Vol 13 (2020)

Published: 2020-02-23

Original Article(s)

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    Professionalism is a set of behaviors that build trust in physicians’ relationships with patients and the public. The aim of this study was to assess professionalism among residents in Kashan University of Medical Sciences, Kashan, Iran.
    This cross-sectional study was conducted on 139 residents recruited through the census method. Data were collected using the American Board of Internal Medicine Professionalism Questionnaire. The first part of the questionnaire was on residents’ personal characteristics, and the second part contained fifteen items in the three domains of professionalism, namely excellence, honor/integrity, and altruism/respect. The mean scores of the questionnaire and its domains were calculated and their relationships with residents’ personal characteristics were evaluated.
    The mean scores (± SD) of professionalism and its excellence, honor/integrity, and altruism/respect domains were 4.93 ± 2.4, 5.92 ± 1.85, 4.94 ± 3.39, and 4.35 ± 3.27, respectively (in a range of 0 -10). Professionalism had significant relationships only with residents’ specialty and gender.
    The level of professionalism in residents was low, which requires the attention of educational authorities. Moreover, the mean score of professionalism among residents in surgical specialties was significantly lower than non-surgical specialties. Various factors can be considered in this regard and it cannot be concluded that the lower score means worse professional behavior.

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    Adolescence is a period in one’s lifetime during which sexual maturation occurs. Major changes and increased sexual instinct raise many questions in the minds of adolescents. Receiving wrong education or inappropriate information can affect adolescents’ life and future deeply. Obviously, ethical considerations cannot be ignored in nationwide macro policies and educational programs on such a sensitive issue. In this qualitative study, we attempted to explore the ethical considerations and challenges of sex education for adolescents.The study was conducted between May 2015 and March 2017. Data were collected through semi-structured in-depth interviews with 25 participants, and MAXQDA 11 was used for coding.Six hundred sixty-two codes (662) were extracted and classified into four categories: 1) the potential risks of sex education for adolescents; 2) the advantages of sex education for adolescents, and the approaches; 3) the challenges in the interval between sexual maturation and marriage, and the role of religion; and 4) the measures implemented in Iran.Shame, embarrassment, and some cultural beliefs surrounding the subject of sex education are obstacles to providing adolescents with the necessary information. According to the principles of medical ethics, the main principle in sex education is beneficence, and sometimes infringement of confidentiality has its advantages. 

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    Professional behavior with patients and interactions with colleagues, the institution and professional bodies are influenced by many factors. The purpose of this manuscript is to clarify those personal factors affecting medical professionalism in clinical settings affiliated with Tehran University of Medical Sciences.
    For this purpose, a qualitative study was carried out. One hundred and eighty-two participants were recruited through purposive sampling of clinical staff, physicians, and medical students in Tehran. Data were collected through 22 focus group discussions, and conventional content analysis was used to analyze the data. 
    The results were reported in five categories to present the participants’ views. Categories were extracted from 103 codes and consisted of 1) people's belief in professionalism, 2) personality traits, 3) problems in family, 4) mental or physical health status, and 5) communication skills.
    The results showed that despite the facilitator roles of some personal factors, others act as barriers to professional behaviors. In order to control their impact, it is crucial to pay attention to them at the time of student/staff selection. Strengthening support systems in the organization is also essential for decreasing the effect of family problems or physical and mental health problems.

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    The hidden curriculum is considered to be between the designed and experienced curricula. One of the challenges that medical educators face is to understand what students learn in real clinical settings. The aim of the present study was to answer this question: What is hidden in hidden medical curriculum?
    This study was a qualitative content analysis. Participants were selected through purposive sampling. Data collection was performed through unstructured interviews and continued until data saturation.
    Data were analyzed simultaneously with data collection using MAXQDA10 software. Data validity was confirmed based on the proposed Lincoln and Guba criteria.
    The main theme that emerged in this study was implicit learning. Professional ethics, spiritual, social and cultural issues, and clinical skills are the five major themes that were presented in this study. These themes and their subthemes are transferred during an implicit learning experience in hidden curriculum.
    Since a wide range of issues are mostly transferred by hidden curriculum, it is essential to have a dynamic approach to educational environments. This is especially important in clinical settings, as the process of learning is constantly happening in the backyard.

