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Patients' perception of dignity in Iranian healthcare settings: a qualitative content analysis
  1. Hossein Ebrahimi,
  2. Camellia Torabizadeh,
  3. Eesa Mohammadi,
  4. Sousan Valizadeh
  1. Nursing and Midwifery School, Tabriz University of Medical Sciences, Azarbayjan, Islamic Republic of Iran
  1. Correspondence to Camellia Torabizadeh, Nursing and Midwifery School, Tabriz University of Medical Sciences, 51636 39888, Azarbayjan, Islamic Republic of Iran; camellia_torabizadeh{at}yahoo.com

Abstract

Purpose The importance of recognising patient dignity has been realised in recent years. Despite being a central phenomenon in medicine, dignity is a controversial concept, the definition of which in healthcare centres is influenced by a multitude of factors. The aim of this study was to explore the perspective of Iranian patients on respect for their dignity in healthcare centres.

Methods With the use of purposeful sampling, 20 patients were interviewed over an 11-month period in three educational hospitals affiliated with the government. They were questioned about experiences related to respect for their dignity during their hospital encounter. Data were processed by qualitative content analysis.

Results Data analysis identified nine categories and four themes. Respondents expressed their expectations and attitudes about dignity by the following themes: seeking a haven; disrespecting privacy; communicating in a vacuum; and disregard for secondary caregivers. They described how respect for their privacy, effective communication, access to facilities, and a regard for the requirements of their companions made them feel that their dignity had been conserved.

Conclusions The findings indicate that almost no patient is satisfied with the quality of services with respect to maintenance of their dignity. Regardless of their hospital location and state of health, most participants had common complaints. These findings agree with the literature and confirm that grounds should be provided for conserving dignity in the healthcare system. To reach this goal, healthcare professionals should be aware of the factors that violate or preserve dignity from the patient's perspective.

  • Patient dignity
  • qualitative approach
  • human rights
  • healthcare settings
  • content analysis
  • moral psychology
  • clinical ethics
  • concept of mental health
  • applied and professional ethics
  • behavioural research
  • education for healthcare professionals
  • education/programs
  • health promotion

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Introduction

Dignity is one of the fundamental human rights,1 the maintenance of which is desired by any human being irrespective of their situation.2 Patient dignity is an important element of care that has long been mentioned as a significant concept in medicine. The WHO, in a declaration on the promotion of patients' rights, states: ‘Patients have the right to be treated with dignity, which should be rendered with respect for their culture and values’.3

Although many studies have been performed to clarify the nature of dignity, it is unfortunately an abstract and vague concept which is not clearly defined.4–6 The Department of Health makes the same point: ‘There is no clarity about what dignity is and what minimum standards for dignity should be’.7

Furthermore, a review of the literature revealed that maintaining patient dignity in healthcare settings is not well sustained.8–11 Despite the fact that there is nothing definite that affects dignity, some factors have been suggested: The Royal College of Nursing states ‘The physical environment, organisational culture, and staff behaviour and attitudes may also affect dignity’.12 Various studies support this view by indicating that maintenance of dignity in a healthcare setting is influenced by a combination of factors.13–15

The empirical and theoretical literature on dignity suggests a range of conceptual relationships between dignity and other values, such as privacy, autonomy, advocacy, control and respect.4 ,8 ,16–21 Indeed, healthcare professionals may not always have a clear understanding of the meaning of dignity, even those who are willing to take it into account in practice. However, this ambiguity should not be used as an excuse not to explore the meaning of dignity, but rather should stimulate discussion of the concept. Dresser states: ‘Elasticity in the definition of dignity creates the possibility for rich and diverse scholarship about the concept’.22 By focusing on experiences of participants—that is, the way human dignity is perceived by individuals—the meaning of dignity can be understood.23

These concerns indicate that individual social and cultural backgrounds in different healthcare settings may influence preservation of patient dignity in various sociocultural contexts. This study was therefore conducted to explore patients' perception of dignity in Iranian healthcare centres.

Historical background of patient dignity in Iran

The ancient country of Iran has a history of culture, manners and philanthropy, and is also a Muslim country, the Islamic culture of which presupposes respect for individuals' rights. However, it has been neglected and should be brought back into focus.

The Cyrus Cylinder, which is inscribed by Cyrus II, King of Iran 559–530 BCE, is considered to be the first charter of human rights.24 According to the inscription, everyone should have freedom of thought and choice and all individuals should respect one another. It also emphasises the need to respect human dignity. This cylinder is kept in the British Museum in London.

