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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 37-44

Exploring health-care providers understanding and experiences of providing patient-centered care in hospitalized patients based on patient's bill of rights: A qualitative study

1 Student of Ph.D. by Research, Hospital Administration Research Center, Sari Branch, Islamic Azad University, Sari, Iran
2 Ph.D Candidate of Health Services Administration, Sari Branch, Islamic Azad University, Sari, Iran
3 Department of Biostatistics, Health Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran

Date of Submission10-Mar-2021
Date of Acceptance03-May-2021
Date of Web Publication16-Feb-2022

Correspondence Address:
Dr. Ghaahraman Mahmoudi
Hospital Administration Research Center, Sari Branch, Islamic Azad University, Sari
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnms.jnms_38_21

Rights and Permissions

Context: Patient-centered care is associated with a higher rate of patients' satisfaction, better outcomes as well as more cost-effective care. On the other hand, the aim of the patient's bill of rights is to ensure that patients are adequately cared for which in turn increase the quality of medical care.
Aims: This study aimed at explaining the experiences of health-care providers about providing patient-centered care in hospitalized patients based on patient's bill of rights.
Setting and Design: This qualitative study was conducted in 2018 using content analysis approach. Participants were 21 clinical nurses, nurse managers, and other health-care managers who worked in Iranian hospitals.
Materials and Methods: Data were collected purposefully using in-depth semi structured interviews and continued until data saturation. Interviews were recorded, immediately transcribed, and analyzed using Graneheim and Lundman's conventional content analysis.
Statistical Analysis Used: Frequency table was applied for Describing data by using. statistical analysis was done by SPSS software version 26.
Results: Data analysis resulted in the extraction of three main themes (value-based care, accountability in providing information, and providing suitable amenities) and five categories (providing sensitive care, providing ethical care, professional support, in seeking of information, and responding to informational needs).,
Conclusions: The findings of the present study showed that health-care providers have satisfactory understanding and experience in providing patient-centered care in hospitalized patients, based on the patient's bill of rights. Understanding patient-centered care barriers, especially by health-care providers, can secure the patient's legal rights and provide a better and more quality service for patients and their families.

Keywords: Hospital, Patient's bill of rights, Patient's rights, Patient-centered care

How to cite this article:
Asadi Abu Kheili M, Mahmoudi G, Yazdani Charati J. Exploring health-care providers understanding and experiences of providing patient-centered care in hospitalized patients based on patient's bill of rights: A qualitative study. J Nurs Midwifery Sci 2022;9:37-44

How to cite this URL:
Asadi Abu Kheili M, Mahmoudi G, Yazdani Charati J. Exploring health-care providers understanding and experiences of providing patient-centered care in hospitalized patients based on patient's bill of rights: A qualitative study. J Nurs Midwifery Sci [serial online] 2022 [cited 2023 Jun 4];9:37-44. Available from: https://www.jnmsjournal.org/text.asp?2022/9/1/37/337788

  Introduction Top

Health organizations are responsible for providing services to patients and offering a safe environment for them.[1] Attracting the patient's cooperation and making the patient, the center of the care service is very effective in following the treatment instructions and the patient's participation in the treatment process and welcoming the treatment plans.[2],[3] Therefore, patient-centered care should be considered as an important principle for managing hospitalized patients.[4] Patient-centered care is a priority for improving the safety and satisfaction of patients and staff. In addition, patient-centered care is an innovative approach to planning, implementing, and evaluating health care that empowers individuals and families, strengthens their independence, and respects the patient's choice and values, beliefs, and cultural context.[5],[6] A review of the literature indicated the important role of patients in the process of care and treatment as well as presenting new concepts related to patient centeredness in the design of future health systems.[7],[8] Strong and committed leadership, dissemination of patient care culture, proper access of patients to the appropriate care and treatment staff, as well as active participation of patients and their families in the care and treatment process, have been identified as key factors facilitating patient-centered care.[4],[7],[9]

