Patients’ perception of dignity in Iranian general hospital settings

Introduction

Dignity is one of the fundamental human rights. ¹ The word ‘dignity’ is derived from the Latin word ‘dignitus’, which means competence, and ‘dingus’, which means value. ² Dignity takes different meanings across the world, the most important of which are value, sanctity, magnanimity, respect, gentility, humanity, position and dignity. ³ Human dignity has been present in medical fields for a long period of time and it may be rooted in Socrates’ emphasis on the significance of respecting a patient’s dignity. ⁴ Furthermore, dignity is highlighted as a core characteristic of nursing caring related to ontology. ⁵ In this regard, Nightingale points out that we are responsible for respecting every single human being in the world in front of God. ⁶ The means of dignity in nursing entails respecting the individual’s inherent worth and uniqueness while providing culturally competent care and protecting the privacy and confidentiality of patients. ⁷ The word dignity has increasingly become a part of contemporary discussions of healthcare. ⁸ This is because disease, inability, need, decreased power and authority, lack of privacy, medical cures and hospitalization can affect ones’ innate value. Limited human dignity can influence a client’s body, soul, morals and spirituality and can expose people to the danger of stress and discomfort. ⁹ Thus, procedures that aim to maintain dignity can be considered not only as ethical indicators but can also work as effective elements to improve both the patients’ desire for cure and also the relations between the patient and the health professionals. ¹⁰

Dignified care has been considered as one of the main objectives of comprehensive care. ¹¹ In addition, preserving dignity is one of the moral responsibilities of caregivers in nursing care ¹² and all nurses are expected to respect the dignity of patients when they are providing care. ¹³ Many national and international nursing organizations consider observing the patients’ dignity as the basis of nursing care. ^{14 –16} In its declaration on the promotion of patients’ rights, the World Health Organization (WHO) stated that patients have the right to be treated with dignity and respect for their culture and values. ¹⁷ The ‘risk of losing human dignity’ has also been cited by the North American Nursing Diagnosis Association as one of the most important diagnoses in nursing. ¹⁸

Respecting people’s dignity increases their satisfaction with the services provided by the healthcare staff and, consequently, leads to a proper relationship between the client and the professionals, to feelings of security and to a shorter length of stay in hospital by reducing mental health problems and, thereby, lowering the costs and increasing the motivation of the healthcare professionals to provide better services. ⁴

Although preserving the dignity of patients is a high priority and it is necessary to ensure high-quality healthcare, ¹⁹ many studies around the world have demonstrated the risks associated with the loss of patients’ dignity in healthcare environments. ^{13,20 –25} Similarly, the findings of research by Rehnsfeldt et al., ²⁶ carried out in Denmark, Sudan and Norway, revealed that the care services provided were based on a routine caring programme without consideration for the individual’s value and dignity.

According to several studies, dignity is a complex concept that is difficult to define due to its multidimensional nature. ²⁵ Although many efforts have been made to define the concept of dignity and its related factors, these remain complex and obscure. ²⁷ Since it is impossible to respect dignity without clarifying the concept ²¹ and because human dignity is one of the important concerns of healthcare system, ²⁸ considerable emphasis has been placed on the need for more research to identify dignity in different wards of the hospital. ²⁵ Most of the qualitative studies that have been conducted around the world have considered the dignity of particular groups of patients ^{28 –35} and the results of these studies cannot be generalized to other patients. Therefore, studying the dignity of hospitalized patients in the setting of a general hospital can be highly beneficial. Furthermore, because the physical environment, the organizational culture and the attitudes and behaviour of the personnel may have an effect on dignity, ³⁶ it would appear that conducting further studies in different societies and cultures may contribute to illustrating the different aspects of this concept and the factors that are related to maintaining patients’ dignity and providing care services that are based on it. Thus, in considering the importance of maintaining and improving patients’ dignity in the healthcare system and the necessity to explore dignity in the setting of the general hospital and within different social-cultural contexts, the purpose of this study is to explore the concept of dignity from the perspective of Iranian patients hospitalized in general hospital settings.

Methodology

Results

Interviews were conducted with 14 patients hospitalized in different educational public hospitals. The patients participating in this study consisted of nine females and five males. The individual characteristics of the participants are presented in Table 1.

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Table 1.

Individual social characteristics of the participants.

