Intensive care unit dignified care: Development and validation of a questionnaire

Introduction

Dignity is an abstract, complex, and meaningful concept which is of immense relevance to the human experience. According to the literature, the attributes of dignity include personhood (intrinsic value), sociability (situation-dependent), respect, and autonomy.^1–5

Critically ill patients are immensely vulnerable and need a certain level of respect for their dignity. Studies^6–8 have suggested that loss of dignity is a common phenomenon among intensive care unit (ICU) patients. In the ICU, patients with life-threatening illnesses are usually unable to speak, are physically restrained, passively accept various manipulations, are often stripped naked, accompanied by bedside alarms, and are separated from their families. ⁹ “Loss of dignity” in this situation is regarded as intrinsic emotional harm, which may lead to anxiety, depression, or post-traumatic stress disorder syndrome in ICU survivors; ¹⁰ in addition, dying ICU patients suffer severely beyond physical pain. ¹¹

Nurses play an essential role in promoting the sense of dignity among patients. ¹² As a humanistic discipline, the ethical nature of nursing is to provide care for human vulnerability and to preserve and promote patient dignity as much as possible. ¹³ According to Gazarian et al., ¹⁴ positive nurse-patient interactions based on care and compassion represent an excellent way to maintain patient dignity. In the ICU environment, maintaining patient dignity includes understanding and caring for the patient as a unique individual, making an effort to communicate with all patients, protecting their vulnerability and privacy, listening to them, speaking up for them, and empowering them with choices or control.^9,15–17

However, the current status of critical care nurses in preserving patient dignity is not well characterized. There are only two instruments related to maintaining the dignity of ICU patients, that is, CORE-ICU ¹⁸ and DOC. ¹⁹ The CORE-ICU ¹⁸ is a tool for evaluating clinicians’ perspectives of respectful treatment in the ICU. The scale consists of 21 items encompassing 3 dimensions: overall respect, respectful behaviors, disrespectful behaviors. This scale was not designed for nurses specifically. Besides, in Asian culture, individuals are more likely to feel embarrassed and ashamed to report their behaviors that cause disrespect to others. Therefore, Asian clinicians may be more likely to hide their actual behaviors when asked about the dimension of disrespectful behaviors. As reported by the developers ¹⁸ of this scale, Asian respondents reported greater respect for patients than respondents of other races. Thus, this instrument may not be suitable for universal use. Carrese et al. ¹⁹ developed the DOC to assess the level of respect and dignity accorded to patients in the ICU and their families. The DOC is a direct observation checklist with 10 items, consisting of 2 subscales: clinician behavior and clinician demeanor. The DOC can avoid the influence of self-reported bias to some extent. However, the existence of an observer is liable to induce a conscious change in the behavior of the clinicians. ¹⁹ Moreover, DOC requires a skilled observer and the process is time-consuming. Thus, it is not suitable as a conventional screening scale. For these reasons, this study aimed to develop an instrument to provide a more concrete measure of how critical care nurses provide care with respect and dignity. This novel questionnaire is intended for use as a complementary tool along with the currently used instruments for assessing the behaviors of critical care nurses in dignified care.

Aim

The aim of this study was to develop the ICU Dignified Care Questionnaire (IDCQ) and to assess its reliability and validity in order to provide a basis for evaluating the behaviors of critical care nurses in preserving patient dignity.

Methods

Results

Phase 3: Development of the final version

Eventually, of the 432 questionnaires, 392 were valid. The valid response rate of the questionnaire was 90.74%.

Item analysis

The results showed that the total correlation coefficients of all items were greater than the cutoff value of 0.4. ²⁵ The critical ratio showed good discrimination ability of the questionnaire (p < .01). As for internal consistency, the overall Cronbach’s alpha coefficient of the questionnaire decreased after removal of each item individually. Based on these results, all items were retained.