In addition, patients as consumers of health services have the right to receive a culturally appropriate and quality patient-centered care and treatment.[10],[11] The issue of patient rights has received much attention in the last two decades for reasons such as the vulnerability and need of patients and the growing attention of the international community.[12],[13] Undoubtedly, the patients have rights in the health-care system that should be considered and supported and doing so cannot depend on the preference of health-care providers. Patient's rights are defined in terms of what is appropriate and deserving for the patient.[14],[15],[16] In fact, the patient's rights are the observance of legitimate and reasonable physical, mental, spiritual, and social needs, which are presented in the form of medical standards, laws and regulations, and health-care providers are responsible and obliged to implement and observe them.[17],[18],[19] The patient's bill of rights states that the patient has the right to be treated with the utmost care by physicians and other health-care providers that participate in care process. A patient has a right to ask precise information about the diagnosis, treatment plan, and prognosis of the disease and make the decision about keeping up with the recommended treatment and keep the treatment plan confidential.[20],[21],[22] Awareness of patients, their participation in decision-making, and respect for their rights also accelerate their recovery, reduce hospital stays, and lessen the likelihood of their readmission to the hospital, which is economically and socially important.[9],[23],[24] Failure to comply with patients' rights will have other undesirable consequences such as mistrust of medical staff–patient dissatisfaction, protests to legal authorities, and reduced quality of care.[25],[26]

Therefore, all health-care providers are responsible for establishing and maintaining patients' rights to maximize the efficiency and quality of health care.[20],[25]

In addition, it should be emphasized that in dealing with legal, ethical, and moral issues of patient care, paying attention to cultural issues is one of the necessities that lead to more efficient, realistic, and accurate decisions.[12],[27] The results of previous studies conducted in Iran showed that most patients are not usually aware of their rights, and the rate of observance of patients' rights by health-care providers is not appropriate. Therefore, this lack of awareness can lead to problems for patients and health-care system.[15],[28],[29]

Therefore, considering the importance of patient-centered care and needing to comply it with the standards of the patient's bill of rights by health-care providers, as well as the importance of social and cultural contexts in promoting and protecting patients' right, this study aimed to explain the experiences of health-care providers about providing patient-centered care in hospitalized patients based on patient's bill of rights.

  Materials and Methods Top

This study was conducted by a qualitative research method using conventional content analysis in 2020. This method has been used as a systematic method to describe the phenomenon in depth and is suitable for evaluating the people's experiences on a particular subject and is more useful when the theory and studies related to the phenomenon under study are limited.[30],[31] Participants were selected purposefully and with maximum variety. The main participants in this study were clinical nurses who worked in two educational hospitals in the north of Iran (Imam Khomeini Hospital of Sari and Shahid Beheshti Hospital of Babol) that have a responsibility as advocates for patients' rights. Furthermore, nurse managers and other health-care managers were interviewed to explore the emerging concepts and themes. The inclusion criteria were willingness to conduct an interview, at least 5 years of work experience, and the ability to share experiences. Data were collected using semi-structured in-depth interviews individually in a calm environment until data saturation was reached so that no new data were added. All interviews were recorded with the permission of the participants. The duration of the interviews was between 30 and 45 min. Interview questions were “How do you usually care for your patients,” “What comes to mind when you hear about patient-centered care and the patient's bill of rights?” “Can you describe your experience of observing patients' rights while caring of a patient?” “Do you have any experiences about patient-centered care in complying with the patient's bill of rights?” Furthermore, probing questions such as “What do you mean by telling …?” or “Can you explain more about it to me!” were used to clarify a situation or to provide detail to an answer.

To analyze the data, recorded interviews were listened immediately after each interview to get insight into the participants' experiences. After listening to the audio file of the interview and transcribing the contents, the manuscripts were checked again with the content of the tape. The qualitative approach by Graneheim and Lundman was used for data analysis, which suggested five steps to analyze qualitative data as follows: writing down the whole interview immediately after each interview, reading the whole text of the interview to get a general understanding of its content, determining the content of data and initial codes, categorizing the similar initial codes in more general categories, and determining the hidden concept of the data.[32] Transcript of interviews was read several times and the initial codes were extracted. Then, the initial codes related to each other merged and, based on the similarities, formed subcategory, category, and theme.

Guba and Lincoln's proposed criteria were used to assess the rigor of the study.[33] The researcher tried to increase the credibility of the research by a long-term engagement with the subject and sufficient experience of the field under study, as well as through sufficient participation and interaction with the participants, gathering valid information, and confirming the information by the participants. Double-step repetition, data collection and analysis, and reviews of supervisors, counselors, and experts were done to increase dependability. To increase data validity, the approval of the faculty members of the university and their additional comments were used. Transferability of the study was ensured with an attempt to provide a thick description of the study findings, to evaluate and enable the application of research in other fields.

