Microsoft Word - 3 Journal of Medical Ethics and History of Medicine       Occupational therapists and patients’ rights: their level of Clinical  knowledge   Leila Dehghan1, Hamid Dalvand1*, Hojjat Allah Haghgoo2, Seyed Ali Hosseini3 and Masoud Karimlou4   1PhD student of Occupational Therapy, Department of Occupational Therapy, University of Social Welfare & Rehabili- tation Sciences, Tehran, Iran; 2Assistant Professor, Department of Occupational Therapy, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran; 3Associate Professor, Department of Occupational Therapy, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran; 4Associate Professor, Department of Biostatistics and Computer Science, University of Welfare & Rehabilitation, Tehran, Iran.  Corresponding Author: Hamid Dalvand Address: Koodakyar Ave, Daneshjoo Blvd, Evin. Department of Occupational Therapy, University of Social Welfare & Rehabilitation Sciences, Tehran, Iran. Postal Code: 1985713834 Tel: +989122063968 fax: +982122180018 E-mail: hamiddalvand@gmail.com , h.dalvand@uswr.ac.ir Received: 20 Aug 2012 Accepted: 14 Jan 2013 Published: 22 Jan 2013 J Med Ethics Hist Med, 2013, 6:3 http://journals.tums.ac.ir/abs/22986 © 2013 Leila Dehghan et al.; licensee Tehran Univ. Med. Sci. Abstract Addressing patients’ rights issues brings occupational therapists ethical and political responsibilities that  involve  patients’ privileges and new facilitating factors which influence their needs. The goal of this study was to deter‐ mine the level of occupational therapists’ knowledge about patients’ rights.  The present research was a cross‐sectional study which involved 125 occupational therapists chosen by a conven‐ ience sampling strategy in Tehran during the year of 2012. A four‐part questionnaire was used for data collection,  and the degree of the subjects’ self‐assessment of their knowledge was measured based on the obtained numbers  of correct answers in the third part. The validity and reliability of this questionnaire were assessed prior to its being  distributed among participants.   The results demonstrated no significant association between the level of occupational therapists’ knowledge about  patients’ rights and their existing experiences within their areas of occupational therapy (P>0.05). Based on the  result,  53.6%  of  the  respondents  had  high  level  of  knowledge  about  patients’  rights.  Facilitating  factors  which  influence the attainment of patients’ rights were classified into three groups: organizations, therapists and clients.   The  results  of  the  present  research  demonstrated  that  the  level  of  occupational  therapists’  knowledge  about  patients’ rights were high. Furthermore, this study showed that for optimal result, there is a need to provide milieu  for observing the patients’ rights in clinical occupational therapy services.    Keywords: Occupational therapy, Patients’ rights, Medical ethics Leila Dehghan et al. J Med Ethics Hist Med 6:1 jmehm.tums.ac.ir January, 2013  Page 2 of 6 (page number not for citation purposes)     Introduction The patients’ rights movement have promoted patient involvement in health care for 50 years (1). Patients’ rights encompass legal and ethical issues in the provider-patient relationship, including a person’s right to privacy, the right to quality medical care without prejudice, the right to make informed decisions about care and treatment options, and the right to refuse treatment. The Patients’ Rights Charter of Iran was ap- proved by Health Policy Council with a new and comprehensive viewpoint which aimed to clarify the rights of the health service recipients and ensure observance of moral standards in the treatment and medical fields on November 26, 2009, and on December 1st of the same year, it was corresponded to all relevant centers (2, 3). One of the health services which patients may get involved in is occupational therapy (OT). According to the World Federation of Occupational Therapy (WFOT), OT is a client-centered health profession which concerns promoting the health and well-being of patients through their occupation. Professional ethics and standards for regulating ethical conduct will reinforce level of confidence between patients and health professionals in OT, which in turn will result in protection of communi- ty (4). Galheigo reported in 2011 that occupational therapists and scientists need to be attentive of human rights issues (5) and they must provide a supportive environment which facilitates patients’ efforts in getting involved in their own health care services (6). Nowadays, people’s public health information and awareness of patients’ rights has increased. Furthermore, observing patients’ rights may help to achieve more satisfaction among patients and the medical team, while not observing these rights would lead to distrust, damages and losses in the