Test of a Dignity Model in patients with heart failure

Abstract

Background:

Identifying, maintenance, and promotion of dignity in different patients of various cultures is an ethical responsibility of healthcare workers.

Research questions:

This study was conducted to investigate factors related to dignity in patients with heart failure and test the validity of Dignity Model.

Design:

The study had a descriptive-correlational design, and data collection was carried out by means of four specific questionnaires.

Participants and context:

A total of 130 in-patients from cardiac wards in hospitals affiliated with Tehran and Shahid Beheshti University of Medical Sciences participated.

Ethical consideration:

This study was approved by the Research Committee of Shahid Beheshti University of Medical Sciences.

Findings:

Significant correlation showed the following: between illness related worries with dignity conserving repertoire score, between illness related worries with social dignity, between illness related worries with dignity conserving repertoire score, and between social dignity with dignity score. Goodness Fit Index and Comparative Fit Index were calculated greater than 0.9.

Discussion:

This study affirms the importance of careful evaluation of individual patients to determine their needs related to dignity.

Conclusion:

According to the results, the necessity of using appropriate tools to assess various aspects of patients’ dignity by clinical healthcare staff and design activities with particular focus on the main factors affecting dignity such as illness related worries and social dignity is recommended. Attention to this issue in everyday clinical practice can facilitate health professionals/nurses to potentially improve their patients’ dignity, develop quality of care and treatment, and improve patients’ satisfaction.

Keywords

Dignity conserving repertoire Dignity Model heart failure inherent dignity social dignity

Introduction

Studies carried out in the context of patient dignity indicate that the concept of dignity is a contentious value and a global concern and have often insisted on the need for further research in relation to dignity and respect for the dignity of others and also the need to identify factors related to promoting the dignity and deficits of patients’ dignity on care, in different cultures and countries¹ and in different diseases.^2
–4

Among different diseases, heart failure is a major growing problem which affects not only patients but also their families, social network, decreases patients’ functional capacity, and causes social life disorders.^5

–8 The incidence of this disease among people aged over 65 years is 10 out of 1000 people, and approximately 30%–50% of deaths occur suddenly in these patients.⁹ In Iran, heart failure is considered as a major cause of disability and death, and in the near future the current rate of 3500 cases per 100,000 people will be included when the age pyramid and aging society of young people of Iran are changed.^10,11 According to the statistics published by the Center for Disease Control in Iran, the number of patients with heart failure in 18 provinces of the country is reported as 3337 in every 100,000.¹² In patients with heart failure, the inability of the heart to supply blood causes various symptoms like dyspnea, dizziness, angina pectoris, edema, and ascites. These symptoms result in the disability in performing activities, thereby causing changes in the patient’s lifestyle. Limitations caused by heart failure also cause problems in sexual performance, job duties, family and social life, and causes social isolation and depression, which affect the satisfaction and quality of life of the patient.^13
–15 Illnesses with restricted physical ability and being confined to bed can compromise the dignity of the patients.¹⁶

About 48% of patients with heart failure experience worrying psychological symptoms, such as feelings of guilt, hopelessness, low self-esteem, low energy, and depression. Depression affects their perception of health status and this condition can lead to decreased functional status.¹⁷ In these patients, impaired emotional well-being has detrimental effects on the health outcomes in patients with chronic heart failure (CHF).¹⁸ Activity intolerance in patients with heart failure causes independence in the performance of typical life activities, and causes the dependence on others for their care, thereby affecting the quality of life of such families.¹⁹ This can influence their dignity in the family and community.

Patients with heart failure compared to patients with cancer spend more of their life time with disabilities caused by the disease,²⁰ suffer from higher symptom severity,²¹ and have to adapt with unpredicted death. Many of these patients, especially in the later stage of the disease, become distressed and have poor control over their symptoms.²⁰ Therefore, the primary goal of care for patients with heart failure is increasing the life expectancy in these patients.²² So, the need for palliative care is essential in these patients,²³ and one of the essential components of this palliative care is respect for dignity and human rights, which is independent of nationality, race, religion, color, age, sex, or socio-political conditions.²⁰

Identifying and strengthening the dignity of the patient can increase his/her confidence and satisfaction with care, enhance nursing care, reduce the duration of hospitalization, and improve the patient’s outcomes. The destruction of the dignity of a patient can decrease the physical and mental health of the patient.^24,25