Ethical consideration

All participants were informed about the study aim, interview process, confidential data management, and voluntariness of participation. Participation in the present study was completely voluntary, and informed consent was obtained from all participants. All of the interviews were audiotaped with the consent of the participants. This study approved by the Research Ethics Committee of Islamic Azad University (Ethics Code: IR.IAU.CHALUS.1396.38).

  Results Top

In this study, a total of 21 participants were interviewed with maximum variation to reach data saturation [Table 1].
Table 1: Demographic characteristics of participants

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The data analysis resulted in the emergence of three themes (value-based care, accountability in providing information, and providing suitable amenities) and seven subcategories (being human centered in care, providing ethical care, professional support, patient follow-up, responding to the demands, effective care, and continued care) [Table 2].
Table 2: Categories extracted from the experiences of study participants

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Value-based care

This theme includes three categories of “providing sensitive care,” “providing ethical care,” and “professional support.”

Data analysis showed that participants considered respecting the patient and paying attention to his wishes and involving the patient in different stages of treatment based on his sociocultural aspect and educational level as creating and strengthening a sense of trust in the patient and his family. Providing culturally sensitive care as well as professional support are among the most important issues related to patient-centered care based on patient's bill of rights. In this regard, one of the participants stated, “We must respect the patient's wishes and needs. For example, if a young person is ill, we should talk to him according to his level of education. When we see an 80-year-old man who has hearing difficulties, is illiterate that we cannot use harsh words, we have to mention the important factors of the Patient's Bill of Rights to him”(Participant No. 8).

Attention to and respect for the patient's culture and values during hospitalization were among the items stated by the participants. “The patient's culture and beliefs must be respected. For example, if the patient does not like his nurse to be of the opposite sex, it should be respected as much as possible” (Participant No. 10). Another participant stated, “We must observe privacy when examining the patient or doing some procedures for patients such as unitary catheterization” (Participant No. 11).

Observance of justice and equality in care were also among the points emphasized by the participants. “Care must be taken fairly for all, it should not be that because the patient is close to someone or because he/she is working somewhere receive more quality care” (Participant No. 13). Keeping patients' secrets by health-care providers were another issue that participants in the study emphasized on to perform patient-centered care. In this regard, one of the participants stated, “Some patients do not like the others know a series of issues, even their close family. For example, we had a patient in the ward who was HIV positive and asked me not to let the rest of the patients in the room know about his/her problem, and I said OK and I warned my colleagues about this as well”(Participant No. 4).

Appropriate and efficient support of patients from the time of admission to discharge from the hospital was also one of the important issues that the participants in the study emphasized. “The necessary support system including manpower and signposts, for example, should be available from the time the patient enters the hospital to guide nonemergency patients to the admissions unit” (Participant No. 5). Proper supporting of patients creates a sense of satisfaction in patients and their families and makes them more supportive and improves the care and treatment process in patients. “The honesty of the treatment team and keeping promises give the patient and the family a sense of trust, and they pay more attention to what is being told to them and accelerate the patient's recovery” (Participant No. 20). Another participant stated that “patient and compassionate education to the patient and family during discharge, either orally or using posters and pamphlets, reduces subsequent referrals and accelerates patient recovery” (Participant No. 6). “Healthcare providers usually deal with patients in the worst times of their lives, so they need to be patient and supportive” (Participant No. 14).

The experiences of the participants in the study showed that the feeling of job satisfaction in health-care providers, in general, led to better and higher quality care and is accompanied by greater patient satisfaction. “I love my job and I do my job in every shift as much as I can. I do my job carefully and patiently, not just to do my tasks. This also makes patients very satisfied with me, and in shifts that I am not, they ask my colleagues about me.” (Participant No. 19). Increasing patient care beliefs were also among the issues that participants in the study emphasized on regarding patient-centered care based on patient rights. One of the participants stated that “We need to emphasize to the patients that what is being said to them is to improve their own well-being and benefit. We should tell these issues compassionately and emphasize to patient accept it and execute and see the outcomes and his follow-ups will be more after that” (Participant No. 20).

Accountability in providing information

Hospitalization is challenging for patients, and they face many unknowns and are always looking for answers to these questions. Tracking the patient's health status or treatment status and treatment process by his or her family is always one of the most important issues facing the health-care providers, and answering these questions is one of the priorities of them. “Patients and their families are always worried about what the disease is. Is it dangerous? Is it going to be treated? What should they do? What should they consider in their diet?” (Participant No. 2). Another participant stated “Due to high costs of hospital treatments and care, patients and their companions are usually worried about the financial issue and have questions about this” (Participant No. 1).

