midwives and nurses awareness of patients’ rights
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Midwifery (2009) 25, 756–765
0266-6138/$ - sdoi:10.1016/j.m
www.elsevier.com/locate/midw
Midwives and nurses awareness of patients’ rights
M. Hakan Ozdemir MD (Associate Professor)a,�, I. Ozgur Can (Assistant Professor)a,Akc-a T. Ergonen (Assistant Professor)a, Ahmet Hilal (Associate Professor)b,Mustafa Onder (Specialist)a, Demet Meral (Specialist)b
aForensic Medicine Department, Dokuz Eylul University School of Medicine, Inciralti, Izmir 35340, TurkeybForensic Medicine Department, C- ukurova University School of Medicine, Adana, Turkey�Corresponding author. E-mail address: [email protected] (M. Hakan Ozdemir).
Received 16 July 2007; received in revised form 10 December 2007; accepted 20 January 2008
AbstractAim: to determine the level of awareness of patients’ rights among midwives and nurses working in the third andfourth largest cities in Turkey.Methods: cross-sectional descriptive survey conducted among participants working in university hospitals, statehospitals and village clinics. Questionnaires were distributed to 150 midwives and 350 nurses working in universityhospitals (n ¼ 200), state hospitals (n ¼ 100) and village clinics (n ¼ 100); 60% (n ¼ 298) of the forms were returned.Findings: fifty-one per cent (n ¼ 152) of midwives and nurses stated that they had not read any legislation related topatients’ rights. Seventy-five per cent (n ¼ 222) of respondents were aware of the legal arrangements. Only 34%(n ¼ 74) of participants who knew of any legal basis for patients’ rights said that legislation was in the form of adirective. No significant differences were observed in midwives’ answers compared with nurses’ answers.Conclusion: violation of patients’ rights and health professionals’ ignorance of appropriate practice means that thereis an urgent need to reconsider how to approach this issue. It should be included in continuing education programmes atboth graduate and postgraduate midwifery and nursing schools, and also demands more research.& 2008 Elsevier Ltd. All rights reserved.
Keywords Patient’s rights; Midwives and nurses; Legal responsibilities
Introduction
Different aspects of the relationships betweenmidwives or nurses and patients have been underscrutiny in a manner paralleling that of relation-ships between patients and physicians (Delph,1993; Watson, 1994; Teno et al., 1995; Chiltonet al., 1999; Ozdemir et al., 2000). New develop-ments in medical technology can have a profoundimpact on patients’ rights (Delph, 1993; Arda,2000; Ozdemir et al., 2006). Global developments
ee front matter & 2008 Elsevier Ltd. All rights reserveidw.2008.01.010
impacting on social, economic, cultural, politicaland ethical affairs have also affected our under-standing of what is meant by ‘human rights’.However, the fundamental reason for the impor-tance attached to patients’ rights, and the corre-sponding increase in legislation, is that respectingpatients’ rights is an essential part of providinggood health care (Dickens et al., 1991; Brody, 1992;Fletcher, 1992; Chilton et al., 1999; Patients’ RightsLaws in Europe, 2004; Ozdemir et al., 2006). As asignatory to the European Convention, Turkey has
d.
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Midwives and nurses awareness of patients’ rights 757
introduced its principles into domestic law. TheUK and Turkey have produced educational strate-gies and protocols for preventing the violation ofpatients’ rights after other European countries.Delaying their implementation presents no advan-tages for the UK, but Turkey is still grapplingwith the problems and has not yet managed toprevent violation of patients’ rights (Woogara,2001).
Turkey has an obligation to take up and imple-ment European legislation in the fields of occupa-tional health and safety, and public health(including provision for surveillance and control ofcommunicable diseases). In addition, the TurkishGovernment has a duty to take appropriate stepsfor the promotion of access to good quality healthcare, and a general improvement of the healthstatus of the population (EU State Planning Orga-nization, 2003).
There have been many declarations defining theimportance of the right to lead a healthy life(European Convention for the Protection of HumanRights and Fundamental Freedoms, 2005; UniversalDeclaration of Human Rights, 2005; WHO BasicDocuments, 2006). The Lisbon Declaration of WorldDoctors Association (Lisbon Declaration, 1981) wasthe first study to look specifically at patients’rights.