Construct validity testing

EFA and CFA were used to assess the construct validity of the questionnaire. The KMO Index and the Bartlett’s Test of Sphericity indicated the suitability of the instrument for EFA (KMO = 0.955; χ ² = 4347.987, df = 136, p < .001). ²⁶ Because the three dimensions in the original conceptual framework show correlation with each other, the maximum likelihood method with promax rotation technique was used to conduct EFA. Two factors with Eigen values >1 were extracted, accounting for 62.804% of the total variance (Table 1). Factor loadings for each item were greater than the criteria of 0.5 in their respective dimensions, indicating practically significant. ²⁷ Items 1–9 had a more significant loading on Factor 1, and items 10–17 had a more significant loading on Factor 2. This result was not inconsistent with the hypothetical dimension from the original concept model. Based on the result of EFA, the items contained in Factor 1 were consistent with the “shared humanity” of the theoretical dimension, while the items contained in Factor 2 covered the “personal narrative” and “autonomy” of the theoretical dimension. According to the literature,^28,29 dignity can be divided into two parts: absolute dignity and relative dignity. Absolute dignity is the natural birthright of every human being, regardless of age, race, wealthiness, disease, or even social status. ³⁰ Nurses should treat the patient as a living, vulnerable being and provide care without prejudice to maintain absolute dignity. Shared humanity in the original conceptual model ²⁰ refers to the dignity that is “simply by virtue of being human,” which is consistent with the meaning of absolute dignity. Relative dignity is influenced by the individual’s cultural context, growth environment, education, and social status. Nurses need to take cognizance of the uniqueness of each patient, provide personalized nursing care, respect, and safeguard the fundamental rights of patient when maintaining relative dignity. Respect for the patient’s personal narrative and autonomy in the original conceptual model ²⁰ also emphasizes “respect individuals’ perceptions of themselves and what matters to them” and “provide insight into the values underlying a patient’s preferences,” which is consistent with the meaning of relative dignity. Therefore, we named Factor 1 as “absolute dignity,” and Factor 2 as “relative dignity.”

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Table 1.

Findings of exploratory factor analysis.

Item	Naming	Factor
		1	2
1. I greet patients as soon as possible at each shift	Absolute dignity	.581	.024
2. I am polite and gentle in treating		.804	−.067
3. I protect patients’ privacy and avoid unnecessary physical exposure		.692	.057
4. I treat patients as living, dignified individuals and do not mark them (such as calling them by their bed numbers or disease names)		.822	−.115
5. If I were a patient lying in bed, what kind of care would I want? I use this question to guide my nursing behaviours		.672	.147
6. I treat patients as carefully as possible to reduce their pain and discomfort		.802	.012
7. I explain to patients before each nursing operation as long as they are conscious		.794	−.011
8. I provide care for patients with the belief that everyone is equal		.675	.046
9. I make effort to improve the patient’s surroundings, such as lighting and noise		.505	.335
10. I collect patients’ personal information from different aspects (such as education levels, beliefs, customs, economics) to provide personalized care	Relative dignity	.097	.698
11. I adjust the nursing plan dynamically to meet the physical and psychological needs of patients according to their condition		.216	.631
12. I listen to the requests of patients and their families with heart		.308	.510
13. I try my best to alleviate the anxiety, fear, or other bad feelings of patients and their families in different ways		.146	.718
14. I use evaluation instruments to promptly evaluate the self-decision-making ability of patients and try my best to safeguard their autonomy		−.112	.879
15. I involve patients’ families in caring (such as physical restraint plans and early rehabilitation activities)		−.157	.844
16. If patients have self-expressions, I will convey their willingness to their families and doctors		.069	.654
17. I will (or suggest doctors) be patient and give patients and their families enough disease-related information to help them make the best decision		−.036	.800

Note: Bold value means factor loading > 0.5.

To further validate the factor structure of the instrument, the bootstrap technique with maximum likelihood estimation was used to conduct CFA. The results obtained were as follows: χ ² /df = 2.644, GFI = 0.912, NFI = 0.932, IFI = 0.956, CFI = 0.956, RMSEA = 0.065, SRMR = 0.0421 (Figure 2). The standardized factor load of each item ranged from 0.583 to 0.845. The average variance extracted for the “absolute dignity” and “relative dignity” dimensions were 0.543 and 0.581, respectively. The composite reliability of the above dimensions was 0.914 and 0.917, respectively. All the goodness-of-fit indices met the recommendations of the literature: χ ² /df < 5, GFI > 0.9, NFI > 0.9, IFI > 0.9, CFI > 0.9, RMSEA < 0.08, SRMR < 0.08,^31–33 indicating good model fitting. Finally, the final version of the questionnaire was developed with 2 dimensions: absolute dignity (9 items), relative dignity (8 items).OPEN IN VIEWER

Figure 2.

