Nursing Interns ’ Perception Regarding Patients ’ Rights and Patients ’ Advocacy

The role of patient advocacy is not new for nurses, but an advocate is a “supporter, believer, sponsor, promoter, backer, or talk person. Advocate is someone you trust who is apple to action on your behalf as well as someone who can work well with other members of your health team as your medical staff and nurses. [5][6][3][7] emphasized that advocacy is very important nursing role specifically when nurses involved in actions. Lack of patients and nurses supports leads to improper consequences for both. Also, student nurses need an appropriate chance to experience, express their thoughts, emotions and their moral values.

in ethical and legal frameworks as a philosophical foundation for practice. Advocacy also explained in terms of specific actions such as supporting the patient to obtain needed healthcare services, assuring quality of care, protecting the patient's rights, and serving as a coordinator between the Patient and the health care settings.
The role of patient advocacy is not new for nurses, but an advocate is a "supporter, believer, sponsor, promoter, backer, or talk person. Advocate is someone you trust who is apple to action on your behalf as well as someone who can work well with other members of your health team as your medical staff and nurses. [5] [6][3] [7] emphasized that advocacy is very important nursing role specifically when nurses involved in actions. Lack of patients and nurses supports leads to improper consequences for both. Also, student nurses need an appropriate chance to experience, express their thoughts, emotions and their moral values.
Healthcare climate contain many factors that appear the need for advocacy, therefore, there is a need for advocate from health care staff members especially for patients with impaired self advocacy role. Advocacy main objective is to encourage a change in one's self or environment, an organization, program or service, and in rules and regulations. However, healthcare institutions activities focus on health conditions promotion, healthcare resources, the actual and potential needs of the clients and community in general [8][9] [10] .Advocating patient rights is not easily job for nurses in practice settings, the majority of nurses confront obstacles within their work environment that hinder advocacy of patient rights. Therefore, there are a high expectations that advocating patients can't be met when there is a need to protecting their rights, choices and welfare [11] [12] [7] [13]. [14][15] [16] Illustrated that patient's rights submitted under the umbrella of human rights to which patients are entitled while they are undergoing care at healthcare services. Generally, rights are supported and enforced by interactional agreements, laws, and other legislations, which consider abase foundation of the humanity of individuals who require healthcare services. Nursing

Introduction
Healthcare organizations characterized by rapidly change work environment which include a lot of factors that affect practice of ethical patient care. Many associations develop code of ethics for nurses that guide professional nurses how to protect patient rights during healthcare. Ethical principles are vital to the nurse patient relationship and reveal a thought of reverence towards patients as human beings and towards patient's rights [1] [2][3] [4]. Reported that advocacy has been described recently advocacy role stimulated and enhanced based on the main patients needs and requirements. Advocacy is important for vulnerable groups such as elderly people, younger generation, people who live in institutions, prisoners and handicapped or disabled persons. Healthcare team including nurses, medical staff, technical people and social workers and others defined patient advocacy as a process of informing clients who attempt to find healthcare services with appropriate information. Also, there is an important explanation about the appropriate method of nursing education about their role in protection of patients rights [17] [18] [19].
Important principles of patient's rights are the fair relationship with the patient and family's privacy and respecting the privacy of patient information. Additionally, providing care and treatment without discrimination regarding gender, ethnic group, accent, citizenship, type of insurance and poverty should never prevent patients from availability to healthcare with dignity. Lack of application of patients' rights causes stress for patients, their family and can cause bad reputability of healthcare organizations [9].Healthcare team play important role in the application and protection of patient's rights. In this context, nurses are expected to provide safe ethical comprehensive patient care. Particularly, nurse as a direct care provider assign for the role of patients advocacy rights, such as supporting patients to make decisions about themselves. Sometimes nurses act on behalf of patients who can't advocate their rights [20] [21] [22][10] [23].
Global evolution affecting societies worldwide such as believes, economical, governmental and moral issues also influencing our perception of what is meant by "human rights". Overall, the main reason for mandating patients' rights and increase cooperation to legislation is the respecting of consumer rights as a necessary part of conducting quality patient care [24] [25]. Patients' rights founded as one of the basic criterion of healthcare services. As a concept, patient's rights attracting attention and interest of international governing body supporting human rights. Therefore, applications of patients' rights have a major impact on health care throughout the world [26] [27] [28]. The majority of patient's bills of rights are directed to informed consent, confidentiality, privacy, autonomy, safety, respect, alternative treatment, reject the therapy and sharing in the regimen of care plan. These rights are obtained from the values and ethical codes of the profession. Patients must be eligible to gain appropriate interpretations of the pertinent information, relevant choices available and appropriate for them, patients shouldn't be forced to be involved in specific treatment that contradict their well [29] [30].