The World Health Organization published adetailed document (‘A Declaration on the Promo-tion of Patients’ Rights in Europe’) stating theprinciples and strategies of patients’ rights inAmsterdam (28–29 March 1994). Finland (1992),The Netherlands, Israel, Lithuania (1996), Denmark(1998), Norway (2000) and France (2002) have alldrawn up legislation covering patients’ rights(World Medical Association, 1991; Declaration onthe Promotion of Patient’s Rights in Europe, 1994;Francois et al., 2003; Patients’ Rights Laws inEurope, 2004; Ozdemir et al., 2006).
One of the main documents relating to thissubject is the European Charter of Patients’Rights (2002). Article 35 of the Charter providesfor a right to health protection in the form of a‘right of access to preventive health care andthe right to benefit from medical treatment underthe conditions established by national laws andpractices’.
The International Code of Ethics for Midwives(ICM Code) acknowledges women as individualswith human rights. The ICM Code seeks ‘justice forall people and equity in access to health care’. Italso stresses the importance of basing all relation-ships between health professionals and those theycare for on mutual respect, trust and the dignity ofall members of society (ICM, 2005).
The International Council of Nurses (ICN) Code ofEthics for Nurses was first adopted in 1953 and hasbeen revised several times. According to the ICNCode, nurses have four fundamental responsibil-ities: ‘to promote health, to prevent illness,to restore health and to alleviate suffering’(ICN, 2000). Both the ICM and ICN Codes put respectfor patients’ rights at the heart of the caringrelationship.
In Turkey, however, there has been neither aspecific code nor general legislation relevant tomidwifery and nursing covering the issue ofpatients’ rights. On the other hand, the legislationcovering this issue, the Patients’ Rights Directive(PRD), came into effect in 1998 (Patients RightsStatutes, 1998). This legislation covers proceduresas well as such principles as the right to benefitfrom health services, the right to be kept informedand the right to privacy (Nukhet and Erhan, 2004).The drawing up of this legislation was influencedby the European Biomedicine Act (Convention forthe Protection of Human Rights and Dignity of theHuman Being with Regard to the Application ofBiology and Medicine, 1997). In addition, theTurkish Medical Deontology Regulation (1960) andthe Medical Ethics Code of the Turkish PhysiciansAssociation (1998) cover some of the same essentialprinciples (Turkish Medical Deontology Regulation,1960; Medical Ethics Code of the Turkish PhysiciansAssociation, 1998; Nukhet and Erhan, 2004). ThePRD is known to be a definitive text for healthpersonnel, indicating how they should obey therules and what can be done about conditions(outside military hospitals) that violate patients’rights (Nukhet and Erhan, 2004).
Turkey has one general practitioner for every1441 people, one nurse for every 947 people andone midwife for every 1630 people (StatisticalHealth Data and Health Reports of Turkey, 2006).Midwives and nurses work under the line manage-ment of physicians, in accordance with Turkish lawsand directives. Health-care services are more likelyto be found in urban areas than rural areas, andalmost half of all physicians are employed in thecountry’s largest cities (Tokat, 1997; Tezcan, 2001).For this reason, this study was undertaken in Izmirand Adana, the third and fourth largest cities inTurkey.
A report from Turkey states that only 23% ofpatients were able to recognise their rights, andthis showed significant differences related toeducational level categories (Zulfikar and Ulusoy,2001). In another study, the participants werefound to ignore the fact that special regulationsexist regarding their rights (S-ahbudak, 1992).In a study conducted in Greece, the right to
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M. Hakan Ozdemir et al.758
confidentiality was not considered as a right ofprivacy and many patients allowed their doctors tomake decisions; 84% of patients were not aware oflegislation. It was also stated that 60% of patientsdid not have any idea about their rights (Mreakouet al., 2001). Another study found that 60% ofpatients were not aware of the European Conven-tion of Human Rights (Woogara, 2001).
