1 CHAPTER 1 THE PROBLEM AND ITS BACKGROUND

Introduction A certain hospital in the Philippines had a patient who came in for an operation on his rectum, wherein a metal canister was lodged. The patient trusted his doctors in good faith. During the surgical procedure, a nursing student allegedly videotaped the operation where the medical practitioners were yelling and cheering when they had removed the canister from the patients anus. They even sprayed the contents of the can, and described the canister as a baby. This video was then uploaded on the internet without the patients consent. One of the patients friends showed it to him, which led him to file charges against those involved. (Mosqueda, 2008) Patients rights law is intended to secure good medical practice. Though it was aimed for this purpose, it can also serve to improve understanding between patients and medical staffs if both are aware of these rights. Health as a fundamental human right was recognized in the World Health Organization's (WHO) Constitution, stating that The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, and political belief, economic or social condition. (WHO Constitution, 2013, p. 1). Assuring that the rights of patients are protected requires more than education policy makers and health providers. It requires educating citizens to understand about what they should expect from their government and their health care providersabout the kind of treatment and respect they are owed. There are proven increasing number of incidents such as: the Cebu Doctors Scandal

2 (Mosqueda, 2008), the Belo Botched Butt Job (abs-cbnNEWS.com., 2009), and the kidnapping of a baby in a hospital (abs-cbnNEWS.com, 2012). It is through protecting these rights that both parties may be protected and are able to avoid any legal conflicts. These rights are stated in the Philippine Medical Association (PMA) Declaration on the Rights and Obligations of the Patient

(http://www.cmaao.org/cmaao/eventsfl/eve_db_2.html), from their general rights up to the extent of patients obligations. Such rights are inferred from the United Nations Universal Declaration of Human Rights (UDHR)

(http://www.un.org/en/documents/udhr/history.shtml), specifically the provisions that talk about human dignity and the equal and unalienable rights of the human family. In 2004, the House of Representatives came up with House Bill No. 261, a.k.a. An Act Declaring the Rights and Obligations of Patients and Establishing a Grievance Mechanism for Violations Thereof and for Other Purposes, which states, among others, the patients financial rights to waiver emergency medical treatments, as well as protecting the rights of patients through any violations that may be committed. Given the fact that there are existing laws regarding the protection of patients rights, there are still reported and unreported violations of such. This prompted the researchers to conduct a study on whether Filipino patients are aware of their rights. Specifically, the study is aimed at finding if patient of certain hospitals are aware of their rights. The study is grounded in the fact that the patients awareness of his/her rights could lead to his/her empowerment.

3 Statement of the problem The study focuses on the respondents awareness of his/her rights as patients. The researchers specifically aim to answer the following questions: 1) What is the demographic profile of the respondents according to: a. Age,

b. Gender, c. Occupation, d. Educational Attainment, and e. Duration of hospital stay? 2) What is the awareness of the respondents regarding their rights? 3) Is there a significant relation between the respondents demographic profile and their awareness of their rights?

4 Significance of the Study The study aims to provide practical information that will be beneficial to the following: Administrators: The result that they can get from this study may prove useful in formulating hospital policies with emphasis on the rights of the patients and their obligations as a health provider. It will give them a sense of direction as regards their management with their staff as well as in informing their patients with their rights that are often neglected. Medical Staff: The information that they can get from this study enables them to be more effective in their responsibilities in the hospital, particularly in the manner by which they treat and deal with the patients. Clinical Instructors: This will give them sufficient information about the patient that they can infuse in teaching student nurses. It can thereby empower themselves and the student nurses in dealing with their patients, enabling them to be more respectful to their rights and to become more confident educators. Student Nurses: This research will provide them with background information regarding patients rights, which can be useful in their learning process as future nurses. It will eventually prove useful in that they become more respectful in treating their patients. Patients: The outcome of this research will provide the patients with the status quos current level of awareness as regards their rights as a patient. Its implications can also

make them more aware that they have rights that can lead to their empowerment.

5 Future Researchers: This can serve as a source of supplemental data and information that they can use as a springboard for a related study. It can also serve as a guide that permits them to research on the unexplored avenues of patients rights.

