patient’s rights than those who had referred to the hospital in an emergency. Considering that in non-emergency conditions, there is enough opportunity for hospital staff to communicate with the patient and familiarize them with the processes and physical space of the hospital, this reduces the stress level of patients and thus creates a better understanding of the disease.
Based on the results, it is recommended that by presenting the results to the managers of health services, while emphasizing the need to comply with the charter of patients’ rights by health system staff, measures can be taken to improve the status of compliance with the charter of patients’ rights and prevent the violation of patients’ rights, who are considered to be among the most vulnerable groups in society. It is worth mentioning that the drafting of the Charter of patient’s rights and its installation in medical centers alone does not guarantee compliance with it, and managers must take measures to ensure that patients are aware of their rights from the beginning of entering health centers.
An unidentifiable physical and mental condition in the research units and the subjects’ hesitation to state the facts (thinking that if they return to medical centers, there would be a possibility that they would not receive services properly) could affect their response to the questionnaire, and these factors could not be controlled by the researcher.
Because the collection of information in this study was done during the discharge of patients, the condition of discharge and hastening of the patients to leave the hospital as soon as possible could affect their responses. Therefore, it is recommended that a study be conducted on the subject of examining the status of patients’ compliance with the Charter of patient’s rights from the patients’ point of view during the patient’s hospital stay.
Given that the data in this study were collected through a questionnaire, and because patients’ responses to the questionnaire may not be valid for some reason and affect the results, it is recommended to study observations of the status of Charter of patient’s rights.
Ethical Considerations
Compliance with ethical guidelines
After receiving the letter of Vice-Chancellor for Research, and after the issuance of a license by the Ethics Committee of the Vice Chancellor for Research on April 30, 2017, the researcher obtained the permission No. IR.GUMS.REC.1396.398 and referred to all the relevant hospitals.
Funding
This article is taken from MSN. in nursing thesis of Seyedeh Narjes Fazeli at Guilan University of Medical Sciences. Also, this article is the result of an approved research project with the financial support of the Social Determinents of Health Research Center (SDHRC) Guilan University of Medical Sciences.
Authors contributions
Concepts and design: Seyedeh Narjes Fazeli, Mitra Sedghi Sabet, Mohammad Taghi Moghadamnia and Ehsan Kazemnejad; Preparation of manuscript: Seyedeh Narjes Fazeli, Mitra Sedghi Sabet, and Mohammad Taghi Moghadamnia; Analysis and interpretation of data: Ehsan Kazemnejad and the final editing and review was done: All authors.
Conflict of interest
The authors declared no conflict of interest.


References
Parsapoor AR, Bagheri AR, Larijani B. [Review of revolution of patient’s right charter (Persian)]. Medical Ethics and History of Medicine. 2010; 3(1-2):39-47. http://ijme.tums.ac.ir/article-1-247-en.html
Basiri Moghadam K, Basiri Moghadam M, Moslem AR, Ajam Zibad H, Jamal F. [Health providers and patients’ awareness on patient bill of rights and its observing rate in 22 Bahman Hospital (Persian)]. Quarterly of the Horizon of Medical Sciences. 2011; 17(1):45-54. http://hms.gmu.ac.ir/article-1-1083-en.html
Jouzi-Arkawazi H, Ashktorab T, Abbasi M, Delpisheh A, Manti R, Shahmir L. [Investigate organizational factors associated with patient rights from viewpoint nurses and patients in educational hospitals affiliated to the Ilam University of Medical Sciences (Persian)]. Medical Ethics Journal. 2013; 7(23):141-60. http://journals.sbmu.ac.ir/en-me/article/view/12712
Akbari L, Bagheri M, Baghersad Z, Aseman Rafaat N. [Evaluation of the observance of patients’ rights in the selected hospitals of Isfahan University of Medical Sciences (Persian)]. Medical Law Journal. 2015; 9(33):175-96. http://ijmedicallaw.ir/article-1-326-en.html
World Medical Association. WMA declaration of Lisbon on the rights of the patient. Paper presented at: 171st WMA Council Session. October 2005; Santiago, Chile. https://www.wma.net/wp-content/uploads/2005/09/Declaration-of-Lisbon-2005.pdf
Poorabhari-Langeroodi S, Asadinejad M. [Place the patient in medical decisions (Persian)]. Medical Law Journal. 2013; 7(27):11-36. http://ijmedicallaw.ir/article-1-174-en.html
Nekoei Moghaddam M, Amiresmaeili MR, Ghorbaninia R, Sharifi T, Tabatabaie SS. [Awareness of patients’ rights charter and respecting it from the perspective of patients and nurses: A study of limited surgical centers in Kerman city, 2013 (Persian)]. Bioethics Journal. 2014; 4(11):31-56. http://journals.sbmu.ac.ir/en-be/article/view/14179
Sharifi A, Jalali R, Shahbazi N. [Evaluation of awareness on the patient bill of rights and observing rate on the patient’s perspective in Imam Reza Hospital in Kermanshah in 2012 (Persian)]. Medical Law Journal. 2012; 6(23):125-35. http://ijmedicallaw.ir/article-1-72-en.html
Halawany HS, AlTowiher OS, AlManea JT, Abraham NB, Jacob V, AlMaflehi N. Awareness, availability and perception of implementation of patients’ rights in Riyadh, Saudi Arabia. The Saudi Journal for Dental Research. 2016; 7(2):132-7. [DOI:10.1016/j.sjdr.2016.04.003]
Dilawari PK. A study to assess level of facilitation of service delivery by observance of patient rights by healthcare workers & observance of duties by patients in public teaching hospital. International Journal of Applied Research. 2016; 2(5):106-12.