The PRD has principal elements in common withthe standards of ethical conduct outlined in the ICNCode (Patients Rights Statutes, 1998). Turkishpatients’ rights legislation resembles that found inmany other countries (Patients Rights Statutes,1998; Nukhet and Erhan, 2004; Patients’ RightsLaws in Europe, 2004; Ozdemir et al., 2006), all ofwhich have been drawn up in the light of theEuropean Biomedicine Act and the Declaration onthe Act of Patient Rights in Europe (Declarationon the Promotion of Patient’s Rights in Europe,1994; Convention for the Protection of HumanRights and Dignity of the Human Being withregard to the Application of Biology and Medicine,1997).
The Turkish Ministry of Health has been develop-ing new legislation that will enable the PRD to takepractical effect. The ethical codes all make thepoint that nurses, being both health professionalsand citizens, should initiate and support the actionneeded to meet the health and social needs ofmembers of the public (American Nurses Associa-tion Statement, 1994; ICN, 2000). Among healthprofessionals, it is accepted that the greatestresponsibility for preserving patients’ rights lieswith physicians, midwives and nurses. Therefore,the midwifery profession has a duty to gain theappropriate knowledge and develop the necessaryawareness and sensitivity to uphold the rights oftheir patients.
Some authors believe that nurses have moreresponsibility than physicians in this regard. Theargument is that nurses spend more time on routinedaily jobs with patients compared with physicians,and that, in consequence, patients feel closer tonurses (Zulfikar and Ulusoy, 2001). This study alsoexplored the attitudes of midwives and nurses tothe relationship between patients and health-careprofessionals.
The aim of this study was to determine the levelof awareness about legislation concerning patients’rights among midwives and nurses working intraining hospitals. This study breaks new groundin that it is specifically concerned with the powersand duties of midwives and nurses in Turkey, asubject that has not been covered previously in theliterature (Houlihan, 1983; Nukhet and Erhan,2004).
Materials and methods
This cross-sectional descriptive survey was financedby Dokuz Eylul University Research Fund Accoun-tant’s Office (Project No. 0909.20.02.11).
The study focused on midwives and nursesworking in medical faculties, state and privatehospitals and village clinics in the provinces ofAdana and Izmir. Having explored other possiblemethods, the authors decided to use a question-naire because this method seemed particularlyappropriate for researching the attitudes ofmidwives and nurses in two cities in Turkey. Italso appeared to be indicated by the findingsof the background literature. An initial pilotstudy was carried out in primary health-careclinics with 15 midwives and nurses, who wereasked to feedback information regarding whetherthe questionnaire worked well. There was onlyone negative comment related to the question-naire, which was that it was too long. Anothersimilar questionnaire was sent to clinicians,and this appeared to work well (Ozdemir et al.,2006). Questionnaires have the advantages ofbeing cheap to administer, and often havestandardised answers that make data compilationstraightforward.
Subjects were selected by the random samplingmethod. The questionnaires, each of which had 20multiple choice questions, were distributed by anassistant and a specialist physician from theDepartment of Forensic Medicine in the MedicalFaculty of Dokuz Eylul University. In total, 500questionnaires were distributed to prospectiveparticipants: 150 midwives and 350 nurses workingin university hospitals (n ¼ 200), state hospitals(n ¼ 200) and village clinics (n ¼ 100).
The questionnaire was given to participantsafter they had received relevant information aboutthe study. Written consent was not obtainedbecause all participants were adults, and con-sent to participate was considered to be implied bycompletion of the questionnaire. A short noteaccompanying the questionnaire explained thevoluntary and anonymous nature of the study.
Questions were administered in the follow-ing sequence: demographic data, participants’level of knowledge, and awareness about legalarrangements pertaining to patients’ rights inTurkey.
The Ethical Council of Dokuz Eylul UniversitySchool of Medicine Clinics and Laboratory Researchapproved this study (30.03.2004 and 05/05/04).
Data obtained from the questionnaires wereanalysed by w2-test using Statistical Package forthe Social Sciences Version 10.0.
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47.7%
36.6%
7.1%
51.9%45.2%
11.5%
0102030405060708090
100
Nurses (%)
State hospital
Village clinics
University
Midwives (%)
Figure 1 Distribution of midwives and nurses accordingto their institutions.