The proposed model in this study is designed upon the Dignity Model²⁶ to examine factors related to patient dignity in patients with heart failure. The Dignity Model comprises three main categories. These categories include illness related issues, dignity conserving repertoire, and social dignity inventory.²⁶ This model suggests that the inter-relatedness of these themes is as illustrated schematically in Figure 1. The outcome concept in this model is dignity. Both burdensome illness-related concerns and a taxing social dignity inventory are shown as having a deleterious effect on dignity. The model also shows that these negative influences might be buffered by a positive dignity conserving repertoire which includes dignity conserving perspectives and/or dignity conserving practices. In contrast, the model postulates that individuals with a limited dignity conserving repertoire would be more likely to have a diminished sense of dignity (Figure 1).²⁶

Figure 1.

Theoretical model of study (The Dignity Model).

Each of the categories of Dignity Model contains several carefully defined themes and sub-themes, serving as the foundation for a model of understanding dignity and also helps to articulate these issues (Figure 2).²⁶

Figure 2.

Defined categories, themes, and sub-themes of Dignity Model.

The Dignity Model provides therapeutic direction for health professionals, advising that they pay heed to a broad range of physical, psychological, social, and spiritual/existential issues that may affect individual patient perceptions of dignity.²⁷

The Dignity Model is based on patients’ perceptions, has been validated, described as malleable enough for broad application among widely divergent patients, and is a means to structure care actions toward the conservation of dignity.^26,28

–31 This model is unique in that it provides the clinician with guidance and direction on how they may approach dignity concerns.^32,33

According to research works, factors associated with the concept of dignity can be different in cultures and countries because of their multidimensional nature. Meanwhile, most research works in this field have been limited to cancer patients or the older people. On the other hand, the use and validation of Dignity Model in patients from different cultures has been underlined in order to assess the importance of each category, themes, and sub-themes defined in the model.²⁸

This study is a part of a broad research effort which employs qualitative and quantitative methods for data collection and analysis. It is unique in its kind, and according to the information gap in this area of patients with heart failure, it is considered a necessity.

Aim

This study was conducted to investigate factors related to dignity in patients with heart failure and to test the validity of Dignity Model. The ultimate aim was to understand the relationship between factors related to dignity in patients with heart failure based on Dignity Model.

Methods

Design

A cross-sectional descriptive-correlational study was used.

Setting and procedure

The study was performed in Tehran, Iran. It was conducted in the cardiac wards in urban hospitals affiliated with Tehran University (Hazrate Rasoolakram and Shariati Hospitals) and Shahid Beheshti University (Imam Hossein hospital). Written permission for this study was obtained from the hospital officials and the head nurses of the cardiac wards before commencement. The unit staff identified patients who met the study criteria. Permission was obtained to release the patients’ names to the research nurse, who in turn approached the patients. After explaining the purpose of the research and obtaining written consent from the participants, questionnaires were completed by them. The study was conducted over a period of about 11 months.

Participants

A total of 130 in-patients from cardiac wards in hospitals affiliated with Tehran University and Shahid Beheshti University were chosen by un-randomized sampling. To be included in the study, participants had to fulfill the following criteria: patients with heart failure with class II to IV of New York Heart Association classification,³⁴ ability to speak Persian, absence of any complication diseases such as chronic diseases, and competent to sign the informed consent form.

Data collection

The data collection was done using a demographic questionnaire (age, sex, education, marital status, occupation, number of children, monthly income, place of residence, frequency of hospitalization, and disease severity) and the means of four specific questionnaires. Questionnaires were distributed by the researcher to patients with heart failure who satisfied the inclusion criteria.

Four questionnaires which included Illness Related Worries Questionnaire (IRWQ),³⁵ Inherent Dignity Questionnaire (IDQ),³⁶ Social Dignity Questionnaire (SDQ),³⁷ and Dignity Conserving Repertoire Questionnaire (DCRQ)³⁸ were completed by a research team member based on patients’ verbal responses during an interview structured according to the questionnaire items. IRWQ is a 23-item questionnaire which includes two dimensions: independence (cognitive, functional) and patient worries (physical–mental complications and worry about the future of disease). In this questionnaire, the higher score indicates less illness related worries. Reliability of IRWQ was calculated as 0.90 using Cronbach’s alpha coefficient and 0.89 using split-half method.³⁵

