1. Introduction
Patient’s rights are among the main pillars in defining the standards of clinical services. As the attention of international communities to human rights is increased, the concept of patient’s rights has been growingly taken into consideration (Nikbakht-Nasrabadi et al. 2015; World-Health-Organization, 2000). Patient’s rights require observing that the biopsychosocial and spiritual needs of the patient are met; these needs have been classified in the form of standards, rules, and regulations; the healthcare team is responsible and obliged to implement and adhere to those (Vaskooei-Eshkevari et al. 2009). 
The patient’s bill of rights” is advocating the human rights to maintain his sanctity and dignity to ensure that at the time of admission and during medical activities, their body, soul, and health will be well-taken care of without discrimination regarding their age, gender, religion, ethnicity, economic status, and so on (Kent 2014). Therefore, most health systems in most countries have developed and maintained a bill entitled patient’s rights”; it is at the disposal of executive levels and is supported by the authorities of hospitals who are required to submit it to the patients when hospitalized until fully acquainted with their rights (Nami Nehad, 2005). 
In Iran, the patients’ bill of rights was drafted and provided to health centers in 2002, and its text of the amendment was communicated to the relevant centers in 2009 (Parsapoor, Bagheri & Larijani 2010). Accordingly, some of the patients’ rights in this bill include proper and high-quality care and treatment, access to essential and adequate information, right to have a choice and decision-making, the confidentiality of patient’s information, informed consent provision, the right to independence, the right to having health education, observing the patient’s privacy, a peace of mind and death with dignity, and the right to objection, complaint, and compensation, etc. (Hajavi, Tabibi & Sarbaz 2005; Parsapoor et al. 2009). 
A key indicator for assessing the quality of healthcare services is to examine the status of patient rights observance by the healthcare providers and healthcare service recipients (Astaraki & Hosseini 2015). Besides, the observance of patients’ rights is a critical factor in improving and regulating the relationship between the providers and recipients of services; it is naturally of great importance in healthcare system management (Parsapoor et al. 2009). The increasing awareness of communities about health and health issues and the increased costs of healthcare services for the consumers has made patients more likely to care for themselves and follow-up their disease, compared to the past; thus, when their expectations are not fulfilled, they might react to the violation of their basic rights (Almond 2001). Individuals’ health information has been improved; they consider hygiene, health, and the productivity of health services as their basic right (Levinsky 1996). 
Support is an essential part of nursing. Gadow defines it as helping the patients to recognize their needs, inform them of their rights, and protect these rights and interests (Gadow 1990). Nevertheless, some studies indicated that although nurses have a relatively high awareness of the concept of patients’ rights, they believe that the observance of such rights needs some essential requirements which encounter this important ethical issue with difficulty (Hooshmand et al. 2007). 
Most patients believe that some of their rights, including receiving information regarding diagnosis and treatment, the consequences and risks of acceptance or rejection of treatment, paying attention to their demands and what they say are not followed by healthcare providers (Hooshmand et al. 2007). Generally, there are controversial findings of the level of awareness and observance of patient rights by nurses. A study indicated that patient’s rights range from poor to desirable, depending on the definition of right. For example, the highest level of observance of patients’ rights belonged to the patient’s privacy and respect for their confidentiality, which was reported to be 100% desirable by all the investigated individuals. However, the lowest value was related to the provision of sufficient information to patients, where only 48.1% reported it as desirable (Sabzevari et al. 2016). Rohafruz et al. have also reported the Mean±SD score of satisfaction with the observance of the charter of patients’ rights as 71.6±18.2. They also found that 60% of the patients had a satisfactory moderate level of the observance of their rights charter (Rokhafrooz et al. 2017). The first step in observance of these rights is awareness; thus, it is necessary to explore the nurses’ level of knowledge about these rights.
Furthermore, adopting measures to improve nurses’ knowledge of patients’ rights provides them with better conditions for observing these rights. Besides, understanding the viewpoint and knowledge level of nurses regarding the observance of patients’ rights can also be the basis for better observance of these rights (Hooshmand et al. 2007). Additionally, there are structural and cultural differences among the previously studied communities. Accordingly, any policy on developing nurses’ performance in the field of observance of patient rights requires an initial assessment and monitoring of the level of awareness and the current level of observance of patient’s rights in targeted society. This study aimed to evaluate the level of awareness and observance of patients’ rights by nurses.
2. Materials and Methods 
This descriptive cross-sectional study assessed the level of awareness and observance of patients’ rights by nurses working in hospitals affiliated to Larestan University of Medical Sciences. Based on Cochran’s sampling formula, the minimum sample size with a 95% confidence level, an acceptable error of 0.05, and a distribution ratio of 20%, was calculated as 83 nurses. The study participants were selected by convenience sampling method. To collect the required data, a researcher-made questionnaire containing two sections of a patient’s rights awareness and patient’s rights observance was used. This questionnaire consists of 42 questions which 21 questions evaluated the nurses’ awareness of 7 legal components (the right to information and awareness, the right to choose, the right to privacy, the right to respect, the right to refuse, the right to care and appropriate treatment, and the right to complaint) and 21 other questions evaluated the performance of nurses in terms of observing these rights. 
In this study, Cronbach’s alpha coefficient was obtained as 0.51 for the subscale of the patient’s rights awareness and 0.69 for the patient’s rights observance subscale. These data indicate moderate and relatively desirable reliability of the research tool. The validity of the questionnaire was confirmed by 10 faculty members of the university. The achieved data were analyzed in SPSS using descriptive tests such as mean, frequency, and percentage, as well as the Chi-squared test.
3. Results
Among the study subjects, 10% were male, and 90% were female; 67% were married, and 33% were single. Furthermore, 96% had BA, 2.4% had an MA degree, and 1.6% had an associate degree. In total, 26% of the nurses worked in the emergency department, 22% in the intensive care unit, 8.5% in the pediatric ward, 8.5% in the internal ward, and the rest were occupied in other wards. Moreover, 88% were staff nurses, 9% were matrons, and 3% were supervisors. The Mean±SD age of the study participants was 30.76±6.71 years. Frequency distribution and percentage of nurses’ awareness of the patients’ bill of rights and its subscales are illustrated in Table 1.