6 Scope and Limitations This study was conducted to determine the awareness of patients regarding the Patients Bill of Rights. Those included in this study were hospital patients regardless of the hours confined and the diagnosed disease or illness. They were 21 years and above of either gender, conscious and alert, and able to comprehend and answer the questionnaire. Excludes were those in the Intensive Care Unit (ICU), those deemed to be in a critical condition, and those who were mentally incapacitated. A total of 40 respondents were asked to participate. The respondents were chosen through convenient sampling. Each of the respondents were given the same questionnaire, which was either in English or Filipino, depending on the patients preference. Data collection started at the end of June, 2013.

7 Definition of Terms Assessment the act of determining the of awareness of the patients regarding their rights. Awareness having or showing knowledge or consciousness of the patients rights. Patient pertains to persons aged 21 and above and confined in the hospital. Patients Bill of Rights pertains to the rights outlined in the UDHR, and adopted by the Philippine Medical Association (PMA) Declaration on The Rights and Obligations of the Patient, and also stated in the patients rights outlined of the hospitals brochure.

8 CHAPTER 2 Review of Related Literature and Studies

The focus of this study is to determine the patients awareness about their rights. This chapter contains the review of related literature of the study gathered from books, journals, researches and online sources. Through this chapter, the researchers will provide an in-depth discussion on studies related to their topic. It involves a discussion on the importance of the literary works they have compiled together from local and international sources. This will help explain the differences of their study in both global and local domains. Furthermore, the researchers explain as to why these research findings are significant to their studies and it will help the readers gain further understanding about the awareness of patients rights as outlined in by the statement of the problem.

International Scope Universal Declaration of Human Rights (UDHR) The UDHR serves as the fundamental international document that establishes human rights, which include the right of the patients. Article 1 states, All human beings are born free and equal in dignity and rights. This means that human beings are

intrinsically endowed with the right to respect and proper treatment and that no other human being should possess greater or lesser dignity than the others. So long as one is a human being, one has dignity. And rights are subsumed in dignity. Therefore, the very nature of being human already presupposes that one has rights.

9 It is from this provision of the UDHR that the rights of the patient can be inferred. The rights of the patient are then a specific enactment of the said provision (UDHR, http://www.un.org/en/documents/udhr/history.shtml, paragraph 9). According to the WHO (2013): Patients' rights vary in different countries and in different jurisdictions, often depending upon prevailing cultural and social norms (Para 2). Genomics and patients rights assure that patients will receive consistent treatment with the dignity and respect they are owed as human beings. This means providing at minimum, equitable access to quality medical care, ensuring patients privacy and the confidentiality of their medical information, informing patients and obtaining their consent before employing a medical intervention, and providing a safe clinical environment (Para 4). WHO wants to provide the human being the quality of care that they need. They also ensure patients privacy and confidentiality of all the information that the hospital gathered but also earning the trust of the patients. WHO assures that Genomics and patients right will receive the right treatment with dignity and respect. According to Article 3 of UDHR

(http://www.un.org/en/documents/udhr/history.shtml), everyone has the right to life, liberty and security of person (p. 9). This particular provision talks about the basic rights entailed by each individual. A person, regardless of identity or status, is entitled to have protection of his/her life. This implies that the government is duty-bound to ensure that its constituents can live in a peaceful and secure environment, and they can do so freely.

10 The Individuals freedom, however, should not be practiced at the expense of infringing on another persons freedom. Patient Rights (Scotland) Act 2011 Scotlands Patient Rights Act 2011 was passed by the Parliament

in February 2011 and gained Royal Assent in March 2011. According to this document: the Act aims to improve patients' experiences of using health services and to support people to become more involved in their health and health care (The Scottish Government, 2012, para. 2). It established an entity or special department, called the Patient Advice and Support Service (PASS). It gives information and advises the patients on questions arising from the health service they are receiving. It also serves as the patients support system. According to Scottish Citizens Advice Bureau (2012): The service is independent and provides free, confidential information, advice and support to anyone who uses the NHS [National Health Service] in Scotland. It aims to support patients, their careers and families in their dealings with the NHS and in other matters affecting their health.(Para 1) This Patient Advice and Support Service will help clients understand their rights and responsibilities as patients; provide information, advice and support for those wishing to give feedback or comments, raise concerns or make complaints about health care delivered by NHS Scotland; Ensure clients feel listened to, supported, and respected when raising concerns about difficult experiences, and work with the NHS to use feedback to improve NHS service provision (Para. 2).

