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September 2016, Volume 66, Issue 9

Original Article

Protection of nurses rights in Turkey: A study on nurses\' opinions

Nefise Bahcecik  ( Faculty of Health Sciences, Marmara University, Istanbul, Turkey. )
Havva Ozturk  ( Faculty of Health Sciences, Karadeniz Technical University, Trabzon, Turkey. )
Hanife Tiryaki  ( Istanbul Health Directorate, Istanbul, Turkey. )

Abstract

Objective: To evaluate nurses\\\' opinions on the violation and protection of their rights at public hospitals.
Methods: The descriptive study was conducted between May and November 2013 at 11 hospitals affiliated with the Association of Public Hospitals in Istanbul, Turkey. Data was gathered using a questionnaire consisting of 59 questions on demographic characteristics, professions, and rights of nurses.
Results: Of the 1,808 respondents, 1,374(76%) said nurse\\\'s rights were not protected and 994(55%) believed that their rights were not protected at public hospitals. However, 1,027(56.8%) of the nurses stated that their right to job security was protected, while 1,448(80.1%) reported violation of their right to adequate pay and 1,289(71.3%) reported violation or non-recognition of the right to participate in the political decision-making processes that directly affect the nursing profession. Those who were middle-aged and those who had bachelor\\\'s degree believed their rights were not protected, and considered nursing as a weak profession that was unable to protect its rights (p<0.001).
Conclusion: Nurses believed their rights, especially those about salary, were not sufficiently protected.
Keywords: Nurse\\\'s rights, Public, Hospital. (JPMA 66: 1111; 2016)

Introduction
Rights are entitlements that come with birth and recognised by the legal system. 1 Human rights, in the field of health sciences, have been discussed mostly within the context of patient rights. 2 The rights of healthcare workers (HCWs) have been ignored or overlooked. 3 It is noted that nurse rights have not been sufficiently addressed in the last decade, whereas their duties towards patients have been discussed in various ways. 2
Having said that, nurse rights are discussed under three intertwined topics, i.e. human rights, professional rights and employment rights. It is emphasised in the context of human rights that nurses are to be treated respectfully while performing their work. 4 They have the right to work without harassment and discrimination. 5 Professional rights of nurses are grounded on international or national ethical codes or principles and labour laws. These rights consist of the right to perform the profession, getting respect from other health professionals and the society, enhancing the social status that the profession brings and the right to practice in a healthy, secure and ethical environment. They are also related to defending patient interests, using their expertise to provide care to patients and accrued rights of nurses obtained by education and work experience. 4,5 The right to work of nurses is based on the constitution, healthcare law and work contracts. 5 These laws and contracts are directly related to nurses and include rights such as the right to perform the profession. They also include regulations about working hours and compensations and the right to work in a healthy and safe workplace environment. 4,5
Additionally, nurses have some rights as HCWs. These are the right to strike and join a union, the right to fair labour practices, the right to equality between workers, a safe workplace environment for the health and well-being of workers, occupational health and safety rights regarding the protection of workers from accidents and occupational diseases. Another right is the right to compensation for occupational injuries and diseases. Finally, the right to freedom of expression has been addressed to protect workers from possible corruption and unethical practices, especially in the private sector. 3
In Turkey, different aspects of nurse rights are regulated under the labour law, the civil servants law, the nursing law, the constitution in addition to the International Labour Organisation (ILO) commitments. 6-9 Moreover, several regulations related to occupational health and safety support the rights of nurses. 8 However, as Kangasniemi et al. stated in their study conducted in Italy, nurses are not always aware of their own rights and academic studies on the topic are scarce, which is also true for Turkey. 2 Scholars also have paid little attention to the nurse rights in Turkey and this topic was treated only within the context of the rights of HCWs in a single study. 10 Therefore, descriptive and empirical studies regarding nurse rights are required, a point also made by Kangasniemi et al. 2
The current study was planned to find out the views of nurses working in public hospitals regarding nurse rights, their violation and protection.

Subjects and Methods
This descriptive study was conducted in Istanbul, Turkey, between May and November 2013 at 11 hospitals that were selected by disproportional cluster sampling method out of 55 hospitals associated with the Association of Public Hospitals, which is affiliated with Ministry of Health. Nurses who had been working for at least one year and who agreed to answer the questionnaire were included. Nurses who were absent due to reasons such as annual leave, sickness, etc., and those who refused to participate were excluded.
Informed consent was obtained from the participants and written permission from the Public Hospitals Association.
The questionnaire developed by researchers consisted of seven questions about the socio-demographic characteristics, eight questions about the profession of nursing and nurse rights and 44 questions about nurses\\\' views on the rights provided to them.
Frequency and percentage tests were used for evaluating the socio-demographic and professional characteristics of nurses, and chi-square test was used for comparing the data.

