Dignity in nursing care: What does it mean to nursing students?

Abstract

Background:

Despite growing interest in the potential of nursing education to enhance dignity in nursing care, relatively little is known about what dignity means to nursing students.

Research question:

What meaning does dignity in nursing care have for nursing students?

Research design:

Photo-elicitation was embedded within a Nominal Group Technique and responses were analysed by qualitative and quantitative content analysis.

Participants and research context:

Participants were recruited from each year of a 3-year undergraduate preregistration adult nursing programme in Scotland. In total, 31 nursing students participated in the study.

Ethical considerations:

The study was approved by the Ethics Committee of the School of Health, Nursing and Midwifery, University of the West of Scotland.

Findings:

Participants articulated the meaning of dignity in nursing care in terms of the relationships and feelings involved. A total of 10 categories of meaning were identified.

Discussion:

The significance of the nature of the nurse–patient interaction to preserving dignity in nursing care is highlighted.

Conclusion:

Understanding the meaning of dignity for nursing students may help prepare future nurses more able to preserve dignity in nursing care.

Keywords

Content analysis dignity in care ethics education nursing students photo-elicitation topic areas

Background

Dignity is a curious, elusive thing…it matters to all of us and is yearned for by those to whom it is denied…Although difficult to define it is something quite ordinary that we sense particularly when it is threatened (p. 189).¹

This description of dignity – as something most noticeable when absent, something special but, at the same time, ordinary – highlights a lack of consensus on what dignity is.^2
–4 For some, this lack of consensus renders dignity a ‘hopelessly vague’ and ‘useless concept’; a poor substitute for the more precise concept of autonomy (p. 1490).⁵ Some have even argued that it should be possible for healthcare ethics to avoid relying on such a nebulous concept.⁶ Conversely, it has also been argued that the concept of dignity offers something of singular importance to healthcare.³ As a result, it is often cited as a crucial factor in a person’s experience of care^7,8 and a key marker of safe and effective nursing care both nationally and internationally.^7

–10 Initiatives designed to preserve dignity in care in the United Kingdom reflect the priority placed upon it.^11

–14 Yet these aspirations for dignity in care seem very much at odds with the reality portrayed in a range of reports citing a lack of dignity in care settings.^15

–21

Many theoretical,^22,23 organisational,^15,20 professional^24,25 and personal perspectives^26
–28 on dignity have been described, but the perspectives of nursing students have received relatively little specific attention. Significantly, the Commission on Dignity in Care states that nursing students must have dignity ‘instilled into the way they think and act from their very first day’ (p. 35).²⁰ Perhaps unsurprising then is the growing interest in the potential of preregistration undergraduate nursing education to enhance dignity in nursing care^29
–31 but realising this potential will not be without its challenges. Significant organisational, professional, environmental and personal barriers to the promotion of dignity in nursing care have been identified by nursing students.³² Reports of the problems nursing students experience trying to overcome these barriers make difficult reading.^33

–36 It would be disingenuous to suggest that preregistration nursing education is the panacea for these problems but it certainly has an important contribution to make.³⁷

It seems reasonable to suggest that understanding the meaning nursing students attach to dignity will help support the development of future nurses who are more able to preserve dignity and address situations in which dignity is at risk or being violated. This article provides insight into the meaning of dignity in nursing care for nursing students.

Research design

This article describes part of the first strand of a mixed-methods doctoral study exploring nursing students’ perceptions of factors involved in preserving dignity in nursing care. The purpose of the first qualitative strand using Nominal Group Technique (NGT) was to help develop a data collection tool for the second strand. NGT may be defined as a highly structured approach used to explore areas of interest and develop consensus.^38,39