11 The establishment of the PASS is their means to patient empowerment. It enables the patients to maximize the health care services offered by the system. European Charter of Patients Rights Article 35 of the charter of Fundamental Rights of European Union identifies 14 patients rights that aim to guarantee a high level of human health protection and assure the high quality of services provided by the various national health services in Europe. The 14 fundamental rights must be recognized and respected in every country. They are correlated with duties and responsibilities that both citizens and health care stakeholders have to assume European Heart and Lung Transplant Federation (EHLTF). According to the EHLTF (2002), the European Charter of Patients Rights include: (1) Right to Preventive Measures, every individual has the right to a proper service in order to prevent illness. (2) Right of Access, every individual has the right of access to the health services that his or her health needs require; the health services must guarantee equal access to everyone, without discriminating on the basis of financial resources, place of residence, kind of illness or time of access to services. (3) Right to Information, every individual has the right to access to all information regarding their state of health, the health services and how to use them, and all scientific research and technological innovation should be made available. (4) Right to Consent, every individual has the right of access to all information that might enable him/her to actively participate in the decisions regarding his/her health; this information is a prerequisite for any procedure and treatment, including the participation in scientific research. (5) Right

12 to Free Choice, each individual has the right to freely choose from among different treatment procedures and providers on the basis of adequate information. (6) Right to Privacy and Confidentiality, every individual has the right to the confidentiality of personal information, including information regarding his or her state of health and potential diagnostic or therapeutic procedures, as well as the protection of his or her privacy during the performance of diagnostic exams, specialist visits, and medical/surgical treatments in general. (7) Right to Respect of Patients Time, each individual has the right to receive necessary treatment within a swift and predetermined period of time. This right applies at each phase of the treatment. (8) Right to the Observance of Quality Standards, each individual has the right of access to high quality health services on the basis of the specification and observance of precise standards. (9) Right to Safety, each individual has the right to be free from harm caused by the poor functioning of health services, medical malpractice and errors, and the right of access to health services and treatments that meet high safety standards. (10) Right to Innovation, each individual has the right of access to innovative procedures, including diagnostic procedures, according to international standards and independently of economic or financial considerations. (11) Right to Avoid Unnecessary Suffering and Pain, each individual has the right to avoid as much suffering and pain as possible, in each phase of his or her illness. (12) Right to Personalized Treatment, each individual has the right to diagnostic or therapeutic programs tailored as much as possible to his or her personal needs. (13) Right to Complain, each individual has the right to complain whenever he or she has suffered a harm and the right to receive a response or other feedback.

13 (14) Right to Compensation, each individual has the right to receive sufficient compensation within a reasonably short time whenever he or she has suffered physical or moral and psychological harm caused by a health service treatment. Patients' Rights: LA Times "Patients' bill of rights" was proposed by the presidential commission. The bill will increase the cost of medical care by further mandates and regulations on the insurance companies and providers of health care (Nov. 19). Patients' rights can be protected by increasing competition and giving patients the right to choose their own insurance plan. (Los Angeles Times, 2013) The patient has the right to choose which insurance will be purchased. There are limited kinds of insurance service; tax deductible insurance for an employer and non-tax deductible insurance for an individual. A right that a patient wants is to be able to purchase an insurance of his choice without penalty if it is not purchased by the employer. Policy Paper on the Rights of Patients According to WHO, the Council of Europe and the World Medical Association, since the 1970s, several international declarations have been created that cover the principles of patients rights. These international documents demand that the human rights should be observed in medical treatment. They spell out the rights that must be ensured for the people during medical treatment so that they could exercise their right of self-determination. These international documents offer a starting-point where each countrys legislation can engage in creating laws that recognize and assert these rights.