Standardized path coefficient diagram of the questionnaire.

Content validity

The I-CVI of each questionnaire item ranged from 0.80 to 1.00, and the S-CVI/Ave of the questionnaire was 0.98, both exceeding the recommended value (I-CVI > 0.78, S-CVI/Ave ≥ 0.90). ³⁴

Reliability testing

We calculated Cronbach’s alpha coefficient and ICC to measure internal consistency reliability and test-retest reliability, respectively. The Cronbach’s alpha coefficients of the questionnaire were 0.94 (overall), 0.91 (absolute dignity), and 0.92 (relative dignity), which were considered satisfactory. ³⁵ The 2-week test-retest reliability index ICC of the total questionnaire was 0.88 (95% confidence interval was 0.75–0.94), surpassing the cut point of 0.7. ³⁶

The final version of IDCQ

This study eventually developed the IDCQ with 17 items and 2 dimensions of “absolute dignity” and “relative dignity.” Each item was assessed using the 5-point Likert scale (1–5 stands for “never” to “always”) (Supplementary Table). The total score of the questionnaire ranges between 17 and 85 points. Critical care nurse’s behaviors of dignified care are assessed according to the standard score. Standard score = (actual score – theoretical minimum score)/(theoretical maximum score – theoretical minimum score) × 100, with a standard score of ≥80 indicating good behavior, 60–79 indicating intermediate, and <60 indicating poor behavior. ³⁷ Higher scores on this questionnaire represent greater respect provided by the critical care nurses to patients.

The mean (± standard deviation) score of participants’ behaviors of dignified care was 67.58 ± 10.16 (range, 32–85), and the mean standard score was 74.39 ± 14.94 (Table 2). In addition, the standard score of participants in maintaining the patients’ absolute dignity was 78.19 ± 14.62, while that for maintaining the patients’ relative dignity was 70.11 ± 17.76. Specifically, the highest-scoring item was providing equal care for every patient; the lowest-scoring item was involving patients’ families in caring.

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Table 2.

Scores for the ICU dignified care questionnaire (N = 392).

Variable	Item	Mean (SD)
		Actual score		Standard score
Absolute dignity	1. I greet patients as soon as possible at each shift	3.73 (.95)	37.15 (5.26)	78.19 (14.62)
	2. I am polite and gentle in treating	4.18 (.70)
	3. I protect patients’ privacy and avoid unnecessary physical exposure	4.11 (.72)
	4. I treat patients as living, dignified individuals and do not mark them (such as calling them by their bed numbers or disease names)	4.27 (.75)
	5. If I were a patient lying in bed, what kind of care would I want? I use this question to guide my nursing behavior	3.88 (.85)
	6. I treat patients as carefully as possible to reduce their pain and discomfort	4.30 (.66)
	7. I explain to patients before each nursing operation as long as they are conscious	4.26 (.77)
	8. I provide care for patients with the belief that everyone is equal	4.33 (.68)
	9. I make effort to improve the patient’s surroundings, such as lighting and noise	4.08 (.74)
Relative dignity	10. I collect patients’ personal information from different aspects (such as education levels, beliefs, customs, economics) to provide personalized care	3.58 (1.00)	30.44 (5.68)	70.11 (17.76)
	11. I adjust the nursing plan dynamically to meet the physical and psychological needs of patients according to their condition	3.94 (.80)
	12. I listen to the requests of patients and their families with heart	4.13 (.73)
	13. I try my best to alleviate the anxiety, fear, or other bad feelings of patients and their families in different ways	3.92 (.83)
	14. I use evaluation instruments to promptly evaluate the self-decision-making ability of patients and try my best to safeguard their autonomy	3.77 (.90)
	15. I involve patients’ families in caring (such as physical restraint plans and early rehabilitation activities)	3.41 (1.09)
	16. If patients have self-expressions, I will convey their willingness to their families and doctors	3.93 (.87)
	17. I will (or suggest doctors) be patient and give patients and their families enough disease-related information to help them make the best decision	3.76 (.91)
Whole questionnaire			67.58 (10.16)	74.39 (14.94)

Discussion

We strictly followed the protocol ³⁸ to develop a novel instrument-IDCQ, which consisted of two dimensions, absolute dignity (9 items) and relative dignity (8 items). Our findings did not strictly follow the three theoretical dimensions of the original research hypothesis. However, there is no contradiction between the two.

