Patient dignity in an acute hospital setting: A case study

1. Introduction 

Patients in varied settings have identified the importance of dignity to them (Chochinov et al., 2002, Matiti, 2002, Joffe et al., 2003) and respecting people's rights to dignity is inherent in nursing (International Council of Nurses (ICN), 2006). However, dignity has been described as an ambiguous, vague concept (Shotton and Seedhouse, 1998, Tadd et al., 2002, Macklin, 2003). Some studies indicated that patients are vulnerable to a loss of dignity in hospital (Seedhouse and Gallagher, 2002, Matiti, 2002, Jacelon, 2003) but what threatens patients’ dignity and how patients’ dignity can be promoted has been little investigated, particularly in acute hospital settings. In this paper, findings from a qualitative case study are presented which provide insights into the meaning of dignity, how dignity is threatened in hospital and how dignity can be promoted.

2. Background 

3. Method 

The aims of the study were to investigate in an acute hospital setting:

The setting was an acute public hospital in rural England. The ward ‘Heron’ (fictitious name) was a 22-bedded surgical ward specializing in urology, although patients with other conditions were regularly admitted. The 24 patients, aged 34–92 years (mean=64) were purposively selected. There were 15 men and 9 women of varied socio-economic backgrounds; all were white British. Except for two medical patients, all had urological conditions; 20 had surgery during their admission. The inclusion criteria required patients to communicate verbally and speak English, so they could express their experiences. Twelve patients were interviewed post-discharge and they had to have stayed in Heron ward for at least 2 days so they would have adequate experience of the ward. The other 12 patients were observed and interviewed on the ward, immediately following observation. They had to require assistance from staff and be sufficiently orientated to give informed consent for observation and interview. All permanent ward-based staff (26 registered nurses and healthcare assistants) were observed in practice and 13 ward staff, who were most involved with observed patients’ care, were interviewed immediately following observation. Six senior nurses (three ward-based and three hospital-based) were purposively selected for interviews, as they could offer insight into factors influencing dignity from a wider hospital perspective.

The Local Research Ethics Committee gave ethical approval and the study was registered with the hospital's Research and Development Office, thus fulfilling research governance requirements (DH, 2005). Meetings were held with ward staff prior to the study commencing. Ward staff made the initial approach to patients, so that they could decline more easily than if they were approached directly by the researcher. All participants were given written information about the study and time to decide whether they wished to take part and they all gave written consent. Patients were assured that there was no obligation to take part and that their care would not be affected should they decline. All data were anonymised and kept securely in locked filing cabinets and password protected computers.

All data were collected during 2005 by one researcher, thus promoting a consistent approach to data collection. Topic guides with open questions and probes were used for conducting interviews (see Table 1). The post-discharge interviews were taped and conducted in patients’ own homes within 2 weeks of discharge. Participants could thus express their views in the security of their own environment, promoting an open response. Twelve 4-h episodes of participant observation were conducted either in the morning or the first part of the night shift, thus avoiding visiting times when observation could have been intrusive. To increase the likelihood of participants’ behaviour being natural and therefore valid data being collected, the participant observer aimed to integrate into the ward environment. This was achieved by participating in care wearing a nurse's uniform and developing a relationship with the staff through working shifts with them prior to data collection commencing. However, the observer's presence could have affected the situations observed and interpretation of events could have been affected by the researcher's own beliefs and values. A research diary with reflective notes was therefore maintained, as the use of reflexivity assists in managing the researcher's influence on the situation studied (Byrne, 2000). These reflective notes helped to promote rigour during data collection and analysis but were not analysed as data.