The experience of participants revealed that responding with details to the patients or their companions' questions is an important issue patient-centered care. A participant pointed to the role of appropriate response to patients and companions so as to reduce fear and anxiety and increase trust in the medical staff. “Unawareness and ignorance of the patient or his family make them anxious. We should always try to explain these things to them and reduce their anxiety, and apart from the fact that their anxiety decreases and they calm down, their trust in us more. They cooperate in the treatment process and are more satisfied” (Participant No. 17).

Providing suitable amenities

The experiences of the participants in the study showed that providing necessary equipment and tools as well as staff needed during the patient's stay in the hospital is one of the important issues and aspects of patient-centered care and is one of the basic rights of patients that should be given special attention. Lack of proper preparation of these cases can cause discomfort and resentment of patients and challenges in providing appropriate services to patients. “Unfortunately, when the patient is admitted to the center, he cannot get all the services there, and many times, for example, he has to go to another medical center for counseling, which is also a hassle for the patient and at the same time makes providing the appropriate services for the patient difficult” (Participant No. 16).

The main reason of dissatisfaction the patients admitted to wards stated was the lack of amenities including food, cleaning, environmental health, sanitation, bed and clothing cleanliness, and poor food quality. “Providing the hotel is one of the duties. The necessary clothes and the appropriate physical environment, including adequate lighting, adequate heating and cooling, sound and cleaning for the patient should be provided by the staff in the best possible way. Most patients complain about these things” (Participant No. 10).

On the other hand, meeting the welfare requirements in accordance with the dignity and culture of patients can also increase the satisfaction of hospitalized patients. A hospital manager stated: “Providing the necessary and appropriate welfare facilities for patients is very crucial to provide quality services to the patient. The culture of patients should also be respected in this regard. For example, once we wanted to give whole wheat bread to the patient, but according to the culture of the people, most of the patients did not accept this bread, so we returned to the previous conditions” (Participant No. 6). Another participant stated, “Several things may not be very important in appearance, but they are very effective, and with doing them, we show to the patient that they are important to us. For example, the food service should be clean and tidy, not just let's put something in front of the patient and tell him to eat” (Participant No. 13).

Paying attention to the needs of patients' companions was also one of the important issues that participants points to its significant role in providing patient-centered care. “We should all be careful with the patients' companions and their welfare needs, especially in those who have hospitalized patients with chronic disease. Because these patients are usually hospitalized for the longest time and are hospitalized more often” (Participant No. 21).

Providing skilled and needed manpower was also one of the points that the participants emphasized on regarding the implementation of patient-centered care, which is also one of the rights of patients. “We did not have an emergency medicine specialist in our emergency ward. We brought the emergency medicine specialist to respond promptly and appropriately to emergency and critically ill patients to improve the level of care and treatment of patients” (Participant No. 14).

  Discussion Top

The results of this study revealed that providing value-based care, accountability in providing information, and providing suitable amenities are most essential for performing patient-centered care based on patients' bill of right. Quality in the health system is defined as providing safe, timely, effective, efficient, fair, and patient-centered care.[30],[31] Patient-centered care is one of the six pillars of the quality of the health system and one of the vital components of developing the quality of care, which is considered as a global issue today. Patient-centered care is a necessary element in improving the health-care system and gaining public trust, which reduces the average patient stay in the hospital, increases patient satisfaction, reduces hospital costs, and overall improves the treatment status, health outcomes, and patient's quality of life.[4],[6]

Providing culturally sensitive care is an essential element of patient-centered care. It is important for health-care providers to respect patients' value, culture, and beliefs to provide quality patient-centered care. This highlights the importance of paying attention to the cultural background and the bio-psychosocial needs of hospitalized patients.[32],[33] Value-based care is one of the topics in the present study and is one of the most important issues in providing patient-centered care based on patients' basic rights. Although humanism and human-centered care are considered as an underlying value in care systems, the main challenge in achieving this value in practice is up to care and treatment staff.[34],[35] It has been previously indicated that work systems are now dehumanizing employee behavior because health institutions focus more on technical skills. The management of these institutions seeks quantitative products, tasks, and control, and the health system is restricted in a bureaucratic model that does not value the individuals and is in conflict with a new view of the world that focuses on human beings and requires caregivers who prominently provide human care.[36],[37],[38] Evidence shows that despite the fact that the health-care system is expected to be based on human values, little success has been achieved in practice.[39],[40],[41],[42] Providing culturally sensitive and ethical care and paying attention to hospitalized patients' culture, value, and beliefs are absolutely crucial.[42],[43],[44] Furthermore, it has been previously indicated that the health professionals should provide the necessary and quality care to every patient, regardless of illness, gender, age, religion, language, morals, political beliefs, or social issues.[44] However, there are clearly several barriers to the implementation of ethical codes in health-care setting that should be assessed and removed.[45],[46],[47]