Participants	Sex	Age (years)	Marital status	Educational level	Job	Length of hospitalization (days)	Wards
P1	Female	28	Married	MSc.	Self-employed	8	Internal
P2	Female	52	Married	Primary school	Housewife	19	Internal
P3	Female	59	Married	Primary school	Retired	4	Surgery
P4	Female	50	Married	Diploma	Housewife	20	Internal
P5	Female	42	Married	Bachelor	Governmental	5	Orthopaedic
P6	Female	19	Single	High school	Housewife	7	Urology
P7	Male	30	Married	Diploma	Self-employed	12	Surgery
P8	Male	55	Single	MSc.	Governmental	16	Internal
P9	Male	58	Married	Diploma	Retired	20	Internal
P10	Male	44	Single	Primary school	Self-employed	30	Internal
P11	Female	32	Married	Bachelor	Governmental	5	Neurology
P12	Female	50	Married	Diploma	Housewife	6	Internal
P13	Male	28	Single	High School	Self-employed	3	Urology
P14	Female	24	Married	Bachelor	Housewife	6	Internal

Four main themes, including ‘respectful atmosphere’, ‘patient privacy’, ‘patient authority’ and ‘receiving attention’, and 10 categories were extracted from the data. Table 2 represents the themes and categories.

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Table 2.

Themes and categories extracted from the content analysis.

Theme	Category
Respectful atmosphere	Respecting the patient Respecting other patients Respecting the patient’s companions Respecting the nurse
Patient’s privacy	Physical privacy Informational privacy
Patient’s authority	Patient’s decision-making on healthcare issues Self-control of life
Receiving attention	Presence for patient Meeting patients’ needs

Discussion

Preserving dignity is essential to ensure high-quality healthcare. Since an understanding of this concept from the perspective of hospitalized patients can improve the patient’s recovery process and emotional well-being, it is necessary to explore this through in-depth studies.

In this study, from the perspectives of patients in the setting of a general hospital, dignity was understood in terms of four themes: ‘respectful atmosphere’, ‘patient privacy’, ‘patient authority’ and ‘receiving attention’.

One of the main needs of the interviewees was a respectful hospital atmosphere in which the healthcare team respect all of the patients and their companions and, in turn, the patients respect the healthcare team. They believed that this respectful atmosphere could have a significant effect on patients’ comfort and play an important role in their recovery. In the study conducted by Borhani et al., ²⁸ the influence of the care environment, especially the effect of the human environment on preserving the dignity of patients with heart disease, was also noted. In line with the findings of this study, the need for the healthcare team to preserve respect for their patients has been shown in other studies to be one of the important elements in preserving patients’ dignity. ^22,42 The need for respectful interactions between the patients and the nurses has also been identified. ^5,10

In terms of creating a respectful atmosphere, a further finding of this study was the necessity to respect the patient’s companions. In the healthcare system of Iran, having a companion has a special place and, from the perspective of patients, is considered to be a necessity. However, in many cases, the companions of patients are disregarded, despite the fact that they provide for the basic needs of patients in Iran. ²⁰ This factor has not been identified in the findings of other studies based on Western societies ²⁰ and may be due to the different cultural and social contexts of the society and the hospital settings in Iran. In Western-Asian cultures, individual attitudes are more dependent on society and people see themselves as a nature that is connected to society, whereas in Western and North American cultures, a more individualist and independent attitude is reinforced in people. ^43,44 Generally, in contrast to individualistic communities, people in pluralistic communities place more emphasis on doing their duty and accepting responsibility for others, ⁴⁵ thus, in Asian cultures, including Iranian culture, pluralistic values and adapting to the group culture are highly emphasized. As a consequence, teaching individuals to engage in more social interaction and to pay attention to their fellow man is more present in these cultures. Therefore, in such cultures, there is a greater likelihood that people will put themselves in the patient’s shoes and show more empathy for him than it occurs in Western communities. ⁴⁶ Thus, it is common for a patient’s family, relatives and close friends to be present at the bedside to support him and, consequently, importance is placed on the necessary respect for family, group ties and related values.

In this study, patients also wanted respect for nurses. According to some studies, when the dignity of nurses is not preserved, their ability to respect others is reduced. ^{28,47 –49} According to several studies, nurses do not feel worthy and respectful as a result of some influential factors, including patients and their families, doctors, the structure and principles of state systems and, especially, nursing management. ⁵⁰ Korsah’s ⁵¹ study in Ghana also revealed that confrontations between companions and nurses lead to negative interactions between the nurses and their patients. Therefore, providing a supportive environment in which nurses also feel that they are respected is necessary to retain a respectful atmosphere and to improve the quality of care.