Table 1. Interview topic guides for groups of participants

	Participants	Topic guides
	Patients interviewed post-discharge from ward (n=12)	Dignity is often mentioned as being important in healthcare. What does the term dignity mean to you?
		The researcher will use the patient's own expressed understanding of what dignity is to explore their thoughts and feelings about the following topics:
		Whether, before being admitted, they had any thoughts about their dignity being affected in hospital.
		If so, what these thoughts were and where they came from.
		Whether the hospital setting affected their dignity, and if so how.
		Whether staff affected their dignity during their hospital stay, and if so how.
		Whether there were any particular situations while in the ward when they felt they lost, or could have lost, their dignity. If yes, explore:
		what the situation was,
		whether/how it related to their condition, treatment or care,
		their feelings at the time,
		anything they did to try to keep their dignity,
		how staff affected the situation (did they make the situation better or worse),
		anything else they would have liked staff to do in this situation.
		Anything else they would like to say about their dignity as a patient on Heron ward.
	In-patients interviewed following observation episode (n=12)	Opening question:
		Dignity is often mentioned as being important in healthcare. What does the term dignity mean to you?
		The researcher will use the patient's own expressed understanding of what dignity is to explore their thoughts and feelings about the following topics:
		Any occasions during the observation period when they felt they lost, or could have lost their dignity.
		If so, when this happened.
		What they felt caused it.
		What effect staff had on the situation—whether they made the situation better or worse, and if so how.
		Whether there was anything else staff could have done in this situation to help promote their dignity.
		If there were no occasions when the patient felt they lost or nearly lost their dignity:
		What they feel helped promote their dignity during the observation period.
		Whether there was anything staff did which helped to promote their dignity.
		What effect, if any, they feel the ward environment has on their dignity.
		Whether there is anything more that could be done to the ward environment to promote patient dignity.
		Anything else they would like to say about their dignity as a patient on Heron ward.
	Staff interviewed following observation episode (n=13)	What does the term dignity mean to you?
		The following topics will then be explored in relation to the observed patient and their care/treatment of him/her:
		Threats to dignity:
		Whether they felt [patient's name] dignity was lost, or threatened at any point during the observation period.
		If so what they feel caused this to happen.
		What effect they feel they had on the situation—whether they feel they improved or worsened the situation, and how.
		How they feel other staff improved or worsened the situation, and how.
		Whether they feel they or any other staff could have done anything else to promote [patient name]'s dignity in this situation, and if so, what.
		Promotion of dignity:
		If they feel the patient kept their dignity during their care/treatment:
		What they feel helped promote the patient's dignity.
		What their role was in promoting the patient's dignity.
		Effect of the ward environment:
		How they feel the ward environment affected [patient name]'s dignity.
		Whether there is anything more that could be done to the ward environment to promote patient dignity.
		Anything else they would like to say about patient dignity on Heron ward.
	Senior nurses interviewed (n=6)	What does the term ‘dignity’ mean to you?
		Do you feel there are any characteristics of the patient group on Heron ward that could threaten or promote their dignity? If yes, what are these?
		In your experience, how do staff, and their approach to patients, affect patient dignity?
		How do you feel the environment on Heron ward affects the patients’ dignity?
		As a senior member of staff, what do you feel your role is in relation to patient dignity on Heron ward?
		Do you feel there are any factors outside the immediate ward environment which affect patient dignity, positively or negatively? (e.g. hospital, government, society)
		If yes, could you tell me about these?
		Are there any ward/hospital policies that specifically relate to patient dignity?
		If yes, which are they? What effect do you feel these have on patient dignity in practice?
		Is there anything else you would like to say about patient dignity on Heron ward?

During observation fieldnotes were written about the patient's condition, the environment and each event (e.g. care, interaction) occurring (see observation guide, Box 1). Following observation, each patient, and the main staff member(s) involved, were interviewed separately about the patient's dignity on the ward. These interviews were not taped so that they would appear less formal and potentially anxiety provoking. Detailed notes were written using the researcher's own shorthand and some verbatim speech was recorded in the notes. The observation fieldnotes and interview notes were written up in full on the same day, so events could be recalled as fully as possible. Although patients could have been reluctant to voice concerns while still in the ward, due to the rapport developed during the observation period, they appeared to speak freely. All participants were assured of confidentiality. The interviews with senior nurses were taped. All taped interviews were transcribed within 24h. Hospital and ward documents were scrutinized for references to dignity and either copied (with permission) or notes were taken; the senior nurses provided some electronically.