IDQ contains 24 questions which include three dimensions: inherent dignity in family, inherent dignity in community, and inherent dignity in healthcare systems. Higher score indicates higher inherent dignity. Reliability of the IDQ was calculated as 0.94 using Cronbach’s alpha coefficient and 0.96 using the split-half method.³⁶

SDQ contains 77 questions which include two dimensions: Communication and support (family communication and support, social communication and support, care providers’ communication and support) and burden to others (physio-psycho-social, economic). A higher score indicates higher social dignity. Reliability of the SDQ was calculated as 0.97 using Cronbach’s alpha coefficient and 0.99 using the split-half method.³⁷

DCRQ contains 45 questions which include five dimensions: hopefully, religious–spiritual performance, role function, autonomy, and acceptance. Higher score indicates higher social dignity. Reliability of the SDQ was calculated as 0.96 using Cronbach’s alpha coefficient and 0.98 using the split-half method.³⁸

In each questionnaire, scores ranged from 1 to 6 for each phrase and the mean score of the questionnaire phrases is considered as the total score of the questionnaire. The total scores of two questionnaires (IDQ and SDQ) are considered as patient’s dignity score. All questionnaires used in this study were validated in the language of the participants. Completing the questionnaires lasted about 4 months.

Data analysis

The mean score of each variable of Dignity Model and Overall association between each mediator variable and dignity after adjustment for confounders and mediators were calculated by the Statistical Package for Social Sciences (SPSS) version 19, and regression, Chi-square (χ²), path analysis, and structural equation modeling (SEM) (Root Mean Square Error of Approximation (RMSEA), Goodness Fit Index (GFI), Adjusted Goodness Fit Index (AGFI), Comparative Fit Index (CFI)) were carried out by LISREL 8.5.

Path analysis (a form of SEM that facilitates analysis of mediation) was used to investigate whether the association between each mediator variable of Dignity Model (illness related worries, social dignity, and dignity conserving repertoire) and dignity as a final variable of model and whether a multivariate model meet the modeling requirement. Figure 3 depicts the hypothesized relationships in this study.

Figure 3.

Proposed Dignity Model.

For each model, the total effect (the overall association between each mediator variable and dignity after adjustment for confounders and mediators) (Table 2) and the direct effect (the overall association between each mediator variable and dignity after taking account of confounders and mediators) were calculated (Figure 4). For the path analysis, statistical significance was set at the 0.05 level.

Figure 4.

Path analysis diagram. Standardized path coefficients are presented.

Ethical considerations

Ethics approval was granted by the Research Committee of Shahid Beheshti University and research was conducted after obtaining written consent from participants. Each participant was informed of the purpose and nature of the research and the time commitment required, and was assured of confidentiality and anonymity. Patients were informed that they were under no obligation to take part in the study and that their care and treatment would be unaffected by their decision. Questionnaires were completed while participants were in the hospital and lasted about 20–30 min for each patient. To prevent fatigue and enhance patients’ participation, questionnaires were completed through proper communication with patients in comfortable and intimate setting. The patients were allowed to rest for a few minutes if they were tired. The patients were told, if they do not wish to continue completing the questionnaires, they can leave the study.

Results

Based on the results, the average age of studied samples was 62 ± 13.9. Majority of patients (51.5%) were illiterate and had average monthly income less than 10 million Iranian Rials per month (92.3%). The socio-demographic characteristics of patients are displayed in Table 1. From the results, the mean score of illness related worries, social dignity, and dignity conserving repertoire were 3.9, 4.3, and 3.6, respectively.

Table 1.

Characteristics of patients (N = 130).

Personal characteristics		Frequency	Percent
Age (years)	<45 45–65 >65	14 59 57	10.8 45.4 43.8
Sex	Male Female	88 42	67.7 32.3
Education	Illiterate Below diploma Diploma Graduate	67 44 13 6	51.5 33.8 10 4.6
Marital status	Single Married Widow Divorcee	4 99 25 2	3.1 76.2 19.2 1.5
Occupation	Employee Worker Farmer Housewife Self-employment Retired	3 2 8 41 58 18	2.3 1.5 6.2 31.5 44.6 13.8
Number of children	<2 2–5 >5	27 58 45	20.8 44.6 34.6
Monthly income (million Iranian Rials)	<5 5–10 >10	50 70 10	38.5 53.8 7.7
Place of residence	City Village	102 28	78.5 21.5
Frequency of hospitalization	<2 2–5 >5	98 23 9	75.4 17.7 6.9
Disease intensity (LV ejection fraction %)	40–50 20–39 <20	52 69 9	40 53.1 6.9

LV: left ventricular.