The need to respect the patient’s dignity has been identified in this and other studies. However, a distinctive aspect of the findings of this study is the importance that patients placed on the need to create a respectful atmosphere. On one hand, the importance of respect could be rooted in the religious beliefs of the patients, all of whom were Muslim and Shi’a, because in Muslim religious texts, it is highly recommended to have respect for all human beings ^52,53 and to wish for the worthy and desirable things for others that one would wish for oneself. ⁵⁴ On the other hand, this need to respect others could be rooted in orientations towards collectivism and related cultural values among Iranian people. Since a respectful atmosphere has been identified in this study as one of the essential components of dignity preservation, it seems that providing an environment in which the dignity of all individuals, including patients, healthcare staff and companions, is preserved can lead to calmness, satisfaction in people and can provide the context for effective interactions and receipt of various forms of support.

Patients in the study also preferred to preserve their physical and informational privacy during the delivery of care services and also under other conditions. Other studies of factors that impact patient’s dignity have also noted the importance of preserving the patient’s physical ²⁰ and informational ⁵⁵ privacy. In a study by Ebrahimi et al., ²⁰ participants’ perspectives on the lack of respect for privacy included the two categories of indecent body exposure and multi-gender conditions. In this study, the presence of hospital personnel, roommates or visiting attendants of the opposite sex also threatened the dignity of the participants. A number of other studies have also identified informational privacy as an important dimension of preserving patients’ privacy ^55,56 and the results of these studies are in accordance with those obtained from this study. In this study, female participants mostly referred to the importance of preserving their physical privacy. It would appear that this is influenced by some of the social and religious norms of Iranian patients in respect of the necessity of covering the body of a Muslim woman, especially against ghayr mahram (non-mahram) men.

It also seems that some factors, such as a large number of patients in hospital rooms and a crowded healthcare environment, pose important threats to patients’ privacy in the public educational hospitals of Iran. Although people are willing to receive treatment in public hospitals – where the need to keep costs low can result in overcrowded rooms – these conditions can be regarded as a serious problem in terms of observing patient’s privacy. With regard to the privacy of hospitalized patients, taking measures, such as placing patients of the same gender in the same room, emphasizing that healthcare staff should use curtains around a patient when his or her body is naked, taking account of gender homogeneity when allocating nurses to patients, discussing patients’ problems in a quiet tone of voice or in a private conference room and following the principles of confidentially, can all contribute to respecting the privacy of hospitalized patients.

For the hospitalized patients in this study, to preserve their dignity, they needed to be involved in decision-making about their health and care issues and to have sufficient control and freedom to undertake their daily routines during their hospital stay. In a study by Bagheri et al., ³³ the preservation of authority was one of the most important interpersonal factors related to preserving the dignity of patients with heart disease. According to several studies, dependency, lack of control and limitation of activities are related to loss of dignity. ⁵⁷ Matiti and Trorey ²⁵ noted that patients receive dignity when they can be involved in care decisions; thus, dignity is affected if the patient’s expectation of being taken seriously and being involved in individual care is not met. ⁵⁸ In addition, the necessity for the healthcare team to pay attention to the suggestions and priorities of the patients has also been mentioned in other studies. ⁵⁹ It would appear that empowering the patient gives him a sense of being involved in his care and treatment and in controlling what is happening; this plays a role in observing the patient’s dignity. Furthermore, it has been identified that empowering the patients and allowing them greater authority to carry out everyday activities gives them a sense of value and, hence, can have an important impact on improving their sense of dignity.

Therefore, it is likely that when patients have sufficient authority to make decisions about their own health and their affairs, they feel more valuable and more effective. Although certain, appropriate medical decisions are made for them, their participation increases and, ultimately, giving patients greater authority can improve their mental health and their positive health outcomes. ⁶⁰ However, it must be noted that observing authority in East-Asian cultures is also not an individual matter. A disease is a shared family event rather than an individual occurrence in many Asian cultures. ⁶¹ The family is the source of power, hope and connectedness to others. Therefore, the principle of autonomy and, consequently, authority does not hold as much weight as in Western cultures. ⁶² In Western cultures, individuals are usually considered as the target group for counselling and awareness. ⁶³ Nevertheless, it seems that in Asian culture it is the family that must undertake the requirements and commitments for the process of making medical decisions without the patient’s request or permission. ^64,65 Therefore, the family is the core of decision-making. ⁶² Thus, similar to some of the studies conducted in other Asian countries ^66,67 , it seems that in Iran, the patient–family–doctor relationship model can provide a suitable alternative to the patient–doctor relationship model. In this respect, patients must be the focus of counselling and must make decisions about themselves by being the first to be informed of everything related to their conditions. Their families should be engaged in the decision-making processes based on the patient’s priorities and preferences. ⁶³ In this regard, it is suggested that the patient’s family is involved in making decisions related to his curative process, as well as providing an environment in which the patient’s ideas and needs are respected.