patients and the medical team. Hence, OT professionals must be aware of patients’ rights and try to observe them. Up to the present time, no descriptive study has been reported in Iran in regard to the relationship between occupational therapists’ work experience, their educational level and level of their knowledge about patients’ rights in all areas of their clinical practice. Therefore, this study was conducted to examine the level of occupational therapists’ knowledge about patients’ rights in this effective health care professional service. Method The present research was a descriptive, analytic, and cross-sectional study. The study samples consisted of 125 occupational therapists that were chosen by convenience sampling strategy from rehabilitation clinics under the supervision of the University of Social Welfare Rehabilitation Sciences (USWR) and departments of OT in the School of Rehabilitation of USWR, Tehran University of Medical Sciences and Shahid Baheshti University of Medical Sciences. The sample size determined for the current study was five participants per variable (7). Occupational therapists with more than six months’ work experience were included. The study was approved by the ethical committee of USWR, and all participants were informed about study objectives and their written and signed informed consents were obtained. Questionnaires were anonymized and the information got collected privately by the researchers. The data collection instrument was a question- naire designed by the researchers and consisted of four-parts: the first part included demographic information (age, gender, work experience, educational level); the second part consisted of five questions about participants’ self-assessment of their knowledge about deputy police of the medical council Medical Council of Islamic Republic of Iran, legal rules and regulations, ethics committee of medical council, OT code of ethics and Patients’ Rights Charter of Iran; the third part consisted of 20 questions based on ten sections of the Patients’ Rights Charter of Iran (8) and the last part included an open question about facilitating factors involved in patients’ rights. The participants’ answers to the questions of the third part were quantified based on a four-score scale: “high” (4 scores), “moderate” (3 scores), “low” (2 scores) and “none” (1 score). The validity was assessed using content validity. The question- naire was given to 10 faculty members of USWR and their comments were applied accordingly. The reliability was examined using a test-retest method in which the questionnaire was given to 10 eligible participants twice with a 10-day interval, and the respective interclass correlation coefficient (ICC) of the first and second answers obtained was 0.82 (95% CI, 0.146 - 0.951). These eligible participants were excluded from the main study population. The questionnaires were completed within three months in target clinics and universities. Obtained quantitative data were expressed as mean±SD. One-way analysis was used for comparing scores of occupational therapists’ knowledge of patients’ rights according to educational level, areas of practice in occupational therapy and work experi- ence. All statistical analyses were done using SPSS 16.0 statistical software (SPSS Inc, Chicago, IL). Results Demographic data of the participating occupa- tional therapist, including their gender, educational levels, different areas of clinical practice and periods of their work experiences are shown in Leila Dehghan et al. J Med Ethics Hist Med 6:1 jmehm.tums.ac.ir January, 2013  Page 3 of 6 (page number not for citation purposes)     table 1. As it is illustrated, the majority of these participants were females (59.2%). The participants’ self-assessment of their knowledge about deputy police of the Medical Council of Islamic Republic of Iran, legal rules and regulations, ethics committee of medical council and OT code of ethics (second part of the question- naire) are shown in table 2. Furthermore, the sum of the scores based on answers to the questions in the third part of the questionnaire showed 67 (53.6%) of respondents had scores above the median, hence, 67 (53.6%) of occupational therapists had high level of knowledge about sections of Patients’ Rights Charter of Iran. It should be noted that the calculat- ed median score was 62. There was no significant difference between male and female participants’ knowledge of Patients’ Rights Charter of Iran (P>0.05). Likewise, we could not find a relationship between occupa- tional therapists’ knowledge of Patients’ Rights Charter of Iran and their educational level, areas of practice in OT and periods of their work experience (Table 3). Table1. Demographic data of the occupational therapists Variables n (%) Sex Male 51 (40.8%) Female 74 (59.2%) Educational level Bachelor 32 (25.6%) Master student 48 (38.4%) Master 30 (24%) PhD student 15 (12%) Areas of practice Child 69 (55.2%) Adult 34 (27.2%) Psychosocial 22 (17.6%) Work experience < 5 years 65 (52%) 5-10 years 20 (16%) >10 years 40 (32%) Table 2. Level of occupational therapists’ knowledge about general information of ethics Variables High Moderate Low None N (%) N (%) N (%) N (%) How much do you know about the deputy police of the Medical Council of Islamic Republic of Iran? 7 (5.6) 18 (14.4) 19 (15.2) 81 (64.8) How much do you know about the rules and regula- tions of the Ministry of Health and Medical Education? 