Table 2.

Overall association between each mediator variable and dignity after adjustment for confounders and mediators.

	Age	Number of children	Frequency of hospitalization	Disease severity	Illness related worries	Social dignity	Dignity conserving repertoire	Dignity
Age	1	0.478	0.072	0.117	–0.174	–0.162	–0.230	–0.169
p value		<0.001	0.413	0.187	0.047	0.065	0.009	0.055
Number of children		1	0.066	0.010	–0.134	–0.005	–0.123	–0.11
p value			0.457	0.910	0.130	0.954	0.163	0.905
Frequency of hospitalization			1	–0.234	–0.286	–0.189	–0.320	–0.181
p value				0.007	0.001	0.032	<0.001	0.040
Disease severity				1	0.119	0.177	0.072	0.177
p value					0.177	0.044	0.418	0.044
Illness related worries					1	0.455	0.600	0.444
p value						<0.001	<0.001	<0.001
Social dignity						1	0.503	0.997
p value							<0.001	<0.001
Dignity conserving repertoire							1	0.496
p value								<0.001
Dignity								1

Analyzed by Pearson correlation test.

Overall association between each mediator variable and dignity after taking account of confounders and mediators is shown in Figure 4. It shows significant correlation between illness related worries with dignity conserving repertoire score, illness related worries with social dignity, and social dignity with dignity score. Also, it shows significant correlation between frequency of hospitalization with illness related worries and dignity conserving repertoire and between age and disease severity with social dignity (Figure 4). Sex, education, marital status, occupation, number of children, monthly income, and place of residence were dropped from the path model because of non-significance. These non-significant paths were eliminated, respectively to find the most parsimonious model.

Overall association between each mediator variable and dignity after adjustment for confounders and mediators is shown in Table 2. According to this table, the variable which had the highest correlation with dignity was social dignity (0.997, p < 0.001), followed by dignity conserving repertoire (0.496, p < 0.001), and illness related worries (0.444, p < 0.001). Also, there existed a significant correlation between age and number of children with illness related worries and dignity conserving repertoire (p < 0.05) (Table 2).

A significant correlation was observed between frequency of hospitalization with illness related worries (–0.286, p = 0.001), social dignity (–0.189, p = 0.032), dignity conserving repertoire (–0.320, p < 0.001), and dignity (–0.181, p = 0.040). As observed in Table 2, there was a significant correlation (p < 0.001) between mediator variables with each other in the model after adjustment for confounders and mediators.

In order to test the model that explains the structural relationship between relevant variables, the model was fit by the maximum likelihood method. Table 3 summarizes the estimated models’ goodness of fit indices.

Table 3.

The fit indices of research model.

Value	Index
p value (Chi-square χ²)	0.339
Root Mean Square Error of Approximation (RMSEA)	0.031
Goodness Fit Index (GFI)	0.98
Adjusted Goodness Fit Index (AGFI)	0.93
Comparative Fit Index (CFI)	1.00

Discussion

The ultimate aim of this study was focus on understanding the relationship between factors related to dignity in patients with heart failure and paths that lead to dignity based on Dignity Model and testing it and accordingly the “Discussion” section is written. Unfortunately, because few studies have been conducted about dignity in patients with heart failure, the results of this study contribute to this limitation of knowledge. The structural equation model constructed in this study largely confirmed the proposed model, and extended our understanding of the related factors of dignity in patients with heart failure. The present findings point to a positive correlation between illness related worries with social dignity and with the dignity conserving symptoms. In other words, reduction of illness related worries in patients with heart failure strengthens social dignity and improves their dignity conserving perspectives and activities. This is in agreement with a previous study. According to Chochinov et al.,²⁶ increased levels of illness related worries have negative effects on the patients’ dignity, while the improvement of patients’ dignity conserving perspectives and activities may serve as a barrier against the negative effects of illness related worries.²⁶

People with heart failure experience limitations in their lives due to impaired physical and functional capability. These restrictions may cause the individuals to lose their relationships and social support,¹⁴ and experience changes in identity, social roles, and their life as a whole.³⁹ Therefore, these patients express that their dignity has been threatened in the family and community due to the physical limitations caused by the disease.¹⁵