The first patients' bill of rights in Iran was published in 2002 (online appendix 1). It consists of 10 items and is similar to the international versions and therefore not specifically in accordance with Iranian culture. Although respect for human dignity is mentioned in its declaration and a framed copy of it is found on all hospital wards, no patient is informed of its content and there is no provision to ensure it is followed.

Moreover, despite an increase in the number of studies on patients' rights in Iran, priority has been given to either quantitative or other aspects and there is still no qualitative research dedicated to patient dignity. Only recently has research been started to establish a code of ethics for Iranian nurses. Nevertheless, the Iranian Ministry of Health has suggested some codes of ethics, which are being evaluated by stakeholders.

Aim

The aim of this study was to describe the perspective of Iranian patients on respect for their dignity in healthcare centres.

Methods

As the choice of method depends on the aim of the study, qualitative content analysis was used for data gathering and analysis. Qualitative content analysis is a research method for the subjective interpretation of data25 and analysing complex and sensitive subjects, particularly in nursing research.26 According to Elo and Kyngas,26 content analysis has three main stages: data preparation with selection of the unit of analysis; organising the data including open coding, creating categories and abstraction; and finally reporting the results.

Sampling and setting

The study was performed in Shiraz, the fifth most populous city of Iran located in the south west. A purposive sample of 20 patients took part in the study. The research was conducted in three central educational hospitals in Shiraz within an 11-month period (June 2010 to April 2011). The participants were selected from various medical and surgical wards. The inclusion criteria for participation in the study were age over 18 years, having adequate mental capacity and the ability to describe experiences, and a willingness to participate.

The patients included 12 women and eight men aged 21–78 years. Their length of hospital stay was between 4 and 40 days, and 11 had previous experience of hospitalisation. Seven had a university certificate, seven had completed secondary education, five had received incomplete secondary education, and one was illiterate.

Data collection

Data were collected and analysed by the main researcher via interviews and observation. The semistructured interviews lasting 32–90 min were recorded. Interviews were conducted in the participants' mother language. Each interview began with the participant being asked to describe a day during their stay in hospital, as well as their perceptions of the interactions and situations they experienced. The interviews were continued by probing with the following questions in order to reach a broader understanding of the phenomenon under study. ‘What was your experience concerning…?’, ‘Can you give an example to clarify it?’ and ‘Can you elaborate on that?’

Field notes were recorded during observation as another source of data. Direct observations were recorded to provide additional information about the situations, events and interactions between patient and companions, roommates, nursing staff, staff doctor, training physician and nurses during work rounds or teaching rounds. Each observation period lasted at least 2 h and took place on different shifts during the day and night. In total, 18 observation sessions were completed. Data saturation was attained when no new data code could be identified. This was reached by the 16th interview.

Data analysis

Qualitative content analysis was used for data analysis. The data were transcribed verbatim by the researcher and analysed to highlight the participant's perception. Each interview was read several times by the main researcher to gain a general understanding of the content and then coded to signify all words, sentences and statements that had addressed dignity. These meaning units were compared on the basis of similarity and arranged into categories and subcategories. Finally, after several alterations, four themes comprising nine categories were identified.

The collected data and interpretations were shared with the participants to check perceived accuracy and reactions. The coding designation of patients was also rated by three other colleagues to confirm the coding accuracy.

Ethics considerations

The ethics research committee of the university approved the study. At the beginning, each participant received verbal and written information from the main researcher and was assured of anonymity and confidentiality. When patients agreed to participate, they were included in the study. Each patient signed an ‘informed consent’ form. Codes were used instead of names to identify the participants. For an illiterate patient, the researcher read out the consent form, providing the necessary explanations.

Results

The data analysis provided 478 codes, and nine categories and eventually four themes were derived. Themes and categories are summarised in table 1.

Table 1

Overview of the nine categories and four themes derived from the content analysis

Seeking a haven

This theme is abstracted from three categories: lack of facilities and equipment, unhygienic conditions and annoying noise. Most of the patients in this study emphasised environmental requirements as key elements for proper dignity. They stressed that their dignity was not maintained because of lack of adequate services.