Midwives and nurses awareness of patients’ rights 759
Limitations
Limited ethical issues arose in the course of thestudy, such as how to perform the study anon-ymously and ensure reliable, honest answers.Questionnaires were delivered to the clinics, withthe intention of collecting them in 2 days. However,getting the questionnaires completed and returnedwas far from easy. Sometimes, participants wereunable to complete the questionnaire because oftheir heavy workload. There were also financialcosts associated with collecting the completedquestionnaires. In addition, the collection processwas very time consuming. Another problem wasthat some respondents did not complete thequestionnaires completely, or failed to providethe necessary demographic data, which could havedistorted the findings. Participants who providedinsufficient or defective demographic data or whodid not answer sufficient questions were excludedfrom the study. As the questionnaire study waslimited to quantitative research by responses givento questions, triangulation was not possible in theabsence of qualitative inquiry.
Findings
Of the 500 midwives and nurses who were givenquestionnaires, 298 (60%) completed the formscorrectly, answered nearly all of the questions andreturned the forms.
Of the participants, 99% (n ¼ 296) were femaleand 0.7% (n ¼ 2) were male. The mean age was32.35 years [range 21–55, S.D. 6.98]. Among theparticipants, 81% (n ¼ 241) were nurses and 19%(n ¼ 57) were midwives. The distribution ofmidwives and nurses according to their institu-tions is shown in Figure 1. The participantshad an average of 12 years of service in thehealth profession (range 2 months to 33 years,S.D. 7.2).
After the first four questions related to demo-graphic data, the questionnaire asked whethereverybody had the right to self-determination,i.e. to make free decisions regarding himself/herself (Question 5); 60% (n ¼ 180) of respondentsstated that a patient did have this right if he/shewas ‘an adult and conscious’, as specified by thePRD. This was the only question where there was asignificant difference in the answers from respon-dents in different age groups (w2 ¼ 14.104,p ¼ 0.000). Of the participants who had read anylegislation relating to patients’ rights [48.6%(n ¼ 144)] in Turkey, 55.6% (n ¼ 80) answered thisquestion in accordance with the PRD.
Ninety-nine per cent (n ¼ 294) of participantsmade the point (Question 6) that patients have theright to be informed about how to use their healthservice; an answer that correlates positively withthe guidance in the PRD. Similarly, of the partici-pants who had read any legislation relating topatients’ rights (n ¼ 144), 99% (n ¼ 142) answeredthis question in accordance with the PRD.
Thirty-four per cent (n ¼ 100) of participantsstated that patients had the right to change whichinstitution they attended for health care and theright to freedom of choice (Question 7) undercertain limited conditions, while 66% (n ¼ 197)claimed that patients should have this right at alltimes. The proportion of answers consistent withthe PRD was low (although not statistically sig-nificant) among participants working in villageclinics. Of the participants who had read anylegislation relating to patients’ rights (n ¼ 144),30.6% (n ¼ 44) answered this question in accor-dance with the PRD.
Regarding whether patients had the right to askfor a different midwife or nurse to provide care forthem if they were unsatisfied with the care theywere receiving (Question 8), 63% (n ¼ 187) be-lieved that patients did have this right. Correspon-dence with the answers specified by the PRD wasfound to be high, but not statistically significantamong midwives. Statistical significance was ob-served in the consistent answers given to thisquestion between 88% (n ¼ 38) of participantsworking in village clinics and 59% (n ¼ 149) ofparticipants working in state or university hospitals(w2 ¼ 13.537, p ¼ 0.00). Of the participants whohad read any legislation relating to patients’ rights(n ¼ 143) in Turkey, 64% (n ¼ 92) answered thisquestion in accordance with the PRD.
In response to Question 9, 293 (99%) participantssaid that patients had the right to receive appro-priate health care in accordance with modern
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Table 1 Distribution of participants who had readany legislation related to patients’ rights regardingtheir awareness of the form of the legislation.