9 (7.2) 26 (20.8) 44 (35.2) 46 (36.8) How much do you know about the ethics committee of the Medical Council? 9 (7.2) 20 (16) 30 (24) 66 (52.8) How much do you know about the code of ethics in OT? 9 (7.2) 24 (19.2) 20 (16) 72 (57.6) How much do you know about the Patients’ Rights Charter of Iran? 33 (26.4) 33 (26.4) 33 (26.4) 26 (20.8) Table 3: The level of occupational therapists’ knowledge about patients’ rights Occupational therapists’ knowledge about patients’ rights Mean  SD F P value Educational level Bachelor 61.81  8.97 2.268 0.084* Master student 61.58  9.02 Master 59.33  8.34 PhD student 66.73  10.05 Areas of practice in OT Child 61.89  8.38 2.348 0.102* Adult 63.58  8.62 Psychosocial 58.27  11.31 Work experience < 5 years 61.78  9.19 1.999 0.140* 5-10 years 58.35  7.66 >10 years 63.30  9.41 *P> 0.05 was considered as non significant. Leila Dehghan et al. J Med Ethics Hist Med 6:1 jmehm.tums.ac.ir January, 2013  Page 4 of 6 (page number not for citation purposes)     In the next step, regression analysis was per- formed to determine the relationship between total scores of occupational therapists’ knowledge about patients’ rights and sex, educational level, areas of practice in OT and work experience. The obtained results showed that the sex, educational level, areas of practice in occupational therapy and work experience did not have any significant correlation with occupational therapists’ knowledge of patients’ rights (P>0.05). Finally, participants’ answers to open-ended questions about facilitating factors of patients’ rights were categorized. These factors were classified in three groups of factors related to the organization, therapists and clients (Table 4). Table 4: Facilitating factors promotion of patients’ rights Groups Factors N Factors related to the organiza- tion Approval of health insurance 95 Patients’ Rights Charter installed in occupational therapy clinics 50 Ethical committee 38 Dealing with the welfare state of the therapist 23 Careful monitoring of therapeutic interventions 18 Enough staff 21 Consultancy and social work units 9 Factors related to the thera- pists Ethics curricula for undergraduates 85 Workshops for therapists 54 In-service training 32 Using an evidence-based rehabilitation 16 Factors related to the clients Increasing patients’ knowledge of their rights 89 Discussion One of the most important components of pa- tients’ rights is to provide an ethical and humanistic care. European regional office of the World Health Organization (WHO) states that promoting patients’ rights is a multi categorized topic, and goals should be followed through multilateral efforts. In addition, WHO has presented solutions to this issue, most of which involve active partici- pation by both the service recipients and service providers in formulating health policy and develop- ing training programs, specifically for service providers and the entire community (9). Based on the findings of the present study, more than half of the participants had a high level of knowledge in regard to patients’ rights, especially concerning issues of preserving patients’ privacy, the right to receive respectful and prompt care despite cultural and racial differences and also the right to permit the presence of those who are not directly involved in the treatment process. The present results were more consistent with previous studies, which have shown that health care professionals have a high level of knowledge about their patients’ rights (8, 10, 11). On the other hand, the level of knowledge about patients’ rights do not correlate directly to their observance (10, 12). Liedó showed that 84% of professionals know the patients’ rights, but a mere 64.4% observe them (10). Arnetz also showed that physicians, registered nurses, and practical nurses did not differ signifi- cantly in their views of patient involvement, but did differ significantly in behavior (12). Another study demonstrated, however, that there is a relationship between awareness of the rights of the patient and observing them (13). This may be due to the research methods and the questionnaire in the mentioned study to determine the tendency of nurses to implement their roles to advocate patients’ rights. Despite the high knowledge of occupational therapists, there seems to be a gap