Results
Of the 2,576 nurses working at the selected hospitals, 1,808(70.2%) participated in the study. Of them, 832(46%) were aged between 29-39 years, 586(32.4%) between 18-28 and 347(19.2%) were 40-years-old or above. Moreover, 1,067(59%) nurses were married and 723(40%) were single. As for education, 940(52%) of them had bachelor\\\'s degree, 344(19%) had an associate degree and 307(17%) had health high-school degree. In terms of professional experience, 922(51%) had been working for 10 years or less, 524(29%) for 11-21 years, and 217(12%) for 22 years or more. Besides, 1,573(87%) of the respondents were nurses and 217(12%) were nurse managers. Around 922(51%) were working at departments/units, 560(31%) at intensive care units (ICUs), 434(24%) at departments like outpatient/diagnosis clinics, 380(21%) at emergency and 217(12%) at operating room.
Of all, 876(54%) participants reported nursing as a profession that is neither strong nor weak in protecting its rights, 705(39%) as a weak profession that is unable to defend its rights, and only 108(6%) as a strong profession that protects and enhances its rights. On the other hand, 1,374(76%) thought that in Turkey the rights of nursing and nurses were not protected, 362(20%) thought that these were protected from time to time, and 90(5%) thought these were protected. Furthermore, 994(55%) stated that in their institutions nurse rights were not defended/protected, 669(37%) stated that these were protected from time to time and only 127(7%) stated that nurse rights were protected.
In addition, 1,127(62.3%) nurses learned about their rights via internet/media, 968(53.5%) during on-the-job trainings, and 933(51.6%) during their education at school.
About 1,188(65.7%) nurses said they personally defended/protected their own rights in case of problems while 1,323(73.2%) thought that their rights should be protected primarily by the health services manager in charge of nurses (Table-1)


Moreover, 1,027(56.8%) nurses reported that they had job security and they were not laid off. However, 1,449(80.1%) reported not having a wage/wage increase which would enable them to live a comfortable life whereas 1,339(74.1%) reported not receiving any extra payments based on their performance. Similarly, 1,289(71.3%) stated that the legal regulations to protect the dignity and image of nursing were not implemented and the same number of nurses stated that their views were not taken into account in health policymaking (Table-2)


Regarding job security, statistically significant (0.05) difference was found between the views of nurses aged 29 years or above and who had more than 22 years of experience on the one hand, and nurses in other age groups and years of professional experience on the other. Statistically significant (0.05) difference was found between the views of nurses who thought their rights were being protected and those who thought their rights were not protected. Nurses aged 29 years or above, having more than 22 years of experience and who thought their rights were protected stated that they enjoyed right to job security or stated that the fact that they were working for so many years in public hospitals was an evidence of job security. Regarding the issues of wage or wage increase that would enable nurses to maintain a quality life and right to receive extra payments based on performance, statistically significant (0.05) difference was found between the views of nurses aged between 29-39 and above 40, between those who thought nursing as a weak profession that could not protect its rights and those who thought it as a strong profession, between those who thought that nurses\\\' rights were not protected in Turkey\\\'s public hospitals and those who thought the opposite. Nurses aged between 29-39, who perceived nursing as a weak profession and who thought their rights were not protected in Turkey\\\'s public hospitals found their salaries or salary increases or extra payments insufficient or thought that their economic rights were being violated. The fact that nurses with a bachelor\\\'s degree, compared to nurses with lower degrees, found their salaries or salary increases insufficient or thought that their rights were violated was found statistically significant (0.05).
On consulting nurses on the implementation of the necessary legal regulations to protect the image and dignity of profession and the making of national health policies, a statistically significant difference (0.05) was found between views of nurses who thought nursing as a weak profession that could not protect its rights, who thought that their rights were not protected and those who held just the opposite view. Nurses who thought nursing as a weak profession and that their rights were not protected were more concerned with the lack of implementation of the necessary legal regulations to protect the image and dignity of profession and their inability to participate in the making of national health policies. Besides, nurses aged 28 or below were more concerned with a lack of implementation of the necessary legal regulations to protect the image and dignity of the profession compared to nurses who were at least 40 years old (0.05). Nurses with a bachelor\\\'s degree wanted to be more involved in the making of national health policies compared to those having less education.

