Nurses’ attitudes and knowledge regarding patient rights: a systematic review

Objective: To synthesize current evidence on nurses’ attitudes and/or knowledge on the entire spectrum of patient rights. Method: A systematic search of the literature was performed in Web of Science, PubMed, Scopus and CINAHL. Studies were selected according to pre-defined inclusion/exclusion criteria. The Cochrane and PRISMA guidelines, including templates for systematic reviews, were applied. For rigor assessment, the Critical Appraisal Skills Program Qualitative Research Checklist, and the Center for Evidence-Based Management tool were employed. Results: Thirteen studies were included, that exhibited important methodological limitations, such as convenience sampling, mediocre response rates and inadequate instrument validity. Findings indicated: a) low level of awareness regarding patient rights among nurses, b) knowledge discrepancies on specific aspects of patient rights, c) low priority ascribed to a patient’s right to access information, and d) insufficient evidence on formal educational sources of knowledge on the topic of patient rights. Conclusion: Narrow geographical localization, heterogeneity and methodological limitations render generalizability of the conclusions difficult. Further research based on robust methodology is proposed. DESCRIPTORS Patient Rights; Ethics, Nursing; Health Knowledge, Attitudes, Practice; Professional Practice; Systematic Review. Corresponding author:


INTRODUCTION
Patient rights are directly linked to human rights. The former include the right to life, physical and mental integrity, autonomy, privacy and the right to a dignified treatment by healthcare providers (1) . The International Council of Nurses posits that nurses ought to protect patient rights, anywhere and at any time (2) . Thus, nurses are typically viewed as those advocating for patient rights (3) . However, for nurses to fulfill this role, several preconditions apply, including nurses' knowledge (4) and awareness of patient rights. Constructive attitudes, reflecting beliefs and actions, along with the ability to overcome barriers and further negotiate ethically challenging situations, are also crucial (5) . Therefore, when addressing patient rights, it is important to view these as a group of provisions that need to be balanced against each other, and potentially against other priorities, or even against limitations of the law.
Exploration of nurses' awareness on patient rights is important in shaping approaches to support nurses' moral behavior at the patients'/families' best interest (6) . Although various aspects of patient rights have been extensively addressed in the literature (e.g., the right to informed consent), it is difficult to form a comprehensive and integrative picture on patient rights, especially from the viewpoint of nurses. Studies investigating particular aspects of the patient rights topic do not provide evidence on: which rights receive low priority compared to others; possible inconsistencies between education and clinical practice; or advocating for patient rights (6) .
Based on the above, we aimed to systematically review and synthesize current evidence on nurses' knowledge and attitudes regarding the entire spectrum of patient rights. We explored evidence on a) the sources of nurses' knowledge, b) nurses' level of knowledge and associated factors, c) comparative knowledge on specific aspects of patient rights, and d) nurses' attitudes towards patient rights.

Type of sTudy
The following steps, that comprise the main features of a systematic review, were applied: (a) implementation of concise research questions and description of a replicated methodology, (b) systematic review of studies, selected according to predefined inclusion and exclusion criteria, (c) quality appraisal of the reviewed articles, (d) display of the characteristics and main results of the identified studies in a systematic and critical way.