14 According to Hungarian Civil Liberties Union: Advocates legislation under the individual may freely decide matters that affect her person and life. Decisions on medical treatment are as personal as anything can be. When an individual makes such a decision, she expresses her conception of the good life, of the adequate level of health, of the way she wishes to look, and of her views about bodily suffering. We cannot feel secure in our right to self-determination regarding medical treatment unless it is the case that the law provides for our rights in the context of medical treatment and for the conditions which are necessary for the exercise of these rights. By the term patient rights, we do not understand special rights of people under medical treatment. We rather understand these rights as applications of general human rights to the particular context of decisions regarding medical treatment. The rules related to the rights of patients are meant to ensure that you should be able to exercise your human rights even during the period of your life when you are subjected to medical treatment (Policy Documentation Center, n.d., para. 1). Compliance with international standards on patients' rights and implementation of the Law on the Protection of Patients' Rights in the Republic of Macedonia According to Filip Gerovski (2011), Macedonia adopted the Law on the Protection of Patients' Rights back in 2008. The Law introduces some new patients' rights (for example, right to second expert opinion) and new mechanisms for protection of patients' rights e.g. councilors for protection of patients' rights and commissions for promotion of patients' rights.

15 One could say that this was a big step forward for Macedonia in the field of health care and regulation of patients' rights and responsibilities, as well as the rights and responsibilities of the health care providers. In the Republic of Macedonia, caring for one's health is a right and at the same time a responsibility of each citizen guaranteed by their Constitution. Each citizen is guaranteed the right to health care. Until the Law on the Protection of Patients' Rights was introduced into the legal system, patients' rights in Macedonia were regulated with several different laws, which sometimes required complex procedures for adherence to different stipulations in the different laws and created difficulties in the implementation of the laws and respect of the rights. In this regard, the Law on the Protection of Patients' Rights gives a systematic overview of patients' rights and responsibilities and of the rights and responsibilities of health care providers (Gerovski, 2011). In 2010, a new patients bill of rights was introduced along with the Affordable Care Act. This bill gave protection to patients from insurance companies. These include: (1) Annual and Lifetime limits to coverage are being phased out (2) Children will be able to get health insurance in spite of any medical conditions (3) Children are now able to stay on a parents policy until age 26 if they meet other requirements (4) Health insurance companies will no longer be able to take back your health coverage after you get sick because you made an honest mistake on your insurance application. Nevertheless, there are exceptions to these rights. As of late 2012, as stated in the article, existing health plans dont have to follow the new rules so long as they have an old plan in effect. These new rules only apply to those who have issued or renewed their health insurances on or after September 23, 2010 (Patients Bill of Rights, n.d.).

16 Over the past decade, Iran has been making significant development for conducting research on patients rights. The study was conducted, as explained in the article, to review and analyze the previous studies that have been made concerning patients rights in Iran. A total of 41 Persian and five English articles were found for the keywords awareness, attitude, and patients rights. Out of the 41, only 26 fulfilled the objective of the researchers study. Through their research, that indicated that from the year 1999 and onwards, the study has begun to draw attention of Iranian researchers as well as Iranian papers in English being compiled and published in international sources (Patient Rights in Iran, 2011).

Assessment of Level of Awareness in the International Level Internationally, several studies have been made to assess for the level of awareness of patients rights. In turkey, a study was conducted in a state hospital, questioning 128 patients in the medical and surgical wards. The study was conducted by questionnaire which included questions about the rights of the patients and gave sample cases. It was found that only 23% of the patients were able to recognize patients rights, 32% could not and 45% were undecided in recognizing patients rights. (F, Z. & MF, U., 2001) Another study was in Spain. Theyre method was a cross-sectional quota-sampled survey study where a total of 790 patients discharged from hospitals or attended in primary care took a telephone survey, 773 replied. They found that 20% had some knowledge of the rules governing patients rights and that age was related to greater ignorance of these right (P<0.01) (Mira, 2012).

17 While in Kampala, Uganda, in 18 different health units, 450 patients were interviewed right after obtaining treatment. It was found that in each are, close to half stated that patients have rights and they were able to mention at least one of the ten rights. Men were significantly more aware and awareness correlated with the socio-economic status (UNHCO, 2002). In Tehran, Iran a 50-item questionnaire was used on a total of 601 patients, randomly selected from 11 hospitals associated with three medical universities. It was found that the level of awareness was poor in 71.5% and desirable in 5.8%. There was a significant statistical relationship between the level of patients rights and the ward and length of stay(Arab 2010).