Based on the results of the present study, respecting the patient, paying attention to patients' criticisms and suggestions, accepting responsibility toward patients, justice in dealing with patients, and respecting patients' religious beliefs are among the duties of all health-care workers. Respect is a shared moral value among nurses, all of its codes have been documented at all local, national, and international levels.[48],[49] Involving patients in the care and treatment process to implement patient-centered care was also one of the important issues the participants in the present study emphasized. The results of the study by Oxelmark et al. showed that patient involvement means listening to patients, giving some responsibility to patients, and sharing power and cooperation with patients.[50] In this regard, Splaine Wiggins suggested that to involve patients, nurses need to share the responsibility and information with them include them in a decision-making process.[51] In addition, Nilsson et al. demonstrated that giving appropriate information to patients and their companions and involving them in medical decision-making can reduce the length of hospital stay and improved patient satisfaction with health care.[52]

The results of this study revealed that accountability in providing necessary information to patients and their companions is another component in providing patient-centered care based on patients' rights. In line with the present study, the results of a scoping review showed that the need to provide the necessary information in acute health-care settings is a very important factor for patients and their companions and causes patients to have more control over their disease and health care.[53] Despite many studies that have assessed the importance of providing information to patients and their companions, the results of a study in Finland indicated that patients' informational needs are often not met by their health-care providers, especially information regarding the prognosis of the disease and aftercare and patients' right.[54] However, due to the different needs of patients based on the type and nature of their disease, providing essential information should be based on their individual needs.[54],[55] Furthermore, the results of a qualitative study in Iran showed that during hospitalization, “the need for knowing” is an important needs of patients' companions.[56] Also, the results of another study in Finland showed that patients' relative received less information about the available financial support during hospitalization.[57] It has been shown that providing appropriate information to patients can reduce their anxiety about symptoms and improve their reassurance.[58] Furthermore, the results of present study emphasized to providing suitable amenities for patients and their companions to provide patient-centered care based on patients' rights. The results of a study in Iran revealed that only 58.4% of patients were completely satisfied with the hospital welfare services. The highest dissatisfaction of patients was with food services, hospital accommodation, and paid fees, respectively.[59] A study in Brazil indicates that patients' companions in pediatric ward were dissatisfied of their condition of staying in hospital.[60] In fact, patients and their companions believe that providing appropriate welfare services is appropriate when their physical, emotional, psychological, social, and moral needs are met.[61] Therefore, it is essential that providing suitable amenities for patients and their companions should be a component of patient rights. However, a study in Iran showed inappropriateness of provided hospital services for patients.[62] Therefore, by focusing on the quality aspects of hoteling services, policymakers and managers of health care can provide appropriate strategies for the provisioning of suitable amenities for patients and their companions to provide patient-centered care.[63]

  Conclusion Top

The findings of the present study provide a broad range of context-specific concepts that the Iranian health-care providers face in providing patient-centered care based on the patient's bill of rights. Understanding patient-centered care barriers, especially by health experts, can secure the patient's legal rights and provide a better and more quality service for patients and their families.

Conflicts of interest

There are no conflicts of interest.

Authors' contribution

MAA performed interview, analyzed the data, interpreted the result, wrote and revised the manuscript. GHM designed research contributed to contributed to the interpretation and edited the manuscript. JYCh interpreted the result, contributed to designed research, interpretation and edited the manuscript.

Financial support and sponsorship



The present study is part of the findings of the doctoral dissertation in the field of health services management. It was approved by the Ethics Committee of Chalous Islamic Azad University. The researchers would like to express their gratitude to all participants in the interviews and officials of the Islamic Azad University, Sari Branch, and to the organizations providing health and medical education services.

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  [Table 1], [Table 2]


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