Lack of facilities and equipment

Shortage of facilities and equipment is an obstacle to dignity. Many respondents believed that accessibility of resources is very important. The participants described situations in which they were faced with a lack of the necessary facilities. Some patients mentioned that inadequate supplies of sheets and blankets made them feel unvalued and it was their main reason for leaving the hospital. Now look! This IV stand is too high and unsteady but since it is rusted I cannot pull it down. When I go to the bathroom the IV bottles often fall as a result. Patients are not of any value in this system. (Female aged 32) Well, I asked them for an acetaminophen tablet; they said; “we don't have any”. I wanted some piece of pad to cleanse blood stains off my lap; they said; “we don't have one”. I wanted a sheet; they said; “we don't have one”. What a disaster! (Male aged 53)

Not only were the patients dissatisfied with worn-out hospital clothes and broken equipment, they also expected appropriate, adequate and modern equipment. There are no means of entertainment here. They do not provide a DVD player or even a simple TV, at least. (Male aged 21)

On the other hand, a few patients declared that they did not care about the deficiencies regarding facilities and equipment in the hospital. They stated their satisfaction and believed they were ‘easy-going’ people.

Unhygienic conditions

A common theme that emerged from the data analysis was unhygienic conditions. The participants insisted that cleaning of their environment was necessary for them to feel dignity. Their narratives revealed their concerns about hygiene and lack of access to environmental sanitation and cleanliness. The smelly rubbish bins have no lid and are emptied once in a while. It is so contaminated here that I even need to use a tissue for opening the doors. It is really disturbing. (Female aged 45)

The importance of cleaning bathroom and toilet facilities was often mentioned in the responses. Oh my God! Bathrooms are so dirty, even those which have not been in use. It is disgusting to take a shower here. (Female aged 32)

Annoying noise

Crowded wards annoyed the majority of patients preventing peace and tranquillity. Participants were disturbed and distracted mainly because of the noise coming from the nurses' station, relatives' conversations, patients' groans, ward activities and electronic alarms on the equipment. I do not know what they were doing in the nursing station! We could hear metal files slammed into each other till 1am. At sharp 2am the cleaner came here scrunching her feet on the floor and emptied the trash with a loud noise. (Female aged 38) Nurses giving medication always turn on the lights and talk loudly after midnight. I am in a 4-bed room, even if just one of us has medication, the rest are awakened. (Female aged 73) It is my fourth time here and each time, I had to tolerate my roommates' groans. I cannot ask my suffering roommate to be quiet. However, it is difficult to sleep in such conditions. (Male aged 36)

Disregard for secondary caregivers

In this study, ‘companion’ is defined as a family member, friend or any person who stays in the room with the patient. Companions provide care for the patients, yet the basic needs of these caregivers are ignored. This theme will be discussed in two categories: compulsory companionship and lack of companion's comfort.

Compulsory companionship

Companions have a significant role in healthcare centres in Iran. They supply medicines and equipment that are unavailable in hospitals. They are also responsible for some daily nursing care. Not only does the patient want to have a companion, the staff expects them to have one. Well, having a companion is absolutely necessary; in fact, nurses expect you to have a companion. On my arrival day, they asked me: “who is your companion? Who is staying with you?” (Male aged 48)

Although patients need their companions, they feel embarrassed if they think that they have inflicted a challenging or unpleasant job on them or when their companions unexpectedly become involved in private issues. Who is responsible to take care of me? Nurses or my visitor? (Male aged 64) Nurses just give us medicine and measure our blood pressure, nothing else! I have to ask my son whenever I need a bed pan. What kind of dignity is it? (Male aged 53) My sister-in-law is my companion. I feel embarrassed when I have to ask her to change my dirty sheets or empty my bed pan. (Female aged 36)

The field notes of the researcher also reveal this point of view. A companion has to be at the patient's service round the clock. He has to provide his patient with water and food, urinal or bed pan, lowering or lifting up his bed, etc. Since nurses do not reply to buzzers promptly, he also has to fetch the nurse whenever the patient is in pain and distress or is worried about something, for instance when his serum bottle is nearly empty and he worries about air bubbles getting into the patient's bloodstream.

Lack of companion's comfort

Patients expect their visitors to feel as comfortable and valued as possible. They believe that their dignity is not maintained if their companions are not appreciated by the healthcare system. They should provide my companion with at least a bed or blanket. I could not sleep as I was concerned about him sleeping on such an uncomfortable chair. (Female aged 55) There is no place for my companion to sleep. Last night my sister had to sleep on a chair outside, she was freezing till the morning. I felt insulted. (Female aged 40) No food is given to the visitors. I myself witnessed a visitor begging for a piece of bread. (Male aged 64)

Disrespecting privacy

Lack of respect for their privacy was a recurring theme in participants' responses. It comprised two categories: indecent body exposure and mixed-gender situations.