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    Patients’ rights are among the most important criteria for evaluating the quality of health services. The current study aimed to determine the importance and observance of the patient's bill of rights.
    This cross-sectional study was done in Kerman, Iran. The research samples were 217 patients and 204 personnel. The data collection tool was a researcher-made questionnaire in the scope of the patient's bill of rights, and data were analyzed by SPSS 15.
    The results showed a significant difference between patients and the personnel on the subject of the patient's bill of rights and most of its dimensions (P < 0.01). However, no significant difference was found between their views on the observance of the patient's bill of rights and its dimensions. Also, 35.9% of patients as well as 25% of personnel considered the observance of patients’ rights unfavorable.
    The participants were aware of the importance of the patient's bill of rights. It is necessary, however, to codify and approve the laws related to the rights of patients

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    Attention to the history of medicine (HM) has been increasing enormously among the scientific community. History of Culture and Civilization of Iran and Islam (HCCII) is taught in medical schools as a required course. However, data on medical students' level of knowledge and attitude about HM is limited.
    This is a cross-sectional survey conducted between 2016 and 2017. A multi-stage random cluster sampling was done in which 230 medical students were asked to fill a standardized self-administered questionnaire. Univariate statistical tests and ordinary multivariable linear regression were applied.
    Medical students' knowledge level was 50.8%, which is considered fair and weak. Interestingly, the knowledge score of those who attended only in HCCII course did not differ significantly from those who did not attend this course (P = 0.163). The results showed that knowledge scores were considerably greater in those who participated in related volunteer workshops than those who did not (P = 0.0001). The mean score of attitude toward HM was significantly higher in female subjects than male subjects (P = 0.028). Moreover, data indicated that attendance at the HCCII course and workshops was not associated with improvement in attitude.
    According to the outcomes, the authors recommend revising the content, teaching method and structure of the HCCII course curriculum.

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    Social and professional behaviors are driven by extrinsic as well as intrinsic factors including executive rules and regulations enacted by extrinsic agents through coercion, police force and penalties. Despite their effectiveness, these mechanisms undermine the fact that ethics is an intrinsic human quality. The present study seeks strategies to apply extrinsic coercion as an incentive to direct ethics as an intrinsic value.
    Ethical behaviors driven by intrinsic motivations are more permanent and less costly. Legal force can either strengthen or weaken intrinsic requirements. Extrinsic conditions such as considering the interests, attitudes and preferences of others, involving people in the regulation and execution of law, justification of law, avoiding excessive punishment or rewards, and indirect support of ethics by establishing the appropriate social context can help boost intrinsic requirements in individuals.
    Ethics will not be practically established unless we harness individuals’ ‘willingness to act’ as an essential determinant for ethical behavior. This requires adoption of a more psychological approach to ethics. If this aspect of ethical behavior is considered in regulations and executive processes, extrinsic forces can strengthen intrinsic requirements and spread ethics.

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    Many medical schools around the world have included professionalism training in their formal curriculum. However, these efforts may not be adequate; given the exposure of students to unprofessional behaviors in the clinical settings. In the present study, we aimed to design, implement, and evaluate a longitudinal program to improve professionalism among medical students upon their transition to clinical settings. A total of 75 medical students were enrolled in the study and randomly assigned to two groups. The control group did not receive any training, while for the intervention group; a 10-hour program through 16 weeks was organized based on the Holmes' reflection approach. The effectiveness of the program was evaluated by measuring three outcomes in both groups. Data analysis was performed using paired t-test and Multiple Linear Regression. Scores of judgment of professionalism increased in the intervention group (from 7.56 to 10.17; P< 0.001), while there was no significant improvement in the control group’s scores. Students' attitudes towards professionalism and their professional behaviors did not change significantly.Based on our findings, the Holmes reflection approach helps students improve their cognitive base of professionalism. Long-term follow-up and further qualitative studies will help us better understand the effects of this approach on other desirable outcomes. 