Though the terms used in the literature,^{2,28,29,39–42} are not entirely consistent, dignity often can be divided into two sub-categories: absolute dignity and relative dignity. According to literature, everyone has absolute dignity simply because they are human. Absolute dignity, also called universal, human, basic, or intrinsic dignity, stresses the value and meaning of the existence of each person’s life. Maintaining absolute dignity requires that nurses treat each patient as a valuable being with basic respect rather than as an object of illness. Relative dignity, also called acquired, social, personal, or inflorescent dignity, varies from person to person. This implies that people from different sociocultural contexts may have different understanding of dignity. ⁴² Therefore, nurses should endeavor to provide personalized care in order to maintain the patient’s relative dignity. In this study, items 1–9 in the theoretical model dimension of “share humanity” address greetings, courtesy, privacy protection, and general care, reflecting respect for the value of life, which is consistent with the connotation of maintaining the patient’s absolute dignity. Similarly, “personal narrative” (Items 10–13) and “autonomy” (Items 14–17) in the initial theoretical dimensions focus on the patient uniqueness, aiming to provide individualized patient-centered dignified care, which is in line with the implication of preserving the patient’s relative dignity. Therefore, combining the results of EFA, we integrated the original dimensions of “personal narrative” and “autonomy” into “relative dignity.” Correspondingly, the dimension of “shared humanity” was renamed as “absolute dignity.”

We first examined the construct validity of the questionnaire by EFA. The results showed that two factors accounted for 62.804% of the total variance, which exceeded the acceptable value of 50%. ⁴³ Each item had a high loading on the factor to which it attributed. To further demonstrate the construct validity of the questionnaire, CFA was used for analysis. The goodness-of-fit indices of the model were acceptable. The results of CFA showed that the standardized factor loading of each item was >0.5, the average variance extracted was >0.5, and the composite reliability was >0.8, which qualified the requirements. ⁴⁴ These findings indicated acceptable convergent validity of the questionnaire.

Reliability refers to the consistency and stability of test results. Better reliability implies less chance of a random error in the measurement. In this study, the overall Cronbach’s alpha coefficients and that for each dimension were all >0.9, indicating that IDCQ has good internal consistency reliability. Furthermore, the ICC of the total questionnaire was 0.88 after 2 weeks, suggesting that the questionnaire had good reliability and stability across time.

In terms of the scores for the IDCQ, participants showed a medium level of provision of dignified care for patients. Besides, the respondents reported that they performed poorly in maintaining patients’ relative dignity compared to absolute dignity. Although the study used a convenience sampling method, the survey results reflected, to some extent, the need for improving the level of maintenance of patient dignity by critical care nurses, especially relative dignity. ICU patients have different care needs and may have greater expectations regarding respect for their relative dignity. Previous study ⁴⁵ also found some gaps between the patients’ expectations of dignity and their satisfaction with dignified care. More research is needed to use the IDCQ to investigate the level of critical care nurses’ behaviors in dignity-conserving care. In addition, the relationship between patient satisfaction and the extent to which nurses maintain relative dignity needs to be explored.

Conclusions

This study developed a reliable and valid instrument (IDCQ) with 17 items and 2 dimensions to assess the dignified care for critical care nurses. Dignity is an essential element in nursing care. Every patient deserves to be treated with respect, even in critical illness.

The IDCQ can help critical care nurses to conduct self-assessment of their behaviors in dignity maintenance. Improvements can be made in areas where they are deficient, thus enhancing dignified care. Nursing managers can use the IDCQ as a tool for evaluating the quality of humanistic care in the ICU. It can help nursing managers to develop interventions to promote dignified care at the organizational level.

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