To pilot the main data collection methods, two post-discharge interviews and two participant observation episodes were conducted and critically reviewed with the researcher's doctoral supervisors. Together they considered that the data collection methods elicited rich data and so these data were analysed with data subsequently collected.

Lincoln and Guba's (1985) criteria of credibility, transferability, dependability and confirmability guided attention to rigour. Credibility was promoted by using steps to enhance the quality of the data collected, for example, a research diary was maintained to promote reflexivity and early findings were discussed with participants who confirmed the findings were credible. The description of the case should enable readers to assess transferability of the findings to their own settings. One researcher collected all the data using topic guides and an audit trail of decision-making was maintained, thus maintaining dependability. The audit trail also assisted confirmability and the steps to achieve credibility, transferability and dependability also promoted confirmability.

The data were analysed manually using the framework approach (Ritchie and Spencer, 1994), which entailed combining themes from the theoretical framework with themes from the data to develop a coding framework. Applying this tested and systematic approach promoted rigour, which was further enhanced by critical review throughout the analysis process with the researcher's doctoral supervisors. The data were first reduced to ‘significant statements’—phrases or sentences relating to dignity. Each statement was coded using the coding framework and then categorised under themes. Charts relating to each theme and its categories were developed and data were mapped onto the charts. These charts illuminated how widespread different views were, whether age or gender affected responses and whether observational data supported or contrasted with interview data, thus promoting data triangulation. Early findings were presented and discussed with the ward staff who confirmed their credibility.

4. Findings 

The themes presented are: the meaning of patient dignity, patient factors affecting dignity, the impact of the hospital environment on dignity and how staff behaviour affects dignity.

5. Discussion 

The study involved only one English hospital and specifically one ward's staff and patients, although three senior nurses had hospital-wide roles and hospital documents were examined. Ideally, a multiple case study design would have been used with other acute hospitals involved but these require extensive resources and are often beyond the resources of a single researcher (Yin, 2003). The data collection sources focused on patients and staff but relatives’ views might have provided a different perspective and could be included in future research. A further limitation is that participants, particularly staff, might have changed their behaviour when the researcher was observing, for example paying more attention to dignity (according to their interpretation of its meaning) than they do usually. Data from interviews with patients following discharge, when they should have felt able to be entirely honest about their experiences, enabled monitoring of whether there were differences between observed practice and practice described at interview. Conversely, there was a risk that these interviewees may have provided answers which they believed were desirable or that their views may have changed since discharge. However, the observational data and in-patient interviews enabled any such contrasts to be identified. There was actually close consistency between the findings derived from the different data sources. Some findings supported those from previous studies, mainly from different settings, but also identified new perspectives about patient dignity in acute hospitals.

Previous research has indicated that dignity is an internal quality which was well supported by the findings as many participants expressed that the meaning of dignity was about feelings. Some feelings identified in this study's findings supported previous research, in particular: self esteem and self respect (Matiti, 2002). However, feeling comfortable was specified in two of the concept analyses (Mairis, 1994, Fenton and Mitchell, 2002) but in none of the primary research studies. For some Heron ward patients, feeling in control was closely associated with dignity, but this specific interpretation of dignity was not so widely expressed as in some other studies (Chochinov et al., 2002, Matiti, 2002). Thus, for most of this study's participants, other feelings relating to dignity were more prominent.

The meaning of dignity relating to physical presentation supports previous research with older people (Gallagher and Seedhouse, 2002), in terminal care (Chochinov et al., 2002) and acute care (Matiti, 2002). Supporting Matiti's (2002) category of ‘decency’, some participants expressed that dignity was keeping the body covered. However, although Turnock and Kelleher's (2001) ITU-based study assumed dignity solely concerns modesty of the body, this study's findings indicate that few people consider this to be the only meaning of dignity. The study supported the link between behaviour and dignity which is prominent in the literature, reflecting the notion of ‘interpersonal dignity’, whereby behaviour from others conveys feelings of worth (Jacelon, 2003). The association between dignity and respect in previous research (Matiti, 2002) was confirmed in this study's findings too.