Legislation was in the form of Total
Directive Other
Read 50 (35%) 94 (65%) 144 (100%)Not read 27 (18%) 127 (82%) 154 (100%)
Total 77 (26%) 221 (74%) 298 (100%)
w2 ¼ 5.717, p ¼ 0.017.
M. Hakan Ozdemir et al.760
technology and science, while only four (1%)respondents stated that patients had no such right.Statistical significance was observed in the answersconsistent with the PRD between 239 nurses (99.6%responded correctly) and 54 midwives (94.7%responded correctly) (w2 ¼ 8.143, p ¼ 0.04). All ofthe participants who had not read any legislationrelating to patients’ rights answered this questionin accordance with the PRD.
When asked whether the patient or relativehad the right to want euthanasia in Turkey(Question 10), 52% (n ¼ 152) of participants statedthat they had this right according to the PRD andPenal Code. Of the participants who had read anylegislation relating to patients’ rights (n ¼ 143) inTurkey, 53% of them (n ¼ 76) stated that euthanasiais forbidden, as specified by the PRD.
When asked whether it was necessary to informthe patient prior to any medical treatment (Ques-tion 11), 99% (n ¼ 294) of participants said that itwas necessary, as specified by the PRD. When askedwhether it was necessary to gain a patient’sinformed consent prior to any medical treatment(Question 12), 93% (n ¼ 276) of participants statedthat it was necessary, while 7% (n ¼ 20) said that itwas only necessary prior to surgical procedures.The rate of appropriate answers was found to behigh among participants working in village clinics(97.7%).
When asked whether the patient had the right toreview his/her medical records and have themphotocopied (Question 13), only 11% (n ¼ 33)provided a negative answer.
When asked whether patients had the rightto keep their medical records confidential(Question 14), 97% (n ¼ 286) of participants said thatthey should be kept confidential if the patient wished.
When asked whether the relatives of patients hadrights about keeping information pertaining to adeceased patient confidential (Question 15), 91%(n ¼ 266) of participants stated that relatives ofpatients had the right to keep information con-fidential even after their death. When askedwhether information pertaining to a patientcould be shared with relatives with permission(Question 16), the rate of answers consistent withthe PRD was found to be high (86%) amongparticipants working in village clinics (n ¼ 38 of44 participants), with a statistical significantdifference observed in the answers given to thisquestion between 76 (67% of university workers)participants working in university hospitals and 145(80% of others) participants working in villageclinics and state hospitals (w2 ¼ 5.717, p ¼ 0.017).Of the participants who had read any legislationrelating to patients’ rights (n ¼ 143) in Turkey, 74%
(n ¼ 106) answered this question in accordancewith the PRD.
Question 17 asked whether the consent ofa patient aged under 18 years was necessary ifhis/her guardian had already given consent for amedical procedure. The rate of answers consistentwith the PRD was found to be high (not statisticallysignificant) among people working in state hospitals(80%). The rate of answers consistent with the PRDalso seemed to be high (not statistically significant)among participants who stated that they had readthe relevant PRD.
When asked whether they knew about thelegal position regarding patients’ rights in Turkey(Question 18), 75% (n ¼ 222) of participants whoanswered this question stated that they wereinformed about legal sanctions, while only 25%(n ¼ 76) said that they did not know. The rate ofanswers corresponding to those specified by thePRD was high among people working in villageclinics (83%, 34/44 participants), but no statisticalsignificance was observed in the answers given tothis question with respect to age, what areas theyworked in, and whether they were nurses ormidwives. Of the participants who knew aboutthe legal position regarding patients’ rights(n ¼ 222), 56.8% (n ¼ 126) stated that they hadread any legislation relating to this issue.
Only 33.8% (n ¼ 74) of participants who knewof any legal basis for patients’ rights said thatthese legislations were in the form of the PRD(Question 19). A high number of participants whohad read any legislation relating to patients’rights were unaware of the PRD, and these findingswere statistically significant (Table 1). A highnumber of participants who had read any legisla-tion relating to patients’ rights were unawarethat these were in the form of ‘directives’and these findings were statistically significant(Table 1).