Regarding the performance of nurses concerning patients’ rights, except in the area of respect, for which most participants reported good performance with 43.4%; in other areas, nurses had poor to moderate levels of observance of patients’ rights. Frequency distribution and percentage of nurses’ performance and its subscales are presented in Table 2.

The Chi-squared test results indicated that among the demographic variables, only gender was significantly associated with the nurses’ knowledge of patient’s rights. The educational level variable also had a significant relationship with the nurses’ performance in observing patients’ rights (P<0.05) (Tables 3 & 4).

4. Discussion
This descriptive cross-sectional study was conducted on 83 nurses working in hospitals affiliated to Larestan University of Medical Sciences. According to the study results, the knowledge of the majority of nurses (81.9%) regarding patient’s rights was weak, 16.9% of them had moderate, and only 1.2% had good knowledge in this respect. Thus, the knowledge and awareness of nurses about the rights of patients are undesirable. This finding is consistent with those of some studies (Parsinia, Goodarzi, & Babaei 2007; Aghighi et al. 2014 ; Hakan Özdemir et al. 2009; Halawany et al. 2016). However, this finding was inconsistent with those of Salehi Vaziri and Sadeghi. They argued that nurses had a high level of awareness (Salehi Vaziri & Sadeghi, 2015). Ghaljeh et al. reported the mean score of nurses’ knowledge as 45.13, which was moderate (Ghaljeh et al. 2010). Nasiriany et al. also described the nurses’ awareness of patients’ rights to be well (Nasiriany et al. 2002). Furthermore, KhodaMoradi et al. reported that the knowledge of 82.3% of nursing trainees about patient’s rights was good (KhodaMoradi et al. 2010), which was inconsistent with the present findings. 
Contradictory results regarding the level of nurses’ awareness of patient rights were expected because it could be influenced by the sociocultural characteristics of target communities and the training provided to nurses. In addition, the lack of awareness of the patient’s rights by some participants may be due to inadequate or inappropriate information regarding the subject of patient’s rights (Halawany et al. 2016). Accordingly, considering that a key nursing principle is respect for human rights and rewarding the patients’ dignity, nurses are among the leading pillars of the avocation of patients’ rights in hospitals; the awareness of patients’ bill of rights and the provision of conditions for healthcare providers to comply with these rights are essential. Therefore, healthcare providers, including nurses, should be aware of the rights of patients and increase their level of knowledge of the patients’ bill of rights. Besides, it is imperative that hospital managers take measures to enforce patients’ rights and eliminate the existing gap by holding related workshops (Ghaljeh et al. 2010).
Additionally, the obtained results revealed that the overall score of nurses’ performance about patient’s rights was reported as moderate in 83.1%, weak in 13.3%, and good only in 3.6% of the nurses. This finding was consistent with that of another study (Pishgar et al. 2015). Besides, in one other study, the rate of observance of patient’s rights was moderate in 79% of the cases (Rashidi, Foroughan & Hosseini 2012). Poor observance of patients’ rights was reported in a hospital in Esfahan, Iran (Mosadegh-Rad, Mohammd & Esna Ashari 2004). In other words, patients, like other human beings, have vital needs that fail to fully meet some of them due to illness and require other’s help. Therefore, with the awareness of the patients’ needs, they can be better understood, and more appropriate ways could be selected to assist them. Understanding these needs is a useful framework for providing care. Thus, if the healthcare team, including nurses, are not well aware of the needs of patients and how they are satisfied, they fail to observe the patient’s human rights (Mosadegh-Rad, Mohammd & Esna Ashari 2004). The nurses of hospitals affiliated with Larestan University of Medical Sciences had poor knowledge of the patients’ rights charter, and consequently, on average, have been able to comply with patients’ rights; to prevent violations of patient rights in healthcare activities, there is an urgent need to eliminate this issue. Furthermore, the observance of patients’ bill of rights should be considered more seriously in continuing education programs and in-service training for implementing the educational needs of nurses. Moreover, the observance of these rights in practice requires many other needs; thus, these requirements should be identified by the hospital administrators, and the necessary measures be taken to resolve them. 
According to the study findings, gender and education were key variables to be significantly correlated with the awareness and observance of patients’ rights by nurses. This result was in line with that of another study (Parsinia, Goodarzi & Babaei 2007). In addition, Rashidi suggested a positive and significant relationship between the patient’s rights and the level of education; the level of awareness and observance was related to the gender of nurses (Rashidi, Foroughan & Hosseini 2012).
Nurses’ performance and their awareness were found to be undesirable in this study, which requires more attention from the managers of the related hospitals. Conducting interventional research studies to investigate the effect of workshops and other means of education on these variables is recommended.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by Larestan University of Medical Sciences with a Code of Ethics in Medical Research of IR.LARUMS.1396.2. Written consent was obtained from the nurses, they were free to refuse to continue the study, and confidentiality of all their personal information was confirmed.
Funding
This research was financially funded by Larestan University of Medical Sciences.
Authors' contributions
All authors contributed equally in preparing all parts of the research.
Conflict of interest
The authors declared no conflicts of interest.


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