selecTion criTeria
Inclusion criteria were set as follows: a) aim: investigation of nurses' attitudes and/or knowledge, either self-reported or actual (based on the number of correct answers in a patient rights knowledge test), on the entire spectrum of patient rights, irrespective of the methodological approach applied (qualitative, quantitative); b) sample: inclusion of nurses as the main study sample or as a subgroup of healthcare professionals (optionally along with adult patients); and c) form, language, date: full-text published reports from years 1990 to 2019, written in English. The excluded types of papers were: a) literature reviews, meta-analyses, abstracts, reviews, case reports, comments, editorials, letters, nonpeer-reviewed studies (dissertations, conference papers); b) studies surveying healthcare professionals other than nurses; c) studies that did not report on nurses' responses separately; and d) studies addressing a single aspect of patient rights (e.g. only privacy or autonomy), since we exclusively targeted studies that addressed patient rights comprehensively. This last decision was based on our firm belief that the clinicians' approach to patient rights reflects a set of provisions that can almost never be addressed independently from one another; most clinical situations call for a balance between different sets of rights and prioritization of principles. By targeting studies that address the entire spectrum of patient rights, we aimed to identify which rights may receive less attention by clinicians, as well as misconceptions and gaps in educational preparation. This is a difficult task if one looks at the evidence on discrete aspects of the patient rights spectrum. Developing insight into the elusive balances and priorities on the patient rights topic is a precondition for promoting advocacy and ethical decision making in clinicians (7) . Furthermore, aiming to increase the generalizability of the present findings to the entire population of healthcare service users, studies involving special patient populations were excluded. Specifically, studies on patients for whom certain legal issues may apply (e.g., psychiatric inpatients, hospitalized prisoners, individuals with substance use disorders) were excluded, since legislation may differ among countries, and studies originating from multiple backgrounds would not be comparable. Moreover, the inclusion of special populations (e.g., psychiatric patients) might raise distinct issues (e.g., compulsory treatment) which would increase the risk for selection bias.

daTa collecTion
A thorough search of electronic databases (CINAHL, PUBMED, Web of Science and Academic Search Complete) was performed in February 2019, using combinations of the following terms: "nurse*" OR "healthcare professionals" OR "healthcare providers" OR "healthcare workers" OR "healthcare personnel" AND "attitudes" OR "knowledge" OR "perceptions" OR "views" OR "opinions" OR "experiences" OR "awareness" AND "patient rights". An advanced librarian undertook the literature search. Databases were firstly searched for prior, relevant systematic reviews or meta-analyses. Reference lists of retrieved articles were hand-searched for relevant studies.

daTa analysis and TreaTmenT
The Cochrane guidelines (8) and Prisma reporting template for systematic reviews (9) were followed. Duplicate studies were removed and study titles and abstracts were independently checked by three reviewers to identify eligible studies. Abstracts and/or full texts were then studied by each investigator to define compatibility with selection www.scielo.br/reeusp Rev Esc Enferm USP · 2021;55:e03678 criteria. Data from identified studies were extracted, based on a pre-structured survey form, and were verified by all authors. Ambiguities were resolved through consultation. Extracted information included sample characteristics, study design, data and subgroup analyses, statistical methods and main outcomes. In cases of several respondent groups, data regarding nurses were isolated and extracted. Based on the selection criteria, 13 studies were included. The study selection process is depicted in Figure 1. The quality of included studies was independently assessed by three researchers (EP, MK, MM) and consensus was reached over common meetings. The quality of identified quantitative studies was assessed with the CEBM tool (Center for Evidence-Based Management) (10) . This tool includes 12 questions: (i) Does the study address a clearly focused question / issue? (ii) Is the research method (study design) appropriate for answering the research question? (iii) Is the method of selection of the study subjects clearly described? (iv) Can the way the sample was obtained introduce (selection) bias? (v) Is the sample representative of the population to which the findings will be referred to? (vi) Is the sample size based on pre-study considerations of statistical power? (vii) Has a satisfactory response rate been achieved? (viii) Are the measurement tools likely to be valid and reliable? (ix) Has the statistical significance been assessed? (x) Are confidence intervals given for the main results? (xi) Could there be confounding factors that haven't been accounted for? (xii) Can the results be applied to your organization?
For the assessment of rigor of qualitative studies, the Critical Appraisal Skills Program Qualitative Research Checklist (CASP) (11) was used, which included the following questions: (i) Is there a clear statement of the aims of the research? (ii) Is a qualitative methodology appropriate? (iii) Is the research design appropriate to address the aims of the research? (iv) Is the recruitment strategy appropriate to the aims of the research? (v) Are the data collected in a way relevant to the research question? (vi) Has the relationship between researcher and participants been adequately considered? (vii) Have ethical issues been taken into consideration? (viii) Has data analysis been sufficiently rigorous?  Figure 1 -Flow diagram for identifying and including references in the present systematic review based on PRISMA guidelines strategy (9) .