Answers to Question 20 indicated that 51%(n ¼ 152) of respondents had not read any
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Midwives and nurses awareness of patients’ rights 761
legislation relating to patients’ rights in Turkey.Statistical significance was observed in the answersgiven to this question between 47 (41% of universityworkers) participants working in university hospi-tals and 97 (54% of others) participants working instate hospitals and village clinics (w2 ¼ 4.279,p ¼ 0.039).
Overall, there was no statistically significantdifference between participants who had read thePRD and those who had not. The distribution ofparticipants according to their institutions andnumber of answers consistent with the PRD isshown in Table 2.
In the answers given to all the questions (exceptQuestion 5), no statistical significance was ob-served with respect to age.
Table 2 Distribution of participants according to their inPatients’ Rights Directive (PRD)�.
Univer
ConsistentwithPRD
Right to self-determination: w2 ¼ 0.000,p ¼ 1.000
69
Right to be informed: w2 ¼ 0.322,p ¼ 1.000
114
Right to change the health service:w2 ¼ 0.355, p ¼ 0.551
37
Right to change midwife or nurse:w2 ¼ 0.003, p ¼ 0.953
73
Right to use health care using moderntechnology and science: w2 ¼ 0.327,p ¼ 1.000
114
Right to euthanasia: w2 ¼ 0.138, p ¼ 0.710 57Right to inform the patient prior to anymedical treatment: w2 ¼ 0.217, p ¼ 0.642
113
Necessary to take informed consent:w2 ¼ 0.016, p ¼ 0.898
108
Right to review medical records:w2 ¼ 1.462, p ¼ 0.227
104
Right to keep medical recordsconfidential: w2 ¼ 0.004, p ¼ 1.000
110
Right to keep information confidentialeven after death: w2 ¼ 0.127, p ¼ 0.722
103
Confidential information could be sharedwith relatives with permission:w2 ¼ 5.717, p ¼ 0.017��
76
Necessary to obtain consent of a patientaged under 18 years :w2 ¼ 2.937,p ¼ 0.087
80
�Questions including demographic data and awareness and info��Statistically significant.
The significant differences found between theanswers consistent with the PRD, along with thevariables, are shown in Table 3.
Discussion
A survey by Chamberlain stated that 90% of nursesknew of the existence of the Universal Declarationof Human Rights, and 59% of nurses knew about theICN Code (Chamberlain, 2001). In recent years, theICN has drawn up several policy statements onhuman rights. Altun and Ersoy (2003) conducted astudy among first year and final year students at aschool of nursing and midwifery. Almost all of thesestudents stated that access to health care should
stitutions and number of answers consistent with the
sity hospitals State hospitals and villageclinics
Inconsistentwith
Consistentwith
Inconsistentwith
PRD PRD PRD
46 110 72
1 179 3
78 66 116
41 114 67
1 178 3
56 94 822 180 2
7 168 13
9 157 24
3 175 5
9 162 18
37 145 37
31 112 70
rmation questions were excluded.
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Table 3 Midwives’ and nurses’ answers and variables.
Questions related to patients’ rights Number of correct repliesas specified in the Patients’
Rights Directive (%)
Significant differences betweenanswers along with variables
Beingmidwifeor nurse
Employed inuniversity orstate hospital
Years ofemployment
Right to self-determination 180 (60%) � � +�
Right to be informed 294 (99%) � � �
Right to change the institution providing healthservice
197 (66%) � � �
Right to change the nurse or midwife providinghealth service
187 (63%) � � �
Right to take health service adjusted withmodern technology and science
293 (99%) +� � �
Right to want euthanasia in Turkey 152 (52%) � � �
Right to inform the patient prior to any medicaltreatment
294 (99%) � � �
Necessary to take informed consent 276 (93%) � � �
Right to review medical records and have themphotocopied
265 (89%) � � �
Right to keep medical records confidential 286 (97%) � � �
Right to keep information confidential evenafter death
266 (91%) � � �
Confidential information could be shared withrelatives with permission
221 (75%) � +� �
Necessity for the consent of a patient agedunder 18 years even if his/her guardian hadalready given consent for a medical procedure
192 (65%) � � �
�These results showed statistically significant differences (po0.05), detailed in the text.