The groups are ‘nominal’ because although participants work in a group setting, the emphasis is on gathering individual views with little interaction.^40,41 This is to help ensure that all group members have an equal opportunity to participate and no one member dominates the discussion.⁴² The technique varies but is often discussed in relation to four key stages.⁴³ At the first stage, participants are introduced to the topic and invited to engage in a ‘Silent Generation of Ideas’ for around 10 minutes.³⁹ Next, at the second stage, each participant is invited, in-turn, to share one of their ideas with the rest of the group in a ‘Round Robin’ format.⁴⁴ There may be clarification of ideas at this stage to allow them to be listed but, again, there is no discussion.⁴⁵ Each idea is recorded and displayed – usually on flip chart paper – by a facilitator until all ideas have been listed.⁴⁶ These ideas are then discussed briefly at the third stage for the purpose of clarification or removal of duplication.⁴⁵ The fourth and final stage involves the participants voting on and ranking the ideas listed by the group.⁴⁷ In this study, photo-elicitation was employed at the first stage: Silent Generation of Ideas as a ‘trigger’ for the subsequent stages in which group consensus was reached around the factors that help preserve dignity in nursing care.

Photo-elicitation is a technique that uses photographs or other images in an interview setting.⁴⁸ Recommended as a means of stimulating discussion of complex concepts ^49,50 and generating deeper responses than words alone,^48,50,51 it is argued that photo-elicitation may help participants to respond more authentically because images connect with the unconscious to evoke a spontaneous response.^52,53 Furthermore, photo-elicitation has been recommended for use in situations where participants might struggle to articulate their understanding.^49,52

A pre-existing collection of 70 images – photographs and abstract representations – ranging from people and animals to landscapes and objects⁵⁴ was used in this study. This eclectic collection has been used to study compassionate care,⁴⁹ the meaning of dignity for care home residents and staff⁵⁵ and in programme evaluation.⁵⁶ Each participant was invited to select an image from the 70 available that captured something of the meaning of dignity for them and to provide a written rationale for their choice in a response booklet. Participants were advised that they would not be asked to share or discuss their chosen image in order to reduce any potential embarrassment and avoid any discussion that might influence their individual response. The nursing student participants in this study may have experienced this difficulty because of a perceived need to say the ‘right’ thing or to give the ‘correct’ answer.

Participants and research context

Participants were invited to one of five groups which were specific to their year of study. The primary purpose of arranging year-specific groups was to facilitate a relaxed and non-threatening environment by bringing together similar participants^45,57 rather than to detect differences between participants at different stages. Groups were arranged on dates and times to minimise any inconvenience to the participants. Attendance varied and group size ranged from between 3 and 11 (Table 1).

Table 1.

Participants.

Group name	Group year	Number
14A	Year 1	7
14B	Year 1	3
13	Year 2	12
12A	Year 3	6
12B	Year 3	3
Total		31

Ethical considerations

The study was approved by the Ethics Committee of the School of Health, Nursing and Midwifery, University of the West of Scotland. Participants were recruited from each year of a 3-year undergraduate preregistration programme in the university where the researcher is employed as a nurse lecturer. Acknowledging the particular need to protect participants from harm in this situation,⁵⁸ the decision to recruit these students is perhaps best understood in terms of what has been described as a careful balance of benefits and risks.^59,60 Involving students as participants may be regarded as more in keeping with students as experts in the research topic and partners⁶¹ while providing educational benefits for students⁶² and a valuable opportunity to reflect on nursing care.⁶⁰

To minimise risk, potential participants were recruited by a member of staff unconnected with the study and received detailed information about the study including what would be expected of them if they participated. Participation was entirely voluntary and participants could withdraw at any stage without giving any reason. All data were treated confidentially and anonymised. Minimal demographic data – age and gender – were collected in order to provide a broad profile of the participants while protecting their anonymity. Images within the set made available by NHS Education for Scotland were licensed for use from iStock (Getty Images) which requires model and property releases for all images supplied. Images were used with the permission of NHS Education for Scotland. Ethical issues related to the researcher and to the quality of the research were considered in the wider context of trustworthiness.