Indecent body exposure

Based on the participants' view, being exposed to others shows disregard for their dignity. They stressed the prevention of unnecessary undressing and inappropriate clothing which threatened their dignity. For instance, hospital gowns do not cover the body properly leaving parts exposed. It is terrible …, wearing such flimsy clothes. (Female aged 73) I have been scheduled for an evening operation but I am obliged to tolerate this degrading open-backed hospital gown from early morning. (Male aged 38)

Some patients complained about disrespect for their dignity during certain daily healthcare activities—for instance unannounced nursing rounds or physician's visits while they were changing or using bed pans. There is no curtain around me. I have to pee under my blanket. It is painful. (Female aged 55) They just pull the blanket aside and checked my dressing while I was exposed to my other roommates and their visitors. (Male aged 30)

Mixed-gender situations

One of the findings of this study was violation of dignity because of the presence of members of the opposite sex, whether hospital personnel or roommates or visitors. Patients felt uncomfortable when they were left with patients of the opposite sex in rooms or wards such as post-coronary care unit or post-angiography units. All patients were in the same unit- operated or non-operated ones. All men and women were kept next to each other. It was such a chaos. (Male aged 53) They had kept me in a room with three male patients. They all were gazing at me! (Female aged 48)

Another aspect was healthcare workers of the opposite sex. A significant number of patients reported that they felt embarrassed when they received care from caregivers of the opposite sex. Surprisingly, this complaint was mentioned by both sexes. A female doctor together with 2 male students came to apply a tube for me. I asked the doctor if they were going to stay. … I did not care if it was an abdominal exam or something, but not for the genitals. (Female aged 59)

Some of the participants complained about the gender of staff and commented that both male and female staff should be available on shifts. I thought a male nurse would check my genitals after operation. I was embarrassed but they didn't pay any attention. (Male aged 48)

The researcher has provided confirmation from observation: The door was opened and a professor together with his medical students came in on a morning round to see a patient while I was observing. They pulled aside the curtain without any prior notice. Shamefully, he was using a urinal… He turned red. He was so embarrassed.

Communicating in a vacuum

The participants in this study often pointed to how healthcare professionals did not provide enough communication. They described situations that made them feel unvalued.

This theme will be discussed in two categories: inadequate verbal and gestural communication, and cultural and social gap.

Inadequate verbal and gestural communication

The importance of a friendly relationship with doctors and nurses was often mentioned by participants. Many patients were dissatisfied with ineffective communication from healthcare providers. Not only was verbal communication thought to be crucial, but facial expressions, gestures and a respectable appearance were also mentioned by the participants. The doctor behaved so harshly that I could not help crying! I felt terrible. I think there would be no way I come to this hospital ever again. (Female aged 55) They even don't say' hi' when they come in the room. They seem to love duty more than humanity. (Male aged 41)

According to the patients, unsatisfactory communication results directly from high workload, inordinate paperwork, overcrowded wards, emergent events and excessive fatigue. From the burnt-out tone of her voice, I gathered that she must be bleary due to her demanding job. (Male aged 21) They are very busy that they cannot communicate with us. They have a lot of paper work at night. (Male aged 38)

Cultural and social gap

One of the most important components of communication challenges is the cultural clash between patients and healthcare providers. Iranian multicultural contexts with different ethnic, language and social classes can prevent the foundation of an effective relationship. The formal language of Iran is Persian, but many patients have other dialects (Turkish, Kurdish, Lurish and Arabic), which can cause language barriers between patients and healthcare workers. They do not understand my language well, neither do I. (Female aged 34)

Moreover, as patients normally have no choice about roommates, some consider that they are not given as much respect as they should be in accordance with their social class. They should realise that urban population is totally different in culture compared to villagers. I think nurses don't like me. That's why they sent me to this room on purpose. (Female aged 32)

Another important aspect in this category is how staff address patients. The way that patients prefer to be addressed is a determining factor of their social class. Many older patients regarded being called by their first name as disgraceful, whereas youngsters found it pleasant. Nurse called us by our first names. It makes us feel at home. They treated us like our family members. (Male aged 25) I was being addressed by my bed number during first week of hospitalization. Later they finally started calling me by first name as if we were intimate friends. They should have called me by my family name. (Male aged 59)

Discussion

This research reveals the perspective of Iranian patients regarding their dignity. Nearly all patients, no matter what their state of health and hospital location, felt that their dignity had been violated while receiving nursing in hospital. As shown in other studies, dignity is still not being maintained in most cases.8–11 Some studies argue that culture plays an important role in how dignity is interpreted and maintained.15 ,27 It is surprising that, despite having a quite different culture, participants in the present research shared similar views with the above studies.