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    This study aimed to investigate dominant predictor components of moral intelligence (MI) based on the Lennick and Kiel's model in students of Shahid Beheshti University of Medical Sciences (SBMU).
    In this descriptive-analytical study, 322 students of SBMU were chosen through cluster sampling. To collect data, a 40-item questionnaire, whose validity and reliability was confirmed in previous studies, based on the Lennick and Kiel's model was used. The collected data were analyzed by SPSS  21 software using appropriate descriptive and analytical statistics. Of 322 participants, 180 and 142 were female and male, respectively. The mean age of the participants was 22.30±2.69 years. The study’s regression analysis revealed that the most and the least direct effects were related to the forgiveness (R2=0.320) and compassion (R2=0.284) components, respectively. Among the inspected components, the responsibility component with an overall effect of R2=0.655 was shown to be the strongest predictor component of MI. Universities play a significant role in students’ moral development and enhancement. The present study’s findings suggest that developing strategic plans and interventions can enhance MI level (e.g., incentive systems for individuals maintaining high moral responsibility).  Since today’s students will be tomorrow’s medical and healthcare professionals, upgrading of MI level in students studying in various divisions of medical sciences enhances their moral responsibility through setting out strong ethics principles to follow and the quality of care that they will provide to patients, thereby improving health.

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    Commitment, a component of clinical competence, includes accountability and responsibility for professional roles and tasks; and, it has a positive correlation with job satisfaction and performance. This study aimed to elaborate on the concept of commitment in the field of occupational therapy using qualitative content analysis. The data was collected through interviewing 13 occupational therapists both in a focus group interview (including four participants) and in one-to-one interviews (nine other participants). The collected data was analyzed based on the Grenheim method, and commitment concept was defined under three main themes: (i) commitment to patient (five subthemes), (ii) commitment to self (three subthemes), and (iii) commitment to profession (three subthemes). This study’s findings indicated that to acquire clinical competence, therapists should be committed to their patients, to themselves, and to their profession. Future research is needed to further examine how and to what extent these commitment themes affect clinical competence as well as the interaction among them.

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    Discharge against medical advice (DAMA) is a common problem in the health-care system. It imposes risks to both patients and medical staff and could be the subject of ethical deliberation. This cross-sectional study was conducted in 2017 on 400 patients who were discharged against medical advice from the emergency ward of Shariati Hospital, Tehran, Iran. Patients’ information was collected using clinical records and telephone calls. The collected data were analyzed using STATA software. DAMA rate was 12% in the emergency department of Shariati Hospital. Male gender was found to be a risk factor for DAMA (OR: 1.90; CI (95%): 1.44 - 2.52; P < 0.0001). In addition, younger patients were more likely to leave hospital against medical advice (p-value: 0.04). The more common reasons for DAMA were feeling better, long delay in diagnostic and therapeutic procedures and the hectic ambience of the emergency ward.
    Patients’ self-discharge is a multi-dimensional phenomenon that is affected by patients’ characteristics, medical conditions and hospital circumstances. It raises some ethical concerns, mainly due to a conflict between patients’ autonomy and beneficence. It is helpful for the medical staff to create an effective relationship with patients who are at higher risk of DAMA, in order to increase their compliance and prevent the consequences of leaving hospital against medical advice.

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    Communication and sharing information with ill children are challenging. To protect a child from the bitter reality, sometimes use of well-intended untruths, or white lies is necessary. This research aimed at studying the experiences of nurses about the use of white lies in in pediatric clinical setting.
    In this qualitative, content-analysis study, 24 on-duty pediatric nurses were interviewed in 2019. Data were collected through purposeful sampling using semi-structured interviews, and the collected data were analyzed according to Granheim and Landman’s method using MAXQDA-10 software.
    Eighteen female and six male nurses with the mean age of 42 ± 3/7 years and mean work experience of 16 ± 4/1 years were selected to participate in this study. Data analysis showed that use of white lies depends on both situation and several other factors classified into five general categories: nature of data, childhood characteristics, family norms, treatment team’s capabilities and organization policies.Treatment team members need to improve their communication skills to convey therapeutic information to the ill child’s family appropriately. To do so, special guidelines should be prepared for healthcare staff in pediatric clinical setting.