Discussion
Nurses have rights as human beings, as members of the profession and as HCWs that protect patient rights, who take charge in providing healthcare services, get a good training to provide these services, and act in accordance with legal and ethical rules while performing their duties.4,10 Similar to the study of Kangasniemi et al. conducted in Italy,4 it was found that nurses in Turkey have never cared for and were not aware of their own rights. Being subject to the civil servants law, the respondents enjoyed job security and their dismissal from work was possible only in specific situations and after the approval of higher disciplinary committees of health authorities and then the courts.9 Therefore, contrary to nurses who feared layoffs in the private sector, more than half of the respondents reported that they enjoyed job security. Nurses who were in their middle ages or older, who thought their rights were not protected supported this view more strongly. This was because they were working at public hospitals and enjoying job security.
The majority of nurses reported that their rights were not protected at public hospitals and in Turkey. This finding was supported by Kangasniemi et al.,4 who noted that nurses, just like other HCWs, were deprived of their rights throughout the history and experienced more problems than other HCWs. In addition, nurses primarily complained about not having enough wage to live a comfortable life, not receiving extra payments based on performance and violation of other economic rights. In the present study, nurses who were 29-39 years old, had bachelor\\\'s degree, thought their rights were not protected, and who thought of nursing as a weak profession supported this view more. Some national11-13 and international14-18 studies supported the results of this study and showed how important salaries were for nurses. The present study showed that nurses were not pleased with their pay. Hassim et al. also stated that HCWs, especially nurses, complain about low wages, long working hours and bad working conditions. They also noted that many nurses leave the state/public healthcare services and transfer to private sector where job security is worse.3 Prestigious professions with high salaries are often more popular among the youth and are thought as professions with a strong image.
In this study, another complaint from nurses was that legislation in place to protect the image and dignity of the profession was not implemented. Nurses who were younger than 28, those who thought nurse rights were not protected and those who thought of nursing as a weak profession supported this view strongly. Some studies show that nursing is seen as a profession that defers to physicians, has limited career opportunities, poor pay and conditions, low academic standards and is based on gender stereotyping17,19,20 or has a poor public image and low social status. 17 In addition, studies report the prestige of nurses is lower than that of physiotherapists, dieticians, lawyers and teachers.17 The image of nursing is very important to nurses, affecting job performances, their turnover intentions, their recruitment and retention, their personal image and dignity and job satisfaction.21 On this account, nurses report that higher education qualifications should be required to help them gain a positive and professional image through specialisation brought by the knowledge, skills, credibility and academic degree acquired in higher education.22,23
Furthermore, the majority of nurses complained that their views were not taken into account in health policymaking. Nurses who had bachelor\\\'s degree, who thought nurse rights were not protected in Turkey and at their hospitals and who thought of nursing as a weak profession supported this view more than the others. However, as noted by Hassim et al., HCWs including nurses have an essential role in the provision of healthcare services and the application of health policies.3 Karaöz also stated that nurses, by using their knowledge and skills the best way they can, should actively take part in political processes to help improve the workplace environment and healthcare services, or should participate in politics to change the healthcare system for the benefit of the society.24 On this account, nurses have political rights including participation in decision-making processes that effect nursing and healthcare, and taking political actions on behalf of nursing and healthcare. Knowledge, consciousness and collaboration are necessary to use those rights. Stated differently, nurses should team up and act together to increase their power, strengthen their relationships with each other, get a good education and intensify their political effectiveness.24
Nurses who participated in this study saw nursing as a profession that was somewhat strong but that needed to be supported. Karaöz stated that for many years nurses, despite being the largest group among HCWs and having the longest relationship with care-given-individuals, have a low professional self-esteem. 24 However, if nurses want to be strong or successful in their struggle to gain strength, they should first be aware of their own power, give up playing the role of the victim, take risks, and reject the suppression of their voices.24 For this, as seen in the results of the study, they need to trust and believe in themselves and their nurse colleagues to have their rights recognised and protected. Additionally, they should take the support of their supervisors and hospital managements who are responsible for the protection of their rights. They should form strong professional associations to overcome the neglect and indifference of physicians and hospital managers towards nurses\\\' rights. 25 On the other hand, approximately half of nurses in the study thought that their rights should be defended by the Turkish Nurses Association. Professional organisations are important to define professional roles, improve ethical rules, determine policies and to act together so as to gain professional rights. They are also effective in influencing public opinion.25

Conclusion
The economic rights of nurses are not provided sufficiently. Nurses, together with professional associations and institution managers, need to draw up action plans and implement them. Moreover, it would be beneficial to conduct descriptive and empirical studies on nurse rights that evaluate the views of nurses working at private hospitals.

Disclosure: No

Conflict of Interest: No

Funding Sources: No

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