M. Hakan Ozdemir et al.762
be a right for all individuals (Altun and Ersoy, 2003).In the present study, 78% of the participantsworking in teaching hospitals claimed that theyalready knew of the legal basis of patients’ rights inTurkey. While these findings indicate a highpercentage of awareness of patients’ rights amongmidwives and nurses in Turkey, this study didnot seek to research the level of awarenessamong midwives and nurses about internationaldeclarations and professional codes. Table 3 showsthe opinions of participants concerning patients’rights.
More than one-quarter (n ¼ 77) of the partici-pants were aware that the legal arrangements werein the form of a set of ‘directives’ (Table 1).However, it is the authors’ belief that the partici-pants did not fully understand what they werereading. The proportion of participants whoseanswers were in accordance with the principlesoutlined in the PRD varied from 23% to 100%. Thisled the authors to believe that the midwives andnurses participating in this study made moreappropriate assessments than the participants in
another study (8–96%) carried out among 567physicians (Ozdemir et al., 2006).
Nearly all of the participants in the present studywere aware that every individual has the right toaccess all forms of information regarding their ownstate of health, the health services and how to usethem, and all that scientific research and techno-logical innovation makes available. Altun and Ersoy(2003) reported that 72% of the nurses in theirstudy stated that patients have the right to knowthe truth about their condition, and nearly all ofthem stated that patients have the right toparticipate in decisions affecting their care. Thisis in accordance with the findings of the presentstudy.
Patients have the right to choose freely andchange his/her physician and hospital or healthservice institution, regardless of whether ornot they are based in the private or public sector(ICN, 2000; European Charter of Patients’ Rights,2002; ICM, 2005). Although nearly all of theparticipants in this study said that patients havethe right to freedom of choice regarding health
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service institutions and midwives and nurses, only34% knew that patients only had this right underlimited situations, as specified by the PRD.
According to Altun and Ersoy (2003), over one-third of nurses stated that physicians and nursesshould be allowed to perform euthanasia when thisis requested by patients. The outcomes of theirstudy demonstrated a need to explore this topicfurther in midwifery and nursing education, as doesthe present study which reported that half of theparticipants would allow euthanasia. Kowalski(1997) and Tanida et al. (2002) reported that 44%and 20% of nurses, respectively, believed thatactive euthanasia was permissible under certaincircumstances. The present study findings were notin accordance with these studies. In the PRD andPenal Code, euthanasia is forbidden; however, only53.1% of the participants were aware of this.
In the present study, nearly all of the participantswere aware of the significance of informed con-sent, although the percentage level of awarenesswas considerably higher in village clinics thanteaching hospitals. This finding was surprising giventhat training programmes on this issue are run inteaching hospitals. However, simply reading therelevant Turkish legislation seemed to be sufficientto ensure this awareness.
Complete information should be given to, andunderstood by, women regarding the risks, benefitsand probable outcomes of each available choice(ICM, 2005). In the present study, 93% (n ¼ 276) ofthe participants answered the questions related toobtaining informed consent in accordance with thePRD. This rate was maintained at the medicalfaculty hospitals, contrary to the findings of an-other study carried out among physicians (Ozdemiret al., 2006).
Altun and Ersoy (2003) reported that 20% of thenurses in their study stated that children aged over7 years should participate in their own decision-making process, but after training programmes, therate of correct answers increased such that almosthalf of the nurses agreed with the statement. Morethan half of the midwives and nurses in the presentstudy agreed with this statement. These findingsand those of Altun and Ersoy (2003) suggest that thenumber of years spent working as a health-careprofessional and improved midwifery and nurseeducation training in Turkey may be affectingmidwives’ and nurses’ attitudes to patients’ rights.