between awareness of patients’ rights and their observation in practice. Hooshmand et al. suggested in 2006 that there are many other requirements that should be recognized and identified in order for patients’ rights to be observed in practice (8). Jolaee et al. showed in 2008 through a qualitative study the facilitating factors which affect patients’ rights in clinical practice. Issues categorized as barriers to patients’ rights practice and facilitators of patients’ rights practice were further classified into three subgroups: awareness, resources and accountability (14). Patients’ rights can be fully implemented only if health services identify the barriers and strategies in employment of such charters of rights (15, 16). In this regard, another finding of the present study was related to facilitating factors of patients’ rights, which were classified in three groups (factors related to the organization, factors related to therapists, factors related to clients). The most important organizational factor was a need for approval of health insurances by the responsible organizations. In economic models, the primary function of health insurance is to alleviate the Leila Dehghan et al. J Med Ethics Hist Med 6:1 jmehm.tums.ac.ir January, 2013  Page 5 of 6 (page number not for citation purposes)     financial risk associated with unanticipated adverse health events. In general, people dislike risk and are willing to trade a small amount of money to buy insurance premium for their protection against a potentially large loss of their income (17). Health insurance improves the quality of care and intro- duces user entitlements known as patients’ rights (18). The next important factor was to test patients’ knowledge level and identify responsive organiza- tions’ roles in accomplishing their needs and rights as clients. Findings of other studies have shown only few patients knew the rules composed within their charter of rights (19). This indicates the need for extensive education of patients and healthcare professionals in related subjects. Other important facilitating factors in the pro- motion of patients’ rights are ethics courses designed for undergraduate students, workshops for therapists, patients’ rights charter installations in occupational therapy clinics and the generation of ethical committees within related organizations. A report by the Association of American Medi- cal Colleges (AAMC) argued that medical schools “must ensure that before graduation, a student will have demonstrated knowledge of the theories and principles that govern ethical decision making and of the major ethical dilemmas in medicine…” (20). The AAMC’s statement reflects a growing consen- sus among medical educators that ethics education should be a core component of medical schools’ curricula. At the present time, there is no ethics curriculum for occupational therapists in Iran and this study hopes to initiate introduction of such courses in Iranian academic centers. Our findings revealed that occupational thera- pists had a high knowledge of patients’ rights, but they would need to train for their implementation. Students of occupational therapy should gradu- ate with a baseline level of knowledge in ethics, as they do in the basic sciences. The current state of education, however, does not ensure a common standard for ethics education in occupational therapy. Furthermore, as the client-centered approach is very important in OT, ethics are dependent on the cultural and social characteristics of societies (21), and therefore the view of the Iranian patients towards the issue urges the Ministry of Health and Medical Education of the Islamic Republic of Iran to accelerate the implementation of the Patients’ Rights Charter of Iran (22). It is suggested that a qualitative research be done to determine the views of occupational therapists and clients about observing the patients’ rights in Iran. One of the limitations of our study was the greater number of Bachelor-level participants compared to other educational levels, due to the convenience sampling method. This may affect the results based on analyses of the relationship between the level of knowledge about patients’ rights and educational level Conclusion Although, the level of occupational therapists’ knowledge about the Patients’ Rights Charter are high, it is necessary to provide context for observ- ing patients’ rights by involving related facilitating factors such as different organizations, therapists, and clients within the field of clinical occupational therapy professionalism. Acknowledgement The authors are grateful to all the occupational therapists that devoted time and participated in this study. References 1. Gibson CH. A concept analysis of empowerment. J Adv Nurs 1991; 16(3): 354-61. 2. Rad M, Mohammd A, Esna Ashari P. 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