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    Nurses' professional and ethical performances are influenced by the health organizations' environment, and high quality and holistic care can only be provided by observing the principles of professional ethics and organizational commitment. Therefore, this study aimed at investigating the relationship between professional ethics and organizational commitment in nurses. This descriptive-analytic study was conducted in hospitals affiliated to Shiraz University of Medical Sciences (SUMS) in 2019 in Iran. The study participants included 210 public ward nurses selected using the stratified random sampling method. Data were collected using Petty Professional Ethics and Allen-Meyer Organizational Commitment questionnaires, and then analyzed by SPSS V.25.
    Both the mean score of the nurses' professional ethics (102.21 ± 10.89) and the mean score of the nurses' organizational commitment (95.30 ± 16.54) were at high levels. Moreover, a direct and significant relationship was found between professional ethics and organizational commitment (P= 0.009, r = 0.179). In other words, a positive correlation was found between professional ethics and organizational commitment.
    Considering the relationship between professional ethics and organizational commitment in nurses, managers should enhance nurses' level of adherence to ethical principles, organizational commitment and organizational attachment. Additionally, training courses can help improve nurses' professional capabilities, and hence enhancing the quality of providing healthcare services.

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    Assessment of scientific misconduct is considered to be an increasingly important topic in medical sciences. Providing a definition for scientific research misconduct and proposing practical methods for evaluating and measuring it in various fields of medicine discipline are required. This study aimed at assessing the psychometric properties of Scientific Research Misconduct-Revised (SMQ-R) and Publication Pressure Questionnaires (PPQ). After translation and merging of these two questionnaires, the validity of the translated draft was evaluated by 11-member expert panel using Content Validity Index (CVI) and Content Validity Ratio (CVR). Reliability of the final questionnaire, completed by 100 participants randomly chosen from medical academic members, was assessed by calculating Cronbach’s alpha coefficient. The final version was named Persian Research Misconduct Questionnaire (PRMQ) and consisted of 63 question items. The item-level content validity indices of 61 questions were above 0.79, and reliability assessment showed that 6 out of 7 subscales had alpha values higher than 0.6. Hence, PRMQ can be considered an acceptable, valid and reliable tool to measure research misconduct in biomedical sciences researches in Iran.

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    Medical universities have called for a professional dress code to preserve the dignity of the medical profession, creating a sense of respect, tranquility, and trust in healthcare recipients and improve patient safety. This study aims to explain the reasons behind poor adherence to the professional dress code by students of the dentistry school.
    A qualitative study was conducted to explain the viewpoints of dentistry students of Tehran University of Medical Sciences (TUMS). Twenty-three in-depth interviews with dentistry students of different genders, study years, living in different accommodations, and having different tuition payment status were conducted. Conventional content analysis was used to analyze the data. 
    One hundred and twenty initial codes were extracted. They were categorized into common causes of non-adherence to the TUMS Dress Code and specific causes of not following a specific section of the dress code (hygiene, jewelry, and makeup sections). The codes of common causes were categorized into 4 main categories including defects in education, management shortcomings, changes in societal culture, and personal factors.
    All components of the educational system must be aligned with each other to overcome the barriers against the students’ adherence to professional dress and put forward appropriate interventions at the policymaking, regulatory and educational levels.