Local Scope Philippine Medical Association (PMA) The PMA (http://www.cmaao.org/cmaao/eventsfl/eve_db_2.html) divides the rights of the patients into two categories: (1) Individual Patient Rights (2) Societal Rights of the Patients. On the one hand, individual rights refers to right to (1) Good Quality Health Care and Humane Treatment, (2) Right to Dignity, (3) Right to be informed of his rights and obligations as a patient, (4) Right to choose his physician/ health institution, (5) Right to Informed consent, (6) Right to Refuse Diagnostic and Medical Treatment, (7) Right to refuse participation in medical research, (8) Right to religious belief and assistance, (9) Right to privacy and confidentiality, (10) Right to disclosure of, and access to, information, (11) Right to correspondence and to receive visitors, (12) Right to Medical Records, (13) Right to Health Education, (14) and Right to express grievances.

18 On the other hand, societal rights pertains to Rights to health, right to access to quality public Health care right to healthy and safe workplace, right to medical and education information and programs, right to participate in policy decisions, right to access to health facilities, right to equitable and economic use of resources, right to continuing health care and right to be provided quality health care in times of insolvency. There were proposed patients rights in Corazon Locsin Montelibano Regional Hospital located in the city of Bacolod. It enumerates 10 rights of a patient and his responsibilities. The hospital based this from the bill of rights as proposed by the PMA. It covers the confidentiality, autonomy, privacy and dignity of every patient (Patients Rights and Responsibilities, n.d.). Hospitals in the Philippines see to it that they maintain a law which the whole institution would follow. Cardinal Santos Medical Center (CSMC) also implemented the said patients rights of PMA. Regarding these rights, CSMC also listed important rights on how the patients in their facility are to be respected and protected (Cardinal Santos Medical Center, n.d.). The Chong Hua hospital in Cebu City also lists some rights of the patient. One of these rights is to treat patients with respect concerning spiritual and cultural issues, to maintain the dignity of the patient as well as to provide privacy in every procedure to be done. It also cites that the patient must receive urgent treatment regardless of ability to pay (Patient Rights and Responsibilities - Chong Hua Hospital, n.d.). In the management of pain experienced by the patient, it should be addressed quickly by the health care providers and that the patients should be treated to alleviate pain.

19 The patient also has the right to be informed about the diagnosis and treatments regarding his/her condition. S/he is to be advised of the procedures that may affect his/her care (Patient Rights and Responsibilities - Chong Hua Hospital, n.d.). Every patient has the right to be involved in the decisions concerning his or her care. S/he must give an informed consent before all the procedures are to be done. And in due respect to the patient, autonomy is honored whether s/he accepts or refuses treatment (Patient Rights and Responsibilities - Chong Hua Hospital, n.d.).

Assessment of Awareness on the International Level In the Philippines, there has not been any study that attempts to measure the patients level of awareness of his/her rights. This prompted the researchers to further look into the issue locally.

Synthesis From international to local research, actual awareness of patients rights is a study that has been a path less looked into. It is with this found knowledge, which the

observers and researchers have collected, that a broader spectrum of this very topic can be achieved. The relevance of the researchers data is that there was very little to no actual research on the awareness of patient rights here in the Philippines. It was only through our neighboring continent of Europe that some forms of ethical study were performed. It is through this adopted frame of rights that the Philippines base their own ethical status. As in the studies found, the researchers will compare the significant relation between the patients demographic profile and their awareness level.

20 Conceptual Framework The first box on the left indicates the different criteria of the patients demographic profile: age, gender, occupation, educational attainment and duration of stay in CMC. The box on the right shows the high or low level of awareness. Within this framework, the data will be analyzed on an individual standpoint: best in age, gender, occupational attainment, and duration of stay in CMC; best being defined as the highest level of awareness within each demographic profile. Once the data is compiled, the research, with the aid of the diagram will explain the relationship between the demographic profile and their level of awareness.

21 Conceptual Framework

Demographic Profile Age Gender Occupation Education Attainment Current duration of stay (in CMC) Awareness of Patients Rights

22 CHAPTER 3 METHODOLOGY

This chapter presents the description of the research method used, the respondents, the instruments used, the procedures and statistical treatment utilized in the analyses of the data.

Research Design The research design uses descriptive and correlational type of research. A descriptive type of research is used for fact-finding. The focus is on prevailing conditions or how a person, group, or thing behaves or functions in the present (Calderon, 2004, p.61). While correlational type of research measures the statistical association or relationship of two or more dependent variables (Schmidt, 2013; Price and Oswald, 2008). The researchers will use the descriptive type of research. Data will be collected in order to answer questions and determine the level of awareness of patients in a hospital regarding their patients rights. This research will also make use of correlational type of research to determine the degree of relationship between the patients demographic profile and their awareness regarding their rights.