Based on the results of this study, in the initial model, it was determined that social dignity has direct effect on dignity, while illness-related worries factor do not have direct effects on dignity, and are therefore non-significant (p > 0.05), but it was shown to indirectly affect the dignity by mediation through social dignity. Also, there was a direct correlation between social dignity and dignity conserving repertoire. In other words, the improvement of social dignity in patients with heart failure promotes dignity conserving symptoms, and meanwhile it can directly increase their dignity. Interpersonal interactions (communication, respect, privacy, and authority) and environmental resources (facilities and physical space) are factors of social dignity⁴⁰ that is experienced, bestowed, or earned through interactions in social settings,⁴¹ and this affects dignity.⁴⁰ Studies show that multiple factors, including sense of burden to others, can lead to frustration and even threaten patients’ dignity.⁴² Other studies indicate that reinforcing social dignity has positive effects on patient dignity and vice versa.^26,29,43,44

According to the Dignity Model, social dignity includes social concerns and communications that could strengthen or weaken the patient’s dignity.^27,32 Anyway, the direct relationship between social dignity and human dignity in this research could be due to the large overlap of the contents of these variables (social dignity and dignity).

In the initial model, also direct paths from dignity conserving repertoire to dignity (p > 0.05) became non-significant, indicating that dignity conserving repertoire within the research model and along with other variables, are not considered predictor variables of dignity in patients with heart failure, and this indicates a fully mediating effect of social dignity. However, it is impossible to deny their relationship unless other variables are examined based on Pearson statistical test. Thus, developing the perspectives and dignity conserving activities in heart failure patients plays a significant role in promoting their dignity.

In line with the results of this study and according to the study of Baillie,² the perspectives of patients and their performance in different situations where dignity is reinforced or threatened, plays a key role in increasing their sense of worth.² In this regard, Chochinov et al.²⁹ also concluded in their study that dignity conserving activities and perspectives can improve the sense of dignity in cancer patients.²⁹ Isis et al.⁴⁵ believed that a temporarily diminished sense of dignity can be considered as a normal human reaction to the situation in which the severely, chronically ill find themselves as part of the process of coming to terms with the numerous losses and life changes caused by the disease before commencement of acceptance, refocusing, and rebuilding identity. This suggests that informal and formal caregivers can make a substantial contribution to restoring the dignity in patients suffering from severe and chronic illness.⁴⁵

The absence of correlation between dignity conserving activities and dignity within the present model, compared to the theoretical modes which suggests that there is a correlation between these two variables,²⁶ could be due to the differences in the study population or sample size in this study. The study population in the theoretical model consists of cancer patients, and the empirical model consists of patients with heart failure.

This study analyzed the effects of demographic factors and health behavior factors (age, frequency of hospitalization, and disease severity). These factors do not have direct effect on dignity, but they show indirect effects by mediation through mediator variables (illness related worries, social dignity, and dignity conserving repertoire). Among the demographic factors, frequency of hospitalization was closely associated with dignity conserving repertoire (β = –0.14, p < 0.05), suggesting the value of this variable in the model. This is consistent with results from a previous study stated in this work. Considering the results of the studies, older patients have more concerns about the complications of cognitive, physical, mental, and also concerns about the future of their disease than younger patients. Chochinov et al.²⁹ in their study found significant positive correlation between age and inability of patients to perform tasks related to daily life (p = 0.003), problems related to physical performance (p = 0.002), and uncertainty of future of life (p = 0.018).²⁹ On the other hand, path analysis conducted on the proposed model showed that there existed a significant correlation between age and disease severity and also between age and social dignity. Therefore, it can be concluded that with increase in age and disease severity (decrease in left ventricular ejection fraction) of older patients with heart failure, the signs and symptoms of cognitive, physical, and mental health of patients will increase and this can exacerbate disease related concerns of patients with heart failure.