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    After the emergence of Islam and its advancement in the past three centuries in various countries and the Muslims' acquaintance with civilizations emanating from the empires of Iran, Greece, and India, a civilization emerged that affected different aspects of people's lives in Islamic lands and other countries. One of the components of this civilization was medical sciences that were collected and compiled by Muslims using the resources of other civilizations and their own experiences and resources.
    Rhazes (Muhammad ibn Zakaryyā al-Rāzī), who lived in the ninth century AD (fourth century AH), compiled a comprehensive textbook of medicine (named in Arabic: Al-Hawi fi al-Tibb) in all specialized medical disciplines in accordance with the latest achievements of his era. This book has been published in the contemporary period as a 25-volume collection and contains knowledge and experiences from the medical resources of various civilizations and Rhazes’ own knowledge and experiences. The first volume of this collection and some other volumes are devoted to the knowledge of neuroscience, psychiatry, and related diseases, illnesses, and disorders.
    In this review, we cite topics from "Al-Hawi" and other Rhāzes’ manuscripts related to the definition and description of diseases and disorders associated with the nervous system as well as psychiatry and neurology and compare them with modern medical sciences in a comparative manner. This is intended to make their importance and validity clear in terms of usability as part of medical history as well as for some medical research that requires historical and contextual information.

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    This study aimed at examining the approval rate of the medical students’ regarding active euthanasia, passive euthanasia, and physician-assisted-suicide over the last ten years. To do so, the arguments and variables affecting students’ choices were examined and a systematic review was conducted, using PubMed and Web of Science databases, including articles from January 2009 to December 2018.
    From 135 identified articles, 13 met the inclusion criteria. The highest acceptance rates for euthanasia and physician-assisted suicide were from European countries. The most common arguments supporting euthanasia and physician-assisted suicide were the followings: (i) patient’s autonomy (n = 6), (ii) relief of suffering (n = 4), and (ii) the thought that terminally-ill patients are additional burden (n = 2). The most common arguments against euthanasia were as follows: (i) religious and personal beliefs (n = 4), (ii) the “slippery slope” argument and the risk of abuse (n = 4), and (iii) the physician’s role in preserving life (n = 2). Religion (n = 7), religiosity (n = 5), and the attributes of the medical school of origin (n = 3) were the most significant variables to influence the students’ attitude. However, age, previous academic experience, family income, and place of residence had no significant impact.
    Medical students' opinions on euthanasia and physician-assisted suicide should be appropriately addressed and evaluated because their moral compass, under the influence of such opinions, will guide them in solving future ethical and therapeutic dilemmas in the medical field.

Review Article(s)

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    End-of-life decisions are usually required when a neonate is at high risk of disability or death, and such decisions involve many legal and ethical challenges. This article reviewed the processes of ethical decision-making for severely ill or terminal neonates, considering controversial issues including the followings: (i) identifying primary decision makers, (ii) the role of law and guidelines, and (iii) changes in treatment controversy, law and regulations over twenty years in several European countries such as Switzerland, Germany, Italy, United Kingdom, France, the Netherlands, Sweden, and Spain. This review study conducted on accessible articles from PubMed, Google Scholar, Web of Science and Scopus databases. Based on two studies in 2016 and 1996, neonatologists reported that withholding intensive care, withdrawing mechanical ventilation or life-saving drugs, and involvement of parents in decision-makings have become more acceptable as time passes, indicative of trend change. Trend of physicians on how end the life of neonates, at risk of death, varies in different countries, and cultural factors, parents’ involvement in decisions and gestational age are factors considered in end-of-life decision-making. Future investigations continuously need to identify upcoming ethical aspects of proper decision-making.

Commentary

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    Quarantine is a broad public health strategy used to control infectious diseases outbreaks. An arguably most aggressive public health intervention, quarantine limits the asymptomatic individuals’ liberty and can result in significant harm. Quarantine was used in an attempt to control several Ebola outbreaks during the Ebola epidemic in West Africa in 2014. The most concerning quarantine intervention occurred at West Point, a slum of 75,000 people in the capital Liberian capital, Monrovia. This work critically reviews present ethical frameworks in public health for the examination of outbreaks in West Africa. This work utilizes the nine public health ethical principles described by Kerridge, Lowe and Stewart to argue that the quarantine at West Point was not ethically justified; and, it concludes that a new ethical framework for quarantine is required to address future outbreaks in the West African context.