The analysis formulated four main themes that describe how patient dignity is affected in healthcare centres. The first theme, ‘seeking a haven’, reveals that an inappropriate environment made participants feel undignified. In some cases, it even made them leave the hospital. The importance of physical environment in the maintenance of dignity has also been emphasised in other studies.9 ,15 ,28 In the above research, the environment particularly alluded to privacy-related issues such as unavailability of private lavatory facilities and body exposure. In the present study, however, excessive noise, lack of cleanliness, and lack of facilities were the issues related to the physical environment. On the other hand, this research is consistent with the study of the Health Advisory Service 2000,13 which pointed to inadequate equipment and defects in the physical environment and personal hygiene as being important for preservation of patient dignity. Moreover, in the survey of Ipsos MORI,29 hospital cleanliness was mentioned as the most important factor in patient dignity. There is a study in Iran30 that reveals that facility limitations and unsuitable hospital and ward structures are obstacles to fulfilment of patient's rights.

The second theme, ‘disregard for secondary caregivers’, refers to ignoring patients' ‘companions’, in spite of their important role in patients' daily care. As stated by Joolaee et al,30 ‘Having a companion is an embedded concept within Iran's healthcare system and is a necessity based on patients' view’. In spite of the fact that companions are providing for patients' primary needs, common complaints indicated that their own comfort in hospitals was completely ignored. This appears relevant to a thesis (S Joolaee, unpublished doctoral dissertation, 2009) on patients' rights, which points to the unavoidable presence of a companion from the patient's point of view. The fact that ignoring companions' comfort is not mentioned as a factor that affects patient dignity in most Western studies highlights some deficiencies in Iranian healthcare centres. In this study, despite the compulsory presence of companions as caregivers, in most cases, they were not given food or even a seat next to their patients.

Many of the participants' statements revolved around the third theme, ‘disrespecting privacy’. Fourteen of 20 participants stressed that being exposed in hospital or in a mixed-gender situation, whether to a healthcare provider or roommate, had called their sense of dignity into question. The results of a study in Tehran, the capital of Iran, showed that only 23.6% of patients were satisfied with the privacy afforded to them.31 This study confirms the findings of other research that respecting privacy is crucial in supporting patient dignity.8 ,13 ,18 ,28 However, other aspects of privacy, such as privacy of information, that were highlighted in the work of Woogara,10 Widang and Fridlund,19 and Matiti and Trorey21 were not noted by the participants of the present study.

The fourth theme of our study, ‘communicating in a vacuum’, is related to the communication problems that leave patients feeling undignified. This is in line with studies that confirm a relation between communication and promotion of dignity.30 ,32 The importance of friendly verbal or gestural communication was stated by all participants in this study. The results of a study in Iran (M Ghanbarzadegan, unpublished thesis, 1992) showed that only a few patients were satisfied with their verbal and/or non-verbal communication with nurses. However, most of the participants in this study asserted that inefficient communication had not been on purpose, but the result of a heavy workload. According to other studies, a heavy workload and staff shortages resulted in an inability to provide the desirable33–35 respectful care for patients.36 Some patients experienced ineffective relations because of language and culture barriers. This is also evident in the work of Jacobs et al 37 and Julliard et al.38 In some cases, even the way the patients are addressed by the healthcare team irritated them. This point has been brought up by Marini,39 who found that addressing patients without prior notice had threatened their dignity.

In addition to workload pressure, insufficient support of nurses and physicians by managers and institutional deficiencies—such as inadequate salary, insecure workplaces and inadequate accountability—were recognised as some of the factors affecting the practice of patients' rights.35

Conclusion

There is no doubt that patient dignity in healthcare settings is often devalued, and promotion of dignity is crucial. This study reveals that, on the basis of patients' views, there are still gaps in the conception, interpretation and consequent preservation of dignity in the healthcare system of Iran. It is inferred from patients' complaints that the physical care environment and organisational restrictions are considerable obstacles to fulfilment of dignity. However, there is no systematic professional organisation to assess responsibility for protecting and promoting patient dignity in Iran.

This conclusion provides a comprehensive explanation that is consistent with other studies on dignity. It can therefore be concluded that, despite having a different culture, patients in Iranian healthcare centres encounter similar problems to those in other countries, although certain themes are more strongly highlighted in their statements. Whatever the cause, further attention and action are necessary to improve the maintenance of patient dignity in Iran.

These experiential dimensions of dignity have implications for the design of a framework to address the issues that are important to patients in Iranian healthcare services, which could also be used for further studies in other centres.

Acknowledgments

We thank all patients who shared their valuable experiences by participating in this study. We also gratefully acknowledge financial support from the Tabriz University of Medical Sciences.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

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Footnotes

  • Funding This study was supported by Tabriz University of Medical Sciences.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by The Research Center of Tabriz University of Medical Sciences.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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