The definition of the meaning of patient dignity which emerged from the study's findings was:

Patient dignity is feeling valued and comfortable psychologically with one's physical presentation and behaviour, level of control over the situation, and the behaviour of other people in the environment.

Fig. 1 portrays how the hospital environment, staff behaviour and patient factors affect patients’ dignity. The patient has centre place in the model, surrounded by the environment and staff behaviour which threaten or promote dignity. The model's upper half portrays why patients are vulnerable to loss of dignity in hospital. Patients’ impaired health results in loss of function and older age may increase vulnerability. The potential loss of dignity is compounded by staff behaviour and the hospital environment. The model's lower half identifies how patient factors, the hospital environment and staff behaviour can promote dignity, despite patients’ vulnerability.

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Fig. 1. How patients’ dignity is promoted or threatened in hospital.

The findings supported previous research that impaired health negatively impacts on patients’ dignity (Matiti, 2002, Enes, 2003). Having a urological condition increased the likelihood of patients undergoing intimate care which threatens dignity (Lai and Levy, 2002, Matiti, 2002, Jacelon, 2003). This study's specific findings about how urological conditions affect patients’ dignity has been previously published (Baillie, 2007). The psychological impact of illness on dignity was identified in research with terminally ill patients (Chochinov et al., 2004) and older people (Jacelon, 2004) but Heron ward patients expressing this view were of varied ages and conditions. Some younger patients considered that older people were more vulnerable because of greater physical dependency, also expressed by European professionals (Calnan et al., 2005). The view that older people were more vulnerable for psycho-social reasons has not been previously reported. One senior nurse expressed the view that hospital culture made older patients more at risk of losing their dignity. Some UK health policies have particularly focused on older people's dignity (DH, 2001b, DH, 2006a) which could indicate that from a government perspective, they are considered a group at greater risk.

Despite their vulnerability, patients adjusted their perception of their dignity in hospital, supporting Matiti's (2002) perceptual adjustment level theory. However, staff seemed unaware of the efforts patients put in to adjust their attitude, using rationalisation and acceptance. An attitude of acceptance was previously reported regarding dignity in chronic and terminal disease (Chochinov et al., 2004, Campbell, 2005) but has not been highlighted previously in acute care. Patients’ use of humour to reduce embarrassment supports other findings from acute care (Matiti, 2002, Walsh and Kowanko, 2002). As previously reported (Matiti, 2002, Jacelon, 2004), patients discussed developing and maintaining relationships with staff to promote their dignity. Such comments highlighted the powerful position of staff in hospital settings; no staff participants identified that patients used this strategy. Disempowerment of older people in hospital has been previously suggested (DH, 2001b, DH, 2006a, Woolhead et al., 2004) but in this study, younger patients also expressed these views, highlighting the vulnerability of acutely ill patients of all ages when in hospital. A few participants associated ability and control with dignity; similarly independence has been associated with dignity (Jacelon, 2004, Matiti, 2002).

As in other studies (Turnock and Kelleher, 2001, Gallagher and Seedhouse, 2002, Enes, 2003, Randers and Mattiasson, 2004, Ariňo-Blasco et al., 2005), privacy was important for dignity. However, only two patients viewed being in a five-bedded bay negatively; most patients’ dignity was instead enhanced by the camaraderie of other patients. It was important to many patients however that other patients in the bay were of the same sex and had similar conditions. Two studies of terminally ill patients have associated social support/relationships with dignity (Enes, 2003, Chochinov et al., 2004) but otherwise, the dignity-enhancing impact of other patients has not been reported.

A lack of auditory privacy in hospitals is well recognised (Matiti, 2002, Walsh and Kowanko, 2002, Woogara, 2004) but only a few participants expressed that inadequate auditory privacy threatened dignity. Thus either most participants did not perceive a lack of auditory privacy or they did not associate it with a loss of dignity. However, lack of privacy of the body (bodily exposure) clearly threatened patients’ dignity, supporting previous findings (Matthews and Callister, 2004, Turnock and Kelleher, 2001, Walsh and Kowanko, 2002). As in other studies (Matiti, 2002, Walsh and Kowanko, 2002, Woogara, 2004), wearing hospital gowns increased vulnerability due to potential bodily exposure but staff were largely unaware of how seriously these affected patients’ dignity.