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    Nurses face several challenges in providing care for patients with coronavirus disease in 2019 (COVID-19). The study aimed to explain the nurses' perception of ethical challenges in this regard. The qualitative study was carried out using a content analysis method. Individual and semi-structured interviews were conducted with 24 nurses. Inductive content analysis was used to categorize the data. Nurses' narratives indicated that ethical challenges in caring for patients with COVID-19 included threats to professional values ​​and the absence of a holistic COVID-19 care approach. The first category was subcategorized into the risk of declining quality of patient care and a stigmatized public image about COVID-19 care. The second category was divided into poor spiritual care, poor compassionate care, and lack of family-centered care. Health care managers must develop protocols for nurses that address these issues to alleviate the ethical challenges of COVID-19 care.

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    Exposing medical students to real-world situations and clinical practice experiences during their education years can help them build their professional value frameworks. The COVID-19 pandemic is one of the most challenging conditions that medical students have experienced; however, this pandemic have provided value-rich opportunities assisting in development and enhancement of their professional identity. This commentary aimed to emphasize the importance of medical students’ exposure to clinical practice during the pandemic and the potential that such encounters provide for internalizing values.

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    Maintaining confidentiality, both in national and international codes of ethics, is considered an important principle in healthcare and the medical profession for both patients and physicians. This case-report article focused on a real case. Based on the request of the Iranian Blood Transfusion Organization (IBTO) for plasma donation from recovered COVID-19 patients, we asked the names and personal information of those patients from hospitals affiliated with Iran University of Medical Sciences (IUMS) and arranged for the subjects to be referred to the Medical Ethics Department of IUMS for consultation during the COVID-19 pandemic. Various ethical and legal aspects of this case were discussed in a special meeting, and practical solutions were then provided considering the limits of confidentiality and conditions for ethical access to patients’ information during a pandemic.
    Since plasma therapy is not a definitive cure for COVID-19 and considering the ethical and legal points presented in this article, it is not recommended to announce the names of patients in the early stages. Given the potential impacts of the procedure and the possibility of patients being cured, however, their consent should be obtained in different situations and, if necessary, providing information to patients or educating them should be considered.

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    In this paper, we reflect on the COVID-19 pandemic based on medical philosophy. A critical examination of the Corona crisis uncovers that in order to understand and explain the unpreparedness of the health systems, we need a new conceptual framework. This helps us to look at this phenomenon in a new way, address new problems, and come up with creative solutions. Our proposal is that “health lag” is a concept that could help frame and explain this unpreparedness and unreadiness. The term “health lag” refers to the failure of health systems to keep up with clinical medicine. In other words, health issues in most situations fall behind clinical medicine, leading to social, cultural, and economic problems. In the first step to define health lag, we have to explain the distinction between clinical medicine and health and address the role of individual health, public health, and epidemic in this dichotomy. Thereafter, the reasons behind health lag will be analyzed in three levels: theoretical, practical, and institutional. In the third step, we will point out the most important consequences of health lag: the medicalization of health, the inconsistency of biopolitics, inadequate ethical frameworks, and public sphere vulnerabilities. Finally, we try to come up with a set of recommendations based on this philosophical-conceptual analysis.

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    Observance of patients' rights is a significant indicator in evaluating the quality of healthcare services. The COVID-19 pandemic has become a global crisis and affected the interactions between healthcare providers and patients. This study examined the COVID-19 patients’ viewpoint about the observance of their rights by physicians and nurses. This study is a descriptive cross-sectional work of research conducted on the COVID-19 patients in Zanjan Province, Iran, in September 2020. The subjects were selected through convenience sampling, and data was collected using a two-section questionnaire consisting of a demographic characteristics survey and a Likert-type scale for evaluating patients' rights observance. The validity and reliability of the questionnaire were found to be acceptable, and the collected data was analyzed in SPSS v.26 using descriptive statistics, independent t-test, and ANOVA test.
    The mean score of observance of patients' rights was 69.60±7.36, representing a moderate level. The highest and lowest scores for the observance of patients' rights were related to the dimensions of courteous communication and responsibility, respectively. A significant relationship was found between the observance of patients’ rights and their marital status, health insurance, and education level (P<0.05). This study showed that the observance of the COVID-19 patients' rights has not been affected by the social agitation caused by this disease.