RESULTS
The included studies are summarized in Chart 1. We included 13 quantitative studies, conducted in 8 different countries. These studies involved, among other healthcare professionals and patients, 3212 nurses in total, with sample sizes ranging from 80 to 939. Overall, these studies investigated nurse-reported awareness on the patient rights topic and their views regarding unsatisfied demands of different aspects of patient rights, i.e., patient autonomy, privacy and informed consent. Many data were collected through Likert-type survey questionnaires specifically developed for the purpose of each study.

QualiTy assessmenT
Random sampling was employed in two quantitative studies, whereas the rest employed variations of convenience sampling, which may have jeopardized external validity. Apart from six studies with a response rate (RR) between 94.7% and 100%, RR ranged between 50% and 88%. A low response rate may indicate systematic bias, since nurses who did not consent to participate may have had different views compared to those who participated. Small sample sizes together with convenience sampling may have affected the external validity of reported results. Other limitations stem from novel survey instruments; although in most studies the steps of the instrument development are described, issues of validity remain. Moreover, heterogeneous survey tools render comparisons between studies challenging.

specific findings
Sources of nurses' knowledge on the patient rights topic. Seven studies addressed nurses' sources of knowledge on patient rights, exhibiting, however, considerable diversity (12)(13)(14)(15)(16)(17)(18) . The most common sources included undergraduate curricula courses on patient rights, education on nursing ethics, informal experiential learning in the workplace and brochures found in hospitals. In particular, nurses in Egypt identified undergraduate nursing courses, educational programs and sharing experience with colleagues, and to a lesser extent the media or hospital brochures (12)(13) . Nurses from Turkey reported ethics content to be part of the hospital educational program during nursing orientation training (14) . One Iranian study found that nurses with a Master's degree and sufficient work experience seemed to be more aware regarding patient rights (15) , while according to a different Iranian survey, one third of participants had not received any relevant education (19) . On the contrary, most nurses in Finland (61%) (20) reported that they had received formal training related to ethical issues. Nurses in Sudan, Turkey and Barbados reported that hospital training and learning through work were the most prominent sources of knowledge, followed by lectures, seminars and personal study (16)(17)(18) .
Nurses' level of knowledge on patient rights and associated factors. Nurses' level of knowledge on patient rights, either self-reported or actual, was addressed in 12 out of 13 studies (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23) , while the actual level of knowledge was reported in only 2 of these studies (16,20) . Despite low self-perceived levels of knowledge in the majority of the samples reviewed herein, when a knowledge test was administered to the Finnish (20) and the Sudanese (16) nurses, a notable discrepancy was seen between actual and self-reported levels, with 68.8% and 65.8% of respondents respectively scoring highly on the actual knowledge test. The highest self-reported level of knowledge came from the sample of nurses in Turkey (17) . Overall, the relationship of knowledge about patient rights with relevant nursing roles and actual nursing practice may be unclear. In the study involving hospital nurses in Nigeria (21) , no relationship was observed between nurses' level of knowledge and advocating for the rights of patients.
Regarding knowledge on relevant legislation, the percentage of participants reporting being aware of the general provisions of the law on patient rights ranged from 50% to over 90%. Half of the respondents in Egypt (12) , Sudan (16) , Barbados (18) and Finland (20) were not familiar with the content of law on patient rights. Slightly higher self-reported level of knowledge about legislative provisions were observed in the two studies from Iran (82% and 58%, respectively) (15,19) .
As for the factors associated with nurses' knowledge about patient rights, the finnish study (20) concluded that older age, advanced years of clinical experience and personal perception about the importance of patient rights were all positively associated with knowledge on patient rights. In two Iranian studies, the level of nurses' knowledge about patient rights was positively related to employment in academic hospitals (22) and the level of education (15) , while in a study from Turkey (17) the level of knowledge was related to the nurses' marital status, as well as the circumstances under which the participants firstly heard about patient rights or were faced with a relevant problem.
