RIGHTS AND DUTIES IN HEALTH CARE: NURSES’ RIGHTS

The purpose of this study is to describe nurses’ conceptions and experiences of their rights in Italian nursing practice. This study is a part of a larger research project aimed to develop practical and theoretical understanding of nurses’ rights. The rights of a profession are a basis of an occupation, in association with duties and responsibilities. There are few previous studies regarding nurses’ rights and no one in Italian context. Previous research regarding nurses’ rights has mostly been fragmented and theoretical. The basis of nurses’ rights is in legislation and ethics in terms of basic and civil rights, health care legislation, professional ethics and earned rights. This study is qualitative. Data will be collected in May-June 2011 within the focus group using themed interviews (N=37) and analyzed by inductive content analysis. The tentative findings from the analysis can been categorized into three main themes in terms of nurses’ conceptions of their rights as a phenomenon, nurses’ professional rights and the legislation basis of nurses’ rights. Although nurses' rights are widely present in everyday work, awareness of them is poor.Nurses’ rights are a separate and defined issue in professional ethics, but also multifaceted phenomenon that is closely connected to other issues in nurses’ everyday work. Nurses’ rights are part of good care, not contradicted by other rights. They are emancipator by nature, albeit aimed to improve the quality of patient care. Due to daily encountering of their rights, nurses have to obtain more capability to discuss and promote their rights. In nursing science as well as in nursing practice, there is an obvious need for awareness of rights.

Pertaining to rights in health care, the focus has been on patients (Fletcher & Janet 1995, Griffith & Tengnah 2008), emphasizing the rights of the patient and the duties of nurses towards the patient. They are closely connected to nurses’ duties. Over the last decade, the duties of nurses have been widely studied from many points of view (Glick & Bruuis 1997, Elder et al. 2003, Tzeng 2003),which cannot be said about their rights. When the rights and responsibilities of nurses have been discussed, it has been within the context of interpersonal relationships, i.e., that of nurse-patient or nurse-doctor.

Despite the importance of nurses’ duties, the point of view of rights represents the current Western way of individual-centered thinking about equality widely in society and closely in health care. From an ethical perspective, duties and rights constitute a whole, from nurses’ point of view as well. There are few studies of nurses’ rights in nursing science (Kangasniemi et al. 2010, Viitalähde et al. 2010). However, nurses’ rights are in a key position in health care and are both national and international by nature. From a national perspective, legislation in each country varies, but from an international legal and ethical perspective it is a common basis of nurses’ rights. (Kangasniemi et al. 2010.)

Using the definition of ethical questions of Thompson et al. (2000) in at least four different areas in health care, nurses’ rights involve all these areas: firstly, they are part of ethics and legislation within the level of political ethics of general health policy. The questions here include the status of nurses in society, their duties and rights and the goal of health care. Secondly, they are part of ethics in managing nursing services: how nurses’ work is organized and how their duties and tasks in health care are defined. Thirdly, they are linked to the question of professional nursing ethics, i.e., nurses as a profession in relation to other professions in health care as well as to the status of patients. Fourthly, questions of nurses’ rights are part of clinical nursing ethics: what kinds of rights are defined as ethical guidelines and how they arise in nursing practice with patients. (Thompson et al. 2000, Kangasniemi et al. 2010.)

There are few previous studies on nurses’ rights, they are not empirical (Kangasniemi et al. 2010, Viitalähde et al. 2010) and they concern questions such as the right to strike (Dimond 1997, Ketter 1997, McHale et al. 2001), the human rights of nurses (Ketter 1997, McHale et al. 2001, Hardingham 2004), and rights of professional ethics (Maze 2005).Previous research has not been systematic and has ranged from important but specific and isolated questions (i.e., the right to strike) to broad and complicated issue of nurses’ human rights. There is a clear need for both theoretical and empirical research on nurses’ rights. (Kangasniemi et al. 2010, Viitalähde et al. 2010)

This research project is a sub-project of the main project of Professor Anna-Maija Pietilä at the University of Eastern Finland: Early intervention and ethics in health promotion (Table 1). This is a Post Doc research project of University Lecturer, PhD Mari Kangasniemi, grounded on her doctoral thesis (2007). The name of the research project is Rights and duties in Health Care, and this research plan concentrates on its Part II, data 4: Nurses’ Rights in Italy. The object of Kangasniemi’s research project is to describe nurses’ rights both conceptually and empirically,  and the aim is to develop theoretical and empirical knowledge of nurses’ rights for use in nursing science, teaching and developing of health care. 

Table 1. Relations of main project, sub-project, topics, parts and data.

Nurses’ Rights: Research Project with three parts

This research project has been divided into three parts. In the first part (Part I) calledTheoretical Framework of Nurses’ Rights (2008-2009), a tentative conceptual framework regarding nurses’ rights was developed. The research method was theoretical research, and data were collected by systematic literature review (Viitalähde et al. 2010). Knowledge based on systematic literature review connected to other research literature regarding rights. As a result of the first part, a tentative conceptual framework regarding four bases of nurses’ rights was obtained: human and civil rights, rights based on legislation of health care, professional rights, and earned rights. (Kangasniemi et al. 2010.) This result is the first tentative conceptual framework regarding nurses’ rights. It aims to be a framework for later empirical research in this research project.

The second part (Part II) of this research project is named Empirical Point of View to Nurses’ Rights (2010-2011). The aim of this part is to develop empirical knowledge of nurses’ rights. Data will be collected by interviewing nurses regarding their conceptions and experiences of nurses’ rights. Previous research on nurses’ rights does not exist. This research plan will concentrate on this second part of research and clarify it in more detail later in this paper.