Similar to other studies, ^22,68 in this study, receiving attention from others was one of the important components for preserving patients’ dignity and the presence of the healthcare team and the relatives at the patient’s bedside, and consideration of their needs, reflect the attention of others to the patient. Studies have shown that disregarding the needs of patients threatens their dignity. ²⁸ Holistic nursing is a comprehensive patient care system that reflects their spiritual, economic, emotional and physical needs. ²⁸ According to the experiences of the participants in the study conducted by Borhani et al., ²⁸ holistic care was a major factor influencing patient dignity, which led to a sense of security for patients.

In fact, the nature of nursing or healthcare is closely related to ontology. ⁵ Thus, humanistic theories of nursing that are rooted in humanistic, ontological and phenomenological philosophy ⁶⁹ claim to provide new insights for both patient and healthcare professionals and to explain the true meaning of humanity, health and nursing. ⁷⁰ According to some theories, the humanitarian response of the nurses to the patients occurs through the active presence of the nurse in time and space, which is termed ‘being with the patient’. ^69,71 Through this authentic presence, the mutual human love between the spirits of two human beings flows and the nursing care takes place in a true sense, which leads to the patient’s dignity being preserved. ⁵ Furthermore, Watson’s humanistic healthcare theory is developed from humanistic philosophy. ⁷² Based on this theory, Watson defines healthcare as the moment when the patient and the nurse experience a deep spiritual connection that goes beyond time and place and each person identifies the human dignity of the other and tries to proceed on the caring healing-loving journey. ⁷³ All these studies show that an important element of nursing care is the necessity for the nurse to pay full attention to his patient and to respect the patient’s dignity.

A further important issue with regard to the patient’s dignity is the involvement of the family’s support within the health team. ²⁸ However, few studies have noted the effect that family presence and support has on patient’s dignity ⁴² and it seems that the reason for this is that studies mainly conducted in Western culture reflect the different cultural norms of societies regarding the role of the family for hospitalized patients. In Iran, the family is the most important organization influencing a person’s life. Families have complex networks of relationships with relatives and they are the emotional support centre for all family members. Families support and protect their members in critical situations. ⁷⁴ Therefore, in Iranian culture, families play a very significant role in supporting the patient, such that the presence of family members and relatives at the patient’s bedside and addressing the patient’s different needs, as well as visiting relatives and acquaintances, are part of their usual duties towards the patient and this is also an aspect of people’s social and religious values. In such a culture, holistic healthcare performance should imply that healthcare team professionals consider the needs of both the patients and their family members in the hospital environment. ⁷⁵

It seems that one of the most important spiritual needs of humans is for others to take them into account. Perceptions of achieving the others’ attention, which indicate one’s importance and value, are found in the context of social relationships. Therefore, the need for the healthcare team to establish an effective interaction with the patient while maintaining a holistic approach in providing opportunistic services can be a major contributor to meet this need. Developing principles to facilitate the effective participation and care of the families and acquaintances that are at the bedside of the patient may also be helpful in this regard.

Finally, it can be said that one of the most important social care needs of patients is to preserve their dignity. The patients participating in this study felt that their dignity was preserved when they were hospitalized in a respectful atmosphere in which their privacy was respected and where they also had the authority to decide on matters of their personal and medical affairs and to receive the attention of the healthcare team and their relatives. These conditions resulted in satisfaction and positive health outcomes for the patients.

One of the limitations of this study was that the participants were only patients hospitalized in public hospitals. The selection of participants from private hospitals could broaden the scope of our findings. Among the other limitations of this study was that data collection relied on individual interviews – utilizing other qualitative methods of collecting information could lead to a richer outcome. It is, therefore, recommended that future studies on the dignity of patients hospitalized in private hospitals should adopt other methods of gathering qualitative data, such as observation or focus groups, in addition to individual interviews.

Conclusion

Hospitalized patients are susceptible to losing their dignity due to their vulnerability. Given that preserving the dignity of hospitalized patients has resulted in desirable outcomes for them, preserving their dignity has significant importance. It appears that investigating the dignity of patients hospitalized in different cultures and communities can lead to an increase in the knowledge and awareness of this concept among healthcare professionals and can play an important role in improving patients’ dignity. According to the results of this study, providing a respectful hospitalization atmosphere, while respecting the patient’s privacy and paying attention to him, as well as giving patients adequate authority, can help to preserve their dignity. Therefore, it is suggested that a cultural, professional and institutional environment should be provided in which all the principles of the preservation of patients’ dignity are respected and emphasized. In this regard, it seems that health authorities and policy-makers should also consider the findings of this study to provide a suitable support environment in terms of providing patients with the different aspects of dignity. In addition, due to its complex and abstract nature, the concept of dignity should be considered in education, research and in health policies and their implementation.