Findings

Responses were analysed qualitatively and quantitatively by content analysis following a systematic approach.⁶³ Qualitative inductive content analysis used values coding of participants’ responses to identify 10 categories of meaning. Quantitative content analysis focused on the frequency with which certain images were selected and the number of coded units contained in each category. Content analysis has been used effectively with student nurses to explore sensitive issues,^64,65 and, therefore, it seemed appropriate for this study of student nurses’ perceptions of dignity in nursing care.

Qualitative content analysis

Content analysis is appropriate when there is a particular interest in quantifying qualitative data⁶⁶ and is usually a deductive process in which pre-determined categories are applied to text.⁶⁷ Inductive content analysis, however, is the preferred approach when the existing knowledge of the phenomenon under investigation is limited or unclear.⁶³ As relatively little is known about the meaning nursing students attach to dignity in nursing care, an inductive approach was adopted. Analysis followed a recommended three-phase approach of preparation, organisation and reporting.⁶³

During the first – preparation – phase, language-based data contained in the participants’ written explanations of their image selections were selected as the unit of analysis. Saldaña⁶⁸ advises that while coding frameworks for visual data are available, the best approach is to analyse the language-based data associated with the visual data.

At the next – organisational – phase, values coding was used. Values coding involves coding qualitative data according to values, attitudes and beliefs.⁶⁸ The complex relationship between these concepts makes distinguishing between them particularly difficult and it is not necessary to code for all three or differentiate between them.⁶⁸ Analysis focused, therefore, on identifying the beliefs of the participants; beliefs are defined as the acceptance of the existence or truth of a person, object or idea.⁶⁹ For the purpose of this content analysis, beliefs were identified when participants stated their perspectives as fact (Table 2).

Table 2.

Example of values coding.

Image	Participant’s response	Preliminary codes
Participant A12.01 Image 33A⁵⁴	1. I chose the image of the handprint as I feel dignity is about being able to keep things which are personal to yourself 2. and a handprint is a personal thing 3. as no other person has the same one. 4. I also think of dignity as being different for every person and 5. handprints on each individual are different.	1. Dignity is about PRIVACY 2. Dignity is PERSONAL 3. Dignity is UNIQUE (to the person) 4. Dignity is UNIQUE (to the person) 5. Dignity is UNIQUE (to the person)
Preliminary ideas Reflects a view of dignity as something individual and unique to each person. Refers repeatedly to the person and the personal – suggests concern with person-centredness. Suggests an understanding of dignity as something that is not restricted to a person’s ability to maintain physical privacy (e.g. during personal care) but a broader understanding that takes into account private thoughts and feelings too.

Generating categories of meaning formed the basis for the third and final stage: reporting. Similar codes were grouped together under major headings which were then used to generate tentative categories before these were refined by developing definitions for each.⁶⁸ These categories were then named using ‘content characteristic words’.⁶³ Participants’ statements and related images were used to name the categories. The number in brackets is the code of the participant whose statement was used to name the category. Categories were then compared with each other and further refined.

Quantitative content analysis

The units of analysis for this component were the frequency with which certain images were selected and the number of statements contained in each category. Each participant in each group selected one image from the seventy images available. In total, 18 images were selected, and of these, half were selected once and the remainder either two or three times. One image – Image 28A⁵⁴ – was selected four times but it became apparent at an early stage that while different individuals might choose the same image, they usually explained their choice in very different ways (Table 3).

Table 3.

An example of differing rationales for image selection.