Comparative knowledge on specific aspects of patient rights. Nurses' knowledge varied across different patient rights and across studies; however, comparisons are challenging due to an observed heterogeneity in measurement tools used for the assessment of nurses' knowledge on patient rights. In Finland (20) , the authors assessed nurses' knowledge through a 47-item questionnaire, divided in five topics of patient rights: quality of healthcare treatment and access to it, selfdetermination, access to information, confidentiality, and support of patient ombudsman. The highest knowledge level was observed on issues around quality and access to care, while the lowest regarded patient ombudsman issues. Differences were also noted among different types of nursing personnel, with public sector and bachelor's degree nurses exhibiting slightly higher levels.
In two studies in Iranian nurses, the "right to preserve privacy and confidentiality regarding medical information" received the highest knowledge score, while the patient's right to information about healthcare professionals and cost of care, as well as the right to access personal medical records received the lowest rating (15,19) . Similarly, the patient's right to receive information about a healthcare team received the lowest score among Sudanese nurses (16) . In a Turkish study, 99.1% of the responders stated that they safeguard patients' privacy during care and treatment, while 94.3% were concerned about keeping a patient's secret (14) . Equally, in one Egyptian study (13) , the "patient's right to receive respectful care" scored the highest, while the "patient's right to refuse prescribed treatment" the lowest.
Nurses' attitudes toward patient rights. Six studies (14,(17)(18)21,(23)(24) directly addressed nurses' attitudes towards the topic of patient rights, while the researchers draw in 2 more studies relevant conclusions, although this was not included in the main purpose of these studies (15,22) . An Iranian study (24) used a 21-item questionnaire through which nurses' attitudes towards the patient rights to privacy, non-discriminatory treatment and freedom to choose therapy were assessed; the participants put less emphasis on the patient's right to access personal medical records, while emphasized both the www.scielo.br/reeusp Rev Esc Enferm USP · 2021;55:e03678 environment, with respect and no discrimination (17) , while in another Turkish study nurses emphasized positive attitudes towards the patient rights to privacy, confidentiality and informed consent (14) . On the contrary, a Korean study on nurses' attitudes towards the patient rights to autonomy, privacy, informed consent and confidentiality revealed that the respondents had poor awareness on these topics (23) .
need for access to an active complaint system, and for disclosure of medical errors. In a survey in Barbados (18) , adherence to patient wishes was not viewed as important by 77% of respondents, while in Nigeria, 91.8% of the sample agreed that nurses should have an advocacy role (21) . In a Turkish study, approximately 98% of respondents agreed that healthcare services users should be cared for in a safe and friendly  knowledge and attitudes among nurses in diverse healthcare settings is missing. The limitations of the present review process must also be considered. We confined our search to databases that were more likely to render biomedical studies rather than philosophical literature. This decision was made in order to target nursing personnel. Still, we do not deem this as an important source of bias, in as much as checking for cross-references either electronically or by hand did not yield studies indexed in other databases.
The small number of studies addressing nurses' knowledge and/or attitudes towards patient rights is remarkable, especially in view of evidence on multiple ethical dilemmas among nurses (12,19) . One reason could be that nurses may consider that they fulfill their moral obligations by abiding by the codes of ethics of the nursing profession (25) . Codes of ethics do encompass patient rights issues, albeit not in detail, and receive high priority among regulatory and professional bodies (26) . An additional reason could be the "non-visible" nature of patient rights, which may be viewed as a counterincentive towards conducting relevant studies (27) .
The overall level of knowledge regarding patient rights was found to be low, despite the fact that human rights and protection of the public both receive high priority in the nursing codes of ethics (2) . Given the role of nurses as patient advocates and educators, low level of knowledge on patient rights among them may also be associated with low patient rights awareness among patients themselves (6) . Nonetheless, a