23 Research Locale This study was conducted in Philippine Orthopedic Center (POC) located at Maria Clara Cor. Banawe St., Santa Mesa Heights, Quezon City and under the Department of Health (DOH). POC, in 1963, was relocated to Quezon City from Mandaluyong with its bed capacity increasing from 200 to 500 and then to 700. This hospital pioneered the introduction of Physical Therapy and Occupational Therapy through Hospital chief, Benjamin V. Tamesis, M.D. The hospital was renamed several times before it was changed to Philippine Orthopedic Center in 1989. POC chiefly serves clients with orthopedic and neuromuscular conditions and is also the main referral center for spinal injuries in the country. The hospital has an anesthesia department, radiology department, rehabilitation medicine department, laboratory department, specialty services and dental services. As well as trauma services, adult and childrens orthopedic services, tumor unit, hand service and spine surgery service (Philippine Orthopedic Center, 2012).

Target Population The researchers distributed questionnaires to 40 patients confined at a hospital. They were 21 years old or above of either gender, conscious and alert, and able to comprehend and answer the questionnaire. Patients questioned could not be in ICU or in a critical condition, and physically, mentally or emotionally incapacitated.

24 Data gathering procedure In order to gather data, the researchers first wrote a permission letter to a hospital to be approved. Next the questionnaire was formulated. In order to make the questions, the researchers sought out the most common rights printed or stated (Capitol Medical Center, 2012; World Health Organization, American Hospital

http://www.who.int/genomics/public/eu_declaration1994.pdf;

Association, http://www.patienttalk.info/AHA-Patient_Bill_of_Rights.htm; Bill of Rights Patient Guide, 2012; Encanto & Llamas,

http://www.cmaao.org/cmaao/eventsfl/eve_db_2.html). After creating the questionnaire, they will distribute it to a class of 30 nursing students for validation of the questionnaire. Once it is approved, the researchers will start distributing the questionnaire throughout the agreed floors. Once finished, the researchers may start compiling the data and compute the required statistical information.

25 Date Gathering Procedure

Permission Letter obtained and approved to conduct study

Data gathered with questionnaire

Compilation

Interpretation

Conclusion

26 Sampling design The researchers used convenient sampling technique. In stratified sampling, the entire population is divided into separate subgroups or strata and then the final subjects are randomly selected from the different subgroups. The strata in this study will be the different floors of a hospital. Given that each floor will have a different number of patients confined, the researchers chose to use disproportionate stratified random sampling, meaning instead of using a certain percentage of each strata, they decided to choose (6) patients from each floor. This sampling design is most appropriate for their study since the hospital is already divided by floors. The researchers will have to randomly choose the patient to be questioned from the different floors to get their total sample size. Instrumentation The questionnaire will have 14 statements regarding their rights from which the patient will have to distinguish which they are aware of and which they are not unaware of. Before making the questionnaire, the researchers canvased for the most common rights from the local and international documents. They then constructed the questionnaire incorporating 14 rights that were stated in the Philippine Patients Bill of Rights repeated (CMC Brochure, 2012; A declaration on the promotion of Patients rights in Europe, 1994; AHA, http://www.patienttalk.info/AHA-Patient_Bill_of_Rights.htm; MHCC, 2012; PMA, 1999;). After creating the questionnaire, the researchers will distribute it to a class of 30 nursing students to validate of the questionnaire. This will be done in June, 2013.

27 Statistical treatment In this study, the researchers make use of frequency distribution and percentage to show the demographic profile and the sources of information in order to assess the patients level of awareness of their rights. To check if there is a significant relation among them, the researchers will make use of the Chi square. Chi square is a statistical test commonly used to test whether distributions of categorical variables differ from one another. Chi square is the sum of the squared difference between observed and the expected data, divided by the expected data in all possible categories. X2 = (Observed frequencies Expected frequencies)2 Expected frequencies The data description, analysis and interpretation will be based on the results obtained using the test mentioned. From these, a summary, conclusion and recommendation will be generated.

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