The third part (Part III)of the research project is a Synthesis of Theoretical and Empirical Study (2011-2013), aimed to further developing of concepts regarding nurses’ rights. This synthesis is based on previous theoretical and empirical research parts on this project. As a result of this part a tentative conceptual model of nurses’ rights will be developed. 

1.    Adding theoretical knowledge regarding nurses’ rights:

a.    Target: Further development of concepts regarding nurses’ rights.

b.    Method: Tentative theoretical framework of nurses’ rights and synthesis of previous research aiming at a tentative conceptual model of nurses’ rights.

2.    Adding empirical knowledge of nurses’ rights:

a.    Target: Obtaining empirical knowledge of nurses’ rights in several nursing environments.

Method: Empirical interview data and analysis

Selection of the Data: There is little previous research focusing on nurses’ rights, and empirical research does not exist (Kangasniemi et al. 2010, Viitalähde et al. 2010). Due to this, empirical qualitative data collection is required (Fontana & Frey 2000, Polit & Beck 2003). Using nurses as informants is appropriate because they are experienced (Speziale 2007).

Selection of the Method: Qualitative research was selected as a research method, in terms of catching phenomena of nurses’ rights in their natural context (Polit & Beck 2003, Bruns & Grove 2005). Interview as a data collection method was appropriate, based on the presupposition of reaching the research phenomena conceptually. In this research, theme interview was selected as data collection method, because a conceptual framework exists based on previous research (Polit & Beck 2003). The skeleton of the theme interview consists of a conceptual framework developed in the first part of the research project and open questions. Semi-structured interview is suitable for research of nurses’ rights as well, because the interview topic is limited, but thoughtful and deep concentration on the topic achievable (Fontana & Frey 2000, Polit & Beck 2003). Focus group interviews with 3-4 informants was selected, because the phenomenon of nurses’ rights is quite social by nature and mutual communication during interview was desirable (Mäenpää et al. 2002, Eskola & Suoranta 2005, Sipilä et al. 2007).

Data Collection: Because of lack of previous empirical study, the data collected in this study will be multifaceted and extended. Data will be collected in several nursing environments and countries (data 1-4, Table 2). It is expected that several nursing environments give rise to  multifaceted perspectives on nurses’ rights. Due to national variation in terms of  legislation and culture, (Pritchard 2005, Smith & Mackintosh 2007), data will be collected internationally.

Analysis of the Data: Data will be analyzed by inductive content analysis (Polit & Hungler, 1999, Granheim & Lundman, 2004). According to Polit and Hungler (1999), content analysis is the process of organizing and integrating narrative, qualitative information according to emerging themes and concepts; classically, a procedure to analyze written or verbal communications in a systematic and objective fashion, typically with the goal of finding quantitatively measurable variables. The text will be reviewed and analyzed by manifest meanings with a word, combination of words, clause, clause unit or meaning unit (see Granheim & Lundman, 2004, Hsieh & Shannon, 2005) selected as unit of analysis. After analysis, categories and content areas will be created and defined, named according to the focus content of connective units (see Cavanagh, 1997, Granheim & Lundman, 2004). Content areas will furthermore connect together, form unambiguous and exclusionary main categories with relation to each other. Two researchers will categorize the data together and the content areas will be confirmed by two researchers' consensus (see Granheim & Lundman, 2004).

Preservation and Later Use of the Data: Collected data will be used only in this research project due to being answers to presented research questions (Kuula 2007).

Ethical Questions of the Research Project: At the beginning of the research project, selection of the research topic has been evaluated from an ethical perspective (Lötjönen 2003). The conclusion was that research would yield ethically valuable knowledge. The topic might be ethically sensitive or personal to some informants; confidential interviews will be performed in small focus group. Participation is anonymous, voluntary and based on written agreement of participation. Participants have the right to withdraw at any time during the research process. The research project has been ethically evaluated at every institution where data were collected. The research project will be conducted in compliance with research ethical guidelines. (Mäkelä 1991, Pietarinen 2002.) 

 Expected Results of the Project

The results of the research project will be published in both  national and international scientific journals. The knowledge produced by the research project has scientific, societal and educational significance. From a scientific point of view, the new knowledge produced represents basic research. Nursing as a profession can be understood both more deeply and fruitfully than before. Despite the grounding feature of nurses’ profession, there are no previous empirical studies on rights (Kangasniemi et al. 2010). Focusing on the rights of nurses is a tool to analyze other more familiar concepts from a new perspective, i.e. professional ethics, patient rights and duties and division of work in health care.

From a societal point of view, this research project produces knowledge for developing health care widely. From a worldwide perspective, there is large variation in the tasks of nurses and rights as well. In Europe there are initiatives for nurses’ new rights, even though we have no knowledge of their previous rights and how they are realized in practice (Pitchard J 2005, Smith & Macintosh 2007). Otherwise, current European societies emphasize individuality and the rights of individuals. This is connected to nurses as well, i.e. it requires capability of nurses to discuss both their duties and their rights. It is noteworthy that focusing research on rights does not trivialize importance of duties (McHale et al. 2001), quite the contrary: balanced ethical discussion presumes identification of both rights and duties in order to achieve the best possible outcomes. This understanding of ethical background is closely connected to well-being at work (Utriainen et al. 2009) and increased work satisfaction as well (Kanste et al. 2007).

Focusing on nurses’ rights is important for nursing education too. Each profession must be aware of their legal and ethical rights. If professions are not interested in their own rights, at least patients will demand them to be so. (Kangasniemi et al. 2010.)

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