DISCUSSION
The present review demonstrated data that support: a) a low level of knowledge regarding patient rights among nurses, b) insufficient evidence regarding sources of knowledge on patient rights for nurses, c) insufficient data on nurses' attitudes towards patient rights, d) discrepancies regarding knowledge on specific aspects of patient rights, both across and within groups of respondents from different countries, and, finally, e) a low prioritization by nurses of the patients' right to access information about the care they receive. Moreover, a lack of methodologically robust studies addressing nurses' knowledge and attitudes towards the entire spectrum of patient rights was identified.
These results need to be considered in view of significant limitations related to the studies from which they stem. Convenience sampling within the research settings and mediocre response rates are significant shortcomings of the included studies. Additionally, assessment tools were often used for the first time with undefined validity, as implied by the notable discrepancy between actual and self-reported levels of knowledge. Moreover, interpretation and synthesis of results is hindered by the great heterogeneity in assessment tools and study populations. The scant representation of European and North American nursing populations is also remarkable. The geographical localization of studies in eastern Mediterranean countries precludes more broad conclusions. Additionally, evidence on the difference in high level of knowledge does not guarantee implementation in practice, as several barriers may exist, including coercion and conflicts of interest (21) .
The present review suggests potential deficiencies of preand post-registration education on nursing ethics. Gaps in nurses' knowledge may be related to outdated and rigid sources of knowledge, as well. Our results indicate undergraduate curricula as the prevailing source of knowledge on patient rights across countries. However, gaps in undergraduate nursing education regarding ethics and patient rights have been consistently reported in the literature (22,28) . Moreover, disillusionment and encountering ethical misconduct during undergraduate nursing education have been identified as barriers to the development of moral agency in nursing students. Providing opportunities for ethical reflection, rather than lecture-based training alone, has been suggested as a powerful means of instituting ethical principles (3) .
It is noteworthy that brochures and print-outs on patient rights issues were not reported frequently among main sources of knowledge. Therefore, it appears that the popular practice of posting a bill of patient rights in hospital wards can only have a minimal impact on raising awareness among health professionals. Additionally, alternative sources of knowledge, such as colleagues and peer communities, need to be purposefully addressed to increase insight on patient rights.
Although discrepancies in the type and scope of assessment tools render comparisons of knowledge levels on specific patient rights challenging, the results also raise the possibility of discrepancies between actual and self-reported levels of knowledge, with a potential underestimation of real knowledge. This needs to be taken into account in future research. On the other hand, the often-commonsensical content of several provisions of patient rights might also account for deceptively high scores in knowledge tests, even among nurses who report being unaware of the law. While intuition may inform many of the ethical decisions that nurses make (25) , it may also bear pitfalls inasmuch as clinicians may base their judgments on misperceptions rather than on actual knowledge of legislative provisions. The identified studies regarding exploration of factors related to nurses' knowledge on patient rights are limited. However, attitudes appear to be associated with the degree of knowledge (29) . Nurses' knowledge and attitudes towards specific articles of patient rights may be associated with the type of unit nurses are employed in, since different ethical issues arise at different clinical settings (7) . This may account for variance in nurses' awareness due to differential exposure to ethical issues. Although the findings of the Finnish study suggest slightly higher knowledge levels among public sector nurses (20) , overall, data are limited in this respect. Therefore, the clinical setting could be an important determinant of awareness on patient rights.
This review suggests that nurses may be more aware of aspects of the law regarding issues of care quality and access to care, and less aware about patients' freedom of choice. It is worth exploring whether such "partialities" may be associated with inherent priorities dictated by the healthcare system and patients themselves. Although no firm conclusions can be drawn due to data heterogeneity, this review suggests that the patient rights to information and freedom of choice may be jeopardized. This issue is intricately involved in the patient's right to autonomy, which has been suggested as being problematic in previous studies (30) .

CONCLUSION
The scarcity of relevant literature, the narrow geographical localization of identified studies, as well as study heterogeneity and methodological limitations render generalizability of conclusions difficult. The results suggest low levels of awareness regarding patient rights among hospital nurses and discrepancies regarding knowledge and attitudes towards specific rights, both across and within groups of respondents from different countries. Moreover, the results highlight deficiencies of pre-and post-registration education on nursing ethics and identify potential factors associated with nurses' knowledge level, such as positive attitudes and more years of nursing experience. The relationship between knowledge on patient rights and implementation of those rights in everyday practice, as well as the existence of potential barriers to implementation, have not been adequately addressed to date and merit investigation.