Significance of the study
Nurses play a critical role while providing patient care; certain patients' condition required who acts on behalf. Professional nurses are in direct contact with patients. So, they are in the best position to act as a liaison between patients and other different health care providers and hospital departments. Nurses must have positive work conditions and relationship with other health team member to act as an advocate in appropriate way [31].
Egyptian hospitals struggle for adhering to accreditation standards that obligated each hospital to monitor and evaluate practice of patient's rights and advocacy among health care provider. Few researches were found about nurses' experience during internship year regarding their role as an advocate for patient rights. During this period of experience nursing interns' pass with transitional period from being unlicensed student nurse to graduate nurses'. Moreover, they considered junior nurse who characterized by little experience, restricted awareness and inflexibility. [32] Emphasized that nursing intern's learning about the role of patient as an advocate is a complex process that has not been discussed clearly. Added that nurses interns involved in action in work environment that characterized by inadequate support of patients and nurses. Therefore this study is an attempt to assess nurses' intern perceptions regarding patients' rights and patients' advocacy.

Aim of the study
Aim of the present study is to assess nursing interns perceptions regarding patients' rights and ' advocacy

Subjects and methods
Research Design: Descriptive design was utilized in this study. .

Research Questions
What is nurses' intern perceptions regarding patients' rights and advocacy?

Setting
The present study was conducted at Cairo University Teaching Hospital where nurses' interns were trained in the following settings (pediatric intensive care unit (ICU), emergency ICU, high risk ICU, and medical ICU).

Tools
Data for the present study was collected through utilizing the following two tools:, 1-Patient right questionnaire comprises from two parts a-First part: personal characteristic data, was developed by the researchers, it includes such data (sex, age, and marital status, training area ).
b-The second part: was patient right questionnaire modified from [33] , it composed of 15 questions divided into four domains as follows : patients rights to receive respectful and non-discriminatory service (three items ); patients rights to access their own information ( seven items ); patients rights for choosing and deciding freely (three items ) and patient right to follow up their complaints and revealing medical errors (two items ).
Patient advocacy questionnaire was assessed using two-point likert scale (1= yes and 2= indicate no).

Validity and reliability
After the translation of the two questionnaires to Arabic, they were given to five experts specialized in nursing administration, to check the adequacy of items that cover the concepts under investigation. Based on their advise little modifications were made.
Test of reliability for the patient right questionnaire Cranach's coefficient alpha showed 0.97 during pilot study. Also, reliability test for patient advocacy questionnaire 0.87. This indicated that two questionnaires are highly reliable.

Pilot study
A pilot study was carried out on a sample of 10% before starting the actual data collection to ascertain the clarity and applicability of the study tools. It also to measure accessibility and feasibility of the instruments and time consumed in filling tools. Based on the outcome of the pilot study nursing interns' agreed about the questionnaires clarity and applicability. The average time consumed to fill the questioners ranged from 15-20 minutes.

Ethical consideration and Procedure
An official permission was obtained from the head of nursing administration department.
Also, the researcher seeking approval of medical and nursing directors of hospitals where's the study conducted. Permission was also taken from the health facilities' authorities and verbal informed consent obtained from the respondents before the questionnaires were administered. Purpose and aim of the study was explained for the participant prior their participation on the present study by the researcher. Participants were assured about their response confidentiality. Data was collected after five months of nursing interns' starting of the internship year.

Procedure
Once permission was granted from the medical and nursing directors of the selected hospital to proceed with the prepared research, the researcher explained the study purpose to the study sample. They informed that participation was voluntary. Questionnaires were distributed to the study sample at their practice area, during morning and afternoon shifts, with complete explanation of how to answer each questionnaire. They were filled in and collected at the same shift. The collection of data for the present study was completed over two months (January and February 2016).

Statistical design
Collected data were organized, tabulated and statistically analyzed using statistical package of the social sciences "SPSS" software version 21. Frequency, percentage were calculated. The F value of analysis (ANOVA) was calculated for comparison between more than two means. Significance of interpreted results was adopted at p<0.05.

Acknowledgment
We should like to think to nursing director of Alkasar El Aini hospital and our participant nurses interns for their role in the completion of this research Table 1: showed that the percentage (24.3%) of the study participants were from pediatric unit. The highest percentages (64.9%) of the study participants were female. Most of nurses intern (73.9%) their age less than 23 years. Also (84.7%) of the study participants were single. Table 2: the table illustrated that the highest mean percent as perceived by nurses' interns toward rights to receive respectful and non-discrimi natory service and right for choosing and deciding freely (79.6 and 71) respectively. While, the lowest mean percent was the right to follow up their complaints and revealing medical errors and rights to access their own information (68.9 and 69.64) respectively.