Chochinov et al.²⁹ concluded that by increasing the age of patients and more concern about privacy, their dignity is negatively affected. On the other hand, old age and cognitive and functional impairments increase workload of caregivers in their family^29,46 and patients feel burden to others and this affects the social dignity. Patients with heart failure have worse quality of life than the general population and patients with other chronic diseases. Being older, advanced symptoms and recent hospitalization are determinant factors in health-related quality of life in these patients.⁴⁷ Shojaei⁴⁸ in his study observed that there is a statistically significant correlation between different levels of quality of life and age of patients, and older patients have lower family and social function compared to younger ones.⁴⁸ Thus, the present results are confirmed by other studies. However, by increasing age and decreasing physical and communication abilities, the cosmetic changes and decline in revenue in patients with heart failure reduce their ability to communicate with others and have negative influence on the attitudes of others toward them, and this naturally affects their dignity in family, community, and health centers.

Based on the results of previous studies, one of the most important factors in hospital readmissions for patients with heart failure is complications of the disease due to lack of knowledge about symptoms and disease prognosis.^49,50 Studies also show that the disruption caused by heart failure disease in family and social life, work, and recreational activities of patients with heart failure, increase the risk of re-hospitalization and death from the disease.^51,52 The findings of Rahnavard et al.¹² also confirmed this and showed significant correlation between disease severity, duration of disease, frequency of hospitalizations during the past year with physical and mental aspects of patients with heart failure.¹²

In this study, the fitted model was considered satisfactory (Table 3) because all the following conditions were met (model fit in parentheses): (a) RMSEA <0.10, indicating small residual variation⁵³ (model: 0.031) and (b) the CFI >0.95 (model: 1), the GFI (model: 0.98), and AGFI >0.90 (model: 93) which are acceptable for the confirmation of suitability and support a favorable comparison of the proposed model to the saturated and baseline model.⁵⁴

This study is unique because it is the first study of the structural interrelationship between socio-demographic characteristics, illness-related worries, social dignity, and dignity conserving repertoire, and dignity has not been previously evaluated in patients with heart failure. Despite its innovative approach, the study has a number of limitations. The lack of information for the discussion about the association between variables of Dignity Model is the most important limitation of this study. It is possible that the application of other research approaches would reveal more information about the dignity concept in this population. In this regard, Arie¹ believes that perhaps it is necessary to set aside the meaning of dignity which is assumed to be self-evident and reconstruct it for people from the respective different countries.¹

Dignity is a cultural concept. Both its definition and its maintenance are socially and culturally determined. An individual’s standards and expectations relating to the maintenance of dignity are set according to individual attitudes, values, and perceptions.⁵⁵ This study was conducted in Iran, and strategies to preserve and promote patient dignity may differ for patients and professionals in other cultural contexts. The cultural difference in countries makes it difficult to provide a certain definition or pattern for dignity and its maintenance and promotion. On the other hand, this study was conducted in a descriptive-correlational design, and causal relationships between variables could not be stated clearly. So, for clarifying causal relationships between variables, it is essential that prospective and longitudinal studies be performed in this area.

As dignity represents the essence of nursing care, it is our professional duty to clarify the factors that threaten or promote patients’ dignity and proffer solutions to provide more dignified care.⁵⁶ The communication behaviors⁵⁶ and attitude⁵⁷ of staff are the main factors that can influence patient dignity preservation at the bedside and lead to trusting relationships.⁵⁶ This study provides empirical support for the study hypotheses, and an opportunity and future research in different cultures can also be conducted in dignity perspective, because every country is a unique humane community.

Conclusion

The results indicate that the research model is fit and acceptable in patients with heart failure, and dignity-related factors are in correlation with each other. Also, social dignity is the biggest single factor on the dignity of patients with heart failure. But, there is a path that led to dignity by mediation through social dignity without dignity conserving repertoire factor. It revealed that demographic factors can lead to dignity through mediator variables and without dignity conserving repertoire factor. According to the results, the necessity of using appropriate tools to assess various aspects of patients’ dignity by clinical healthcare staff and design activities with particular focus on the main factors affecting dignity such as illness related worries and social dignity is recommended. Attention to this issue in everyday clinical practice can facilitate health professionals/nurses to potentially improve their patients’ dignity, develop quality of care and treatment, and improve patients’ satisfaction.

Relevance to clinical practice

There is a need for nurses and physicians in various departments to consider the dignity of patients with different diseases. Considering the findings in the care and treatment of patients not only improve patients’ dignity, but also help to develop the quality of care and treatment and improve the patient satisfaction with respect to the services provided by the healthcare providers.

Footnotes

Acknowledgements

The authors would like to thank all the participants of this study.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Shahid Beheshti University, Tehran, Iran.

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