Image	Participant 14A.05	Participant 14B.08
	To me dignity is about listening as well as many other things. I think it is important that people should be heard and treated equally. I feel communication is key in ensuring people received dignified care…	…the meaning related to dignity in care is that if you want to have a conversation with someone you have to make sure it’s only him or her that can hear. You don’t have to make it louder so everybody can hear…

Simple frequency analysis as described by Flick⁶⁷ was used to determine the number of coded units in each category as a means of reflecting something of the importance participants attached to each category. Categories 1 and 2 – ‘Dignity in nursing care is not having to worry about leaving it at the door’ and ‘Dignity in nursing care is about being respectful of a person’s individuality’ – contained the most statements. Categories 9 and 10 – ‘Dignity in nursing care is also about the person’s loved ones’ and ‘Dignity in nursing care is about giving people the time they need’ – contained the least. The final categories in order of this frequency analysis are presented in Table 4.

Table 4.

Final categories in rank order.

Category	Defining Image
1. Dignity in nursing care is not having to worry about leaving it at the door (Participant 13.05) The participant expresses a belief that dignity in nursing care is about feelings, for example, happiness, sadness, embarrassment, contentment, fear, anxiety and safety (Image 24A).⁵⁴
2. Dignity in nursing care is about being respectful of a person’s individuality (Participant 12A.01). The participant expresses a belief that dignity in nursing care is about the importance of the uniqueness of the individual and their perspective on what constitutes dignity in their own care (Image 33A).⁵⁴
3. Dignity in nursing care is about doing whatever is possible (Participant 13.02) The participant expresses the belief that dignity in nursing care is about taking action to preserve dignity (Image 36A).⁵⁴
4. Dignity in nursing care is about protecting the vulnerable person (Participant 13.03). The participant expresses a belief that dignity in nursing care is about the vulnerability of the person – for example, during personal care, clinical condition and procedure – their dependency, the power or authority of the practitioner (Image 59A).⁵⁴
5. Dignity in nursing care is about working together (Participant 13.08) The participant expresses a belief that dignity in nursing care is about partnership; the relationship between the person and the practitioner (Image 12A).⁵⁴
6. Dignity in nursing care is about communicating with each other (Participant 14A.06). The participant expresses a belief that dignity in nursing care is about communication (Image 28A).⁵⁴
7. Dignity in nursing care is about respecting the person’s choices (Participant 14.03) The participant expresses the belief that dignity in nursing care is about the person’s right to make their own choices (Image 8A).⁵⁴
8. Dignity in nursing care is about showing that you care (Participant 12B.07) The participant expresses a belief that dignity in nursing care is about demonstrating care and compassion (Image 74A).⁵⁴
9. Dignity in nursing care is about giving people the time they need (Participant 13.11) The participant expresses a belief that dignity in nursing care is about taking or giving time, being patient. (Image 37A).⁵⁴
10. Dignity in nursing care is also about the person’s loved ones (Participant 13.04) The participant expresses a belief that dignity in nursing care includes promoting the dignity of the person’s family, friends or other loved ones (Image 27A).⁵⁴

Discussion

Philosophers often say that, if you want to know the meaning of a word, don’t ask for a definition (p. 192).¹

Regardless of the ongoing debate around the utility of the concept of dignity in healthcare, the concept certainly seemed to resonate with participants in this study. In stark contrast to the theoretical debate around the meaning of dignity, none of the participants showed any hesitation in selecting an image that for them captured something of the meaning of dignity in nursing care and providing a confident rationale for their choice. Of the 10 categories, 9 describe dignity in nursing care in terms of action – something that nurses played an active role in and made a difference to. None of the participants made any explicit reference to policy, ethical principles or professional standards or guidance in their written responses. Instead, each of the 10 categories reflected a personal understanding of dignity in nursing care as something located firmly in the relationships and feelings involved.

A theory of dignity with a singular focus on the importance of these aspects of the participants’ understanding has been developed by Jacobson and is founded on the idea that ‘Every human interaction holds the potential to be a dignity encounter’ (p. 3).⁷⁰ A ‘dignity encounter’ consists of three elements: the wider ‘social order’, the setting and the actors (Figure 1). While these elements have been described elsewhere,^25,71,72 Jacobson’s focus on the interaction within and between them provided a particularly helpful lens through which to view the findings.