Discussion
Worldwide, maintaining and supporting patient's rights become at the priority of health care decision makers and healthcare givers. Patient advocacy is one of the main aspects of nursing profession, the main aspects that measures patients' satisfaction and quality of care during hospitalization is the application of patients' rights [35][36] [37]. The present study revealed that the highest mean percent of nurse's interns' perception regarding patient rights was rights to receive respectful and non-discriminatory service. From the researcher point of view, nursing intern's perception reflected studied knowledge in undergraduate courses that stress equity and fairness of healthcare services accessibility. Also, they know the consequences of acting in unacceptable way or using discriminative approach may threaten their careers and expose them to liability. In agreement with this study, [38] [39] found that nurses awareness about patient's rights were high, they agreed that patients had the right to receive respectful hospitalization and equal treatment regardless race nationality, sex, age, religious.
Results declared that the second highest mean score as perceived by staff nurses was right for choosing and deciding freely. Researcher attributed that most of patients nowadays becoming more literate and their level of awareness about their rights improved and hospital administrators disseminate patient rights all over the hospital. In this respect [40] revealed that nurses provide patient with sufficient information to make decision. Present study results revealed that the least mean score as perceived by nursing interns' that patients have the right to complaint and errors should disclosed to them. Researchers interpretation of this result that the study carried out in teaching hospital, that most of patient receiving care within the hospital were low socio economic status and have no chance to find other hospital provide them with treatment if he/she had complaint. Furthermore, the culture of disclosing errors still low within the healthcare organizations. In agreement with the present study results of [41] who reported that respondents underreporting of errors because of their fear of career planning /advancement to be affected, fear of transfer to unfavorable unit, and incentives Table 3: showed that the highest mean scores were (1.38 ± 0.49) as perceived by nurse's interns' toward patient advocacy, that patients should be provided with interpreters to communicate with health care staff. Followed by, health care staff introduces themselves and request an appropriate assessment and management of pain (1.36 ± 0.48). While, the lowest mean score (1.19 ±0.40 and 1.22 ± 0.41), was to informed patient about the necessary directives and procedures and be provided with appropriate medical services respectively.

Nurses interns' perception regarding patients' advocacy
Mean SD    [42] mention that physicians afraid to disclose errors due to their fear from mistrust of client and the psychological impact on the patients and their relatives.
Regarding patient advocacy the data of the present study revealed that nurse's interns highly perceived that patient should be provided with interpreters to communicate with health care staff. From research point of view this seems logic as foreigner patients must have a translator to communicate properly with the health team. This result supported by [43] who admitted that respondents mostly agreed that patients have the right to get translator. Also, nursing interns perceived that staff should introduce themselves and request an appropriate assessment and management of pain. From researcher point view introduction of staff for others improving communication, decrease stress in the caring relationship. Furthermore, from the first year in studying nursing they were asked to introduce themselves in each procedure they perform. Incongruent with the present study [9] who showed that the patients perceived that their rights had been ignored by health providers in many cases e.g informing patients about their rights on time of admission to the hospital, identify the name of healthcare providers and information about hospitalization costs Moreover, present study revealed that there was no statistical significant difference between sex, marital status, and age and nursing interns' perception of patient right. This interpreted by the researcher as nursing interns considered homogeneous group nearly have the same age, background and experience therefore their opinion regarding patient rights considered the same. Incongruent with the present study [47] [46] who revealed a significant difference between the respondents level of education, age and their awareness of patients' rights. Also, [45] [28] reported that there was statistical significant difference between age and patient right. Furthermore, the study revealed that there is no statistical relation between age, marital status and patient advocacy. Opposite of present study result, [45] revealed that there was significant relation between age and patient advocacy.

Conclusion
Findings of the present study conclude that the highest mean score of nurse's interns perception regarding patient rights was to receive respectful and non-discriminatory service. The lowest mean score as perceived by nursing interns was the right to follow up their complaints and revealing medical errors. Regarding advocacy, highest mean of nurses' intern was regarding that patients should be provided with interpreters to communicate with health care staff. While, the lowest mean regarding advocacy, was to informed patient about the necessary directives and procedures. Moreover the present study revealed that patient right and advocacy had no significant relationship with the socio-demographic data which include (age, sex, marital status) while both had positive significant relationship with clinical area.

Recommendation
Based on the result of the present study the following recommendations were suggested: 1-Developing and disseminating disclosure policy hospital wide.
2-Developing system for patient's complaints follow up and management.
3-Collaboration should be planned between hospitals and faculty of nursing to provide regular education to all health care team about patient rights and advocacy issues.
4-Faculty members and clinical instructors must act as a role model and facilitate learning by providing an environment that promotes holistic care, protecting patient rights 5-Further researches are recommended to be done in the future to: -Identify effect of patient rights and advocacy program on nurses' perception of patient rights and advocacy; -Assess nurses' adherence to code of ethics; -Address barriers for healthcare giver application of patient rights and advocacy -Asses' patient point of view regarding their achievement of rights.