Confidential information in a patient’s recordsabout a third party should not be given to thepatient without the consent of that third party. It ispointed out that all identifiable information abouta patient’s health status, medical condition,diagnosis, prognosis and treatment, as well as all
other information of a personal nature, must bekept confidential, even after death (AmericanNurses Association Statement, 1994; Davis, 1999;ICN, 2000; European Charter of Patients’ Rights,2002; Altun and Ersoy, 2003; American NursesAssociation Ethical Issue, 2004; Claire and Martino,2005; ICM, 2005). Ninety-one per cent of partici-pants in the present study agreed with thisstatement. This outcome is in accordance withthe findings of Altun and Ersoy (2003). A studyconducted in Finland suggested that patients’rights regarding privacy protection may be bettersecured in university hospitals than in statehospitals (Leino-Kilpi et al., 1997). This findingwas explained by availability of examination roomsand by the provision of advanced information topatients. In sharp contrast to the Finnish study,nearly all of the participants in the present studymade appropriate assessments about subjects’right to confidentiality and information, and itwas shown that patients’ rights are well covered instate hospitals in Turkey (Questions 13–16).
The present study found that midwives andnurses showed more support than medical studentsfor informed consent and patients’ involvement inmaking decisions about their treatment. More thanhalf of the nurses supported the idea that patientshave a right to be informed about their illness(Altun and Ersoy, 2003). This outcome is inaccordance with other studies (Ozdemir et al.,2006).
Implementation of patients’ rights should not besomething that restricts the practice of medicine.Rather, it can both contribute to the improvementof health-care practices, and achieve an equaldistribution of responsibility between patient,physician and nurse. However, this study foundthat midwives and nurses are sufficiently informedof the legal arrangements pertaining to patients’rights in Turkey, and that problems have been risingwith the implementation of patients’ rights.
Legal and ethical issues and subjects relating tohuman rights now form part of the curriculum inmidwifery and nursing schools in Greece (Mreakouet al., 2001). A course in midwifery and nursing andmidwifery ethics or deontology is included in thecurriculum of all midwifery–nursing schools inTurkey. In addition, physicians and midwives havea duty to respect patients’ rights in Turkeyaccording to the Patients’ Bill of Rights. Someauthors have suggested that ethics training as partof basic midwifery education is an effective meansof developing the advocacy role (Altun and Ersoy,2003; Nukhet and Erhan, 2004). Human rights andpatients’ rights issues have been taught in a specificmodule within the course on domestic violence and
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M. Hakan Ozdemir et al.764
sexual assault (problem-based learning) for mid-wives and nurses at the School of Nursing, DokuzEylul University (Curriculum Programme, 2006).
Violation of patients’ rights and health profes-sionals’ ignorance of appropriate practice meanthere is an urgent need to reconsider how toapproach this issue.
�
It is imperative to include this particular issue incontinuing education programmes of both grad-uate and postgraduate midwifery and nursingschools, and the topic demands more research(American Nurses Association Statement, 1994;Davis, 1999; Chamberlain, 2001; Davis andJameton, 2002; American Nurses AssociationEthical Issue, 2004; Claire and Martino, 2005;Council of Europe Recommendation, 1985;Ozdemir et al., 2006). In addition, new legisla-tion drafted by the Ministry of Health could putthe PRD into practice. � Implementation of patients’ rights only seemspossible when people who provide or receivehealth care, and institutions where health care isprovided, have reached the desired levels ofinformation and consciousness. Implementationof these rights should not be considered theresponsibility of health-care professionals alone.There are still many problems in the healthservices, and a new study could be designed toinvestigate this issue further.
� Midwives are crucial members of the health-careteam. Their role in the implementation ofpatients’ rights cannot be ignored (Altun andErsoy, 2003; Nukhet and Erhan, 2004). Indeed, ofall health-care workers, midwives and nurses arein a particularly appropriate position to protectand promote the rights of their patients.
� Information and opportunities to learn aboutissues such as the definition and reinforcementof patients’ rights should be available to every-one, not just health-care professionals orpatients (Human Rights Education Associates,2000). Mass communication media, health-careinstitutions, educational institutions, medicalcompanies, political parties and religious groupsshould all have an important role to play in thereinforcement of patients’ rights.
� Health-care workers must learn to enablepatients to recognise their rights. They will alsoneed training in how to put the theory aboutpatients’ rights into practice. Appropriate edu-cation and training programmes should be avail-able for all relevant health-care workers.Further studies measuring health-care workers’attention to patients’ rights and related topicsare necessary in Turkey.
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