Figure 1.

Elements of a dignity encounter.⁷⁰

The social order

The first element – the social order – is comprised of the broader ethical, legal, economic and political factors in which the actors, the setting and the encounter are embedded.⁷⁰ These broader issues – such as government health policy and the legal, ethical and economic factors influencing health – are also highlighted as significant influences on dignity elsewhere in the literature.^{2,25,71,73
–75} This article’s discussion of the broader social order focuses on the extent to which the meanings articulated by participants reflected ethical and professional understandings of dignity.

Primarily, participants might have been expected to express their understanding with some reference to human rights and ethical principles because this approach underpins ethics education in their programme of study. Indeed, it has been reported that this approach characterises most ethics education in healthcare.^76,77 The language of human rights and ethical principles, however, formed no part of participants’ expressed understanding. In particular, participants did not express their understanding in terms of obligation but in personal terms with an emphasis on the nature of the relationships and feelings involved.

Participants may simply have found it easier to articulate their understanding in naturalistic language; however, this finding seems to support the findings of studies of qualified nurses in which personal values and the nature of the nurse–patient relationship were found to exert considerable influence on ethical decision-making.^78
–80 An extensive literature review of nurses’ ethical decision-making highlights the influence of personal and contextual factors on the process.⁸¹ It recommends that nurse education and its partners in healthcare enable nursing students to develop not only theoretical knowledge of ethics, but also the ability to reflect critically on care and to make a positive contribution to meeting ethical challenges in care settings.⁸¹ This seems to lend support to the growing use of approaches designed to facilitate nursing students’ learning in relation to dignity that are orientated more towards personal values and experience.^82

–88

Interestingly, participants did not identify any prerequisites – such as autonomy – when they articulated their understanding of dignity. Much of the theoretical discussion of the meaning of dignity is around whether or not it is absolute and held by all human beings to the same degree⁸⁹ ‘simply by virtue of the fact that they are human’⁹⁰ or whether it requires rational capacities like autonomy to be present.^91,92 This debate has profound implications for healthcare and persons with limited rational capacity.^23,93 Arguably, only categories 2 and 7 – ‘Dignity in nursing care is about being respectful of a person’s individuality’ and ‘Dignity in nursing care is about respecting the person’s choices’ – clearly reference autonomy. It has been asserted that autonomy is a significant aspect of dignity but not its defining characteristic,^79,94 and it is interesting that the participants’ understanding seems to reflect this.

With regard to the professional standards and guidance that frame ethics in a professional context, no explicit reference was made to the Nursing and Midwifery Council’s Code⁸ which obliges nurses to uphold the dignity of those in their care. There is some evidence suggesting that nurses often base their care decisions on experience and instinct rather than on the principles contained in such codes.^95,96 This may lend support to arguments around the extent to which such codes are understood and have practical value for nurses,^10,96 and it would be interesting to explore this further with nursing students. While no explicit reference to the code is made, however, the categories do seem to reflect some of the ways in which the Nursing and Midwifery Council identify nurses should ‘prioritise people’ by, for example, respecting diversity and choice, listening and working in partnership (p. 6).⁸ Moreover, the common attributes of dignity – concepts like respect that are frequently attached to dignity to describe it⁹⁷ – are also reflected in the language of both the code and that of the participants.

The setting

Setting is the second element in Jacobson’s theory and refers to the local context in which the interaction occurs.⁷⁰ Jacobson characterises different settings as ranging between ‘humane’ and ‘harsh’; the former characterised as calm, friendly and accessible and the latter as rigid, hierarchical and obstructive.⁷⁰

Once again, the importance of context – the culture and physical environment of a care setting – is highlighted in the literature.^{24,25,97
–99} Context is likely to be especially significant for nursing students who, as learners, may occupy a particular place in the care setting’s hierarchy – as ‘just’ a student – and feel disempowered to act when confronted by situations in which dignity is threatened.³⁴ Tension between the ideals of the classroom and the realities of practice may further complicate the setting for nursing students.^33,100 Interestingly, participants made no reference to the physical environment of the care setting. In the next stages of the NGT, however, participants did, when prompted, identify some aspects of the physical environment – for example, the availability of single rooms – as important.