Zarzeka A, Boguszewska D, Kaczyńska A, Panczyk M, Belowska J, Gotlib J. Patients’ satisfaction with the observance of their rights by nurses. Paper presented at: Proceedings of EDULEARN15 Conference. 6th-8th July 2015; Barcelona, Spain. https://www.researchgate.net/publication/280076422
Younis AAH, Hassan AHA, Dmyatti EMEH, Elmubarak MAH, Alterife RAA, Salim REO, et al. Awareness and practice of patients’ rights among hospitalized patients at Wad-Medani Teaching Hospital, Sudan. Eastern Mediterranean Health Journal. 2017; 23(2):80-6. [DOI:10.26719/2017.23.2.80] [PMID]
Babamahmoodi F, Meftahi M, Khdemloo M, Hesamzadeh A. [Observation of patient’s right charter in Mazandaran teaching hospitals: Patients view (Persian)]. Medical Ethics and History of Medicine. 2011; 4(4):37-44. http://ijme.tums.ac.ir/article-1-165-en.html
Amani F, Moharami F, Seifi S, Moazzami R, Sadeghifard V. [Evaluation of rights compliance of patients in teaching hospitals in Ardebil (Persian)]. Caduceus. 2012; 2(2):27-37. https://eprints.arums.ac.ir/4925/
Ministry of Health and Medical Education. [The text of the law: Patients’ rights in Iran (Persian)] [Internet]. 2009 [Updated 2009 November 1]. Available from: http://heidari-hosp.umsha.ac.ir/uploads/4_258268267682988251_128148.pdf
Henderson E, Harada N, Amar A. Caring for the forensic population: Recognizing the educational needs of emergency department nurses and physicians. Journal of Forensic Nursing. 2012; 8(4):170-7. [DOI:10.1111/j.1939-3938.2012.01144.x] [PMID]
Potter PA, Perry AG, Hall A, & Stockert PA. (2017). Fundamentals of nursing. Ninth edition. St. Louis, Mo.: Mosby Elsevier.
Khezerloo S, Salehmoghaddam AR, Mazloom SR. [Assessment of nurses professional roles in hospitals affiliated to Mashhad University of Medical Sciences (Persian)]. Hakim. 2013; 15(4):346-51. http://hakim.hbi.ir/article-1-1082-en.html
Dehghani F, Shakeri M, Mohamad Salehi N, Ahmari Tehran H, Amini F, Vafaeimanesh J. Evaluating the Level of observance of patient charter of rights from the perspective of patients admitted to Shahid Beheshti Hospital in Qom. Health, Spirituality and Medical Ethics. 2015; 2(3):9-15. http://jhsme.muq.ac.ir/article-1-20-en.html
Amini A, Tabrizi JS, Shaghaghi A, Narimani MR. [The status of observing patient rights charter in outpatient clinics of Tabriz University of Medical Sciences: Perspectives of health service clients (Persian)]. Iranian Journal of Medical Education. 2013; 13(7):611-22. http://ijme.mui.ac.ir/article-1-2565-en.html
Ghazikhanlo Sani K, Farzanegan Z. [Evaluation of patient’s right charter observance in view point of personnel and patients in Radiology Wards of Hamadan’s educational hospitals in 2015 (Persian)]. Pajouhan Scientific Journal. 2016; 14(4):70-8. [DOI:10.21859/psj-140470]
Astaraki P, Mahmoudi GA, Anbari Kh, Hosseini n. [Evaluation of respect for patient’s rights from the viewpoint of hospitalized patients in Shohada Ashayer hospital of Khorramabad city in 2013-2014 (Persian)]. Yafteh. 2015; 17(1):5-14. http://yafte.lums.ac.ir/article-1-1841-en.html
Ghaljeh M, Khanjani N, Sajadi M, Latifi M, Dastoorpoor M. [Awareness from patient right patent and its observance from patients’ viewpoint (Persian)]. Journal of North Khorasan University of Medical Sciences. 2016; 7(3):657-68. [DOI:10.29252/jnkums.7.3.657]
Kalroozi F, Dadgari F, Zareiyan A. [Patients’ satisfaction from health care group in patient’s bill of right observance (Persian)]. Journal of Military Medicine. 2010; 12(3):143-8. http://militarymedj.ir/article-1-697-en.html