The actors

The actors constitute the third and final element of Jacobson’s theory and are the individuals or groups who are interacting and are influenced by two sets of conditions: their ‘position’ relative to each other and the nature of their relationship.⁷⁰ Arguably, for the participants, these conditions seem to be where the meaning of dignity is found.

For Jacobson, if one actor has a position of compassion and the other actor one of confidence, then dignity is more likely to be promoted.⁷⁰ Conversely, dignity is more likely to be violated if one actor has a position of antipathy and the other actor one of vulnerability.⁷⁰ Categories primarily concerned with helping, protecting, demonstrating care and giving time seem particularly relevant in terms of establishing a position of compassion and confidence (Table 5).

Table 5.

Categories and conditions.

Dignity in nursing care is not having to worry about leaving it at the door (Image 24A).⁵⁴
Conditions
Position	Relationship
• Dignity in nursing care is about doing whatever is possible to help • Dignity in nursing care is about protecting the vulnerable person • Dignity in nursing care is about showing that you care • Dignity in nursing care is about giving people the time they need	• Dignity in nursing care is about being respectful of a person’s individuality • Dignity in nursing care is about working together • Dignity in nursing care is about communicating with each other • Dignity in nursing care is about respecting the person’s choices • Dignity in nursing care is also about the person’s loved ones

Similarly, Jacobson asserts that a relationship of solidarity between actors – characterised by empathy and trust – is more likely to promote dignity while a relationship of asymmetry – characterised by inequity in relation to power, knowledge or control – is more likely to violate it.⁷⁰ Categories primarily concerned with establishing a relationship based on respect for the individual and working in partnership with them and with their loved ones seem particularly relevant to this set of conditions (Table 5).

The highest-ranked category – ‘Dignity in nursing care is not having to worry about leaving it at the door’ – differs from the others because it does not focus on action but on outcome; the outcome being that persons receiving nursing care are not worried about their dignity being violated. Consequently, when viewed in the light of Jacobson’s theory, it may be regarded as describing the result of establishing the conditions conducive to the promotion of dignity.

Conclusion

This article provides insight into the richness and diversity of the meaning of dignity in nursing care for nursing students. Reflection on the findings and conduct of the study has identified a range of implications for future research.

Participants expressed their enjoyment of using the images and were clearly engaged in the process. The resulting fluency and immediacy of the participants’ responses to the images they selected appeared strikingly authentic. Embedding photo-elicitation within the NGT worked well in the broader context of the larger study of which it was a small part. Nevertheless, it is worth noting that the nature of NGT does not offer individuals an opportunity to ‘tell their story’. Exploring the meaning of dignity in nursing care for nursing students using photo-elicitation in an individual interview setting may help provide more detailed insight into nursing students’ personal understanding. Similarly, the opportunity to utilise freely available and high-quality images was beneficial within the limits of the larger study too. Inviting participants, however, to capture something of the meaning of dignity in nursing care for them by taking their own photographs may help participants represent their perceptions even more powerfully.^52,101 Moreover, it would be interesting to explore the meaning of dignity in nursing care with a more diverse sample of nursing students as this sample was self-selected from a single institution.

Understanding what dignity in nursing care means to nursing students may help develop nurses who are able to preserve dignity and to address situations when it is threatened. The meaning of dignity in nursing care for nursing students is articulated in terms of the relationships and feelings involved rather than in terms of the human rights and ethical principles that underpin conventional approaches to ethics education in preregistration nursing education. This lends support to the growing use of approaches that are orientated towards personal values and experience.

Footnotes

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) received no financial support for the research, authorship and/or publication of this article.

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