Due to bed shortages, a mixed sex environment regularly occurred, threatening dignity due to risk of bodily exposure to patients of the opposite sex. UK studies have highlighted that mixed sex wards threaten older people's dignity (Health Advisory Service 2000, 1998, Gallagher and Seedhouse, 2002, Woolhead et al., 2004) but Heron ward patients across the age range expressed discomfort. A few patients commented that high staff workload threatened dignity through its negative impact on staff interactions, supporting previous findings (Matiti, 2002, Walsh and Kowanko, 2002, Enes, 2003).

Staff behaviour strongly influenced whether patients’ dignity was threatened or promoted. However, it should also be recognised that the care environment impacts on behaviour (Moos, 1987) so behaviour cannot be considered in isolation. There were a few examples of staff breaching privacy, a situation highlighted previously (Lai and Levy, 2002, Ariňo-Blasco et al., 2005, Woogara, 2004). However, all data sources indicated that staff were mainly attentive to patients’ privacy. As other studies found that staff frequently breached patients’ privacy (Turnock and Kelleher, 2001, Woogara, 2004) the dignity-promoting ward culture could be influential. Only a few other studies have highlighted the role of a dignity-promoting culture (Gallagher and Seedhouse, 2002, Health Advisory Service 2000, 1998).

Provision of privacy alone was not enough to promote dignity; therapeutic interactions were also required. However, patients emphasised the role of staff communication more strongly than staff who were more focused on privacy aspects. Staff professionalism, use of humour, reassurance and friendliness made patients feel comfortable. Several other studies identified that staff professionalism promoted dignity (Lai and Levy, 2002, Widäng and Fridlund, 2003, Matthews and Callister, 2004). Staff use of humour has only been explicitly linked with promoting dignity in terminal care (Dean, 2003, McClement et al., 2004). References to reassurance and friendliness were reported in only a few studies (Jacelon, 2002, Matthews and Callister, 2004); thus the dignity-promoting role of these interactions has been little recognised. The research findings confirmed that giving explanations promotes dignity (Lai and Levy, 2002, Enes, 2003, Matiti, 2002, Bayer et al., 2005). Previous research indicated that feeling valued is important for patients’ dignity (Chochinov et al., 2002, Jacelon, 2002, Matiti, 2002) but the explicit interactions necessary to achieve this (helpfulness, consideration, courteousness, and conveying concern for patients as individuals) have not been previously elaborated.

Rather than promoting dignity, staff interactions can threaten dignity instead, by displaying curtness—similar to brusqueness (Őhlén, 2004) and harshness (Calnan et al., 2005) identified previously. An authoritarian approach was found to threaten dignity too, supporting several earlier studies (Jacelon, 2002, Őhlén, 2004, Woolhead et al., 2004). Few staff acknowledged that staff interactions could have a detrimental impact on dignity.

6. Conclusion 

Promoting dignity is central to humanistic nursing theory and nurses have a professional duty to promote patients’ dignity. Increasingly, UK health policies have emphasised the importance of patient dignity. As little research about patient dignity has been conducted in acute hospital settings, this study's findings have contributed to this limited body of knowledge.

Patient dignity in hospital was found to comprise feelings, physical presentation and behaviour and can be promoted or threatened by the hospital environment, staff behaviour and patient factors. While some findings supported research conducted in other settings, their impact on dignity has been explained more specifically. The findings highlighted patients’ abilities to adjust their attitudes to dignity in hospital. The important role of non-physical environmental dimensions – ward culture and leadership, and other patients – contributes new perspectives.

There are implications for clinical practice relating to managerial, educational and practice perspectives. From a managerial perspective, the study confirms the importance of a conducive physical environment: cleanliness, provision for privacy and adequate resources. Wards need to be adequately staffed, as high workload affects staff interactions, and have strong leaders who are committed to patient dignity. Bed management policies have an important role, as a single sex environment with patients with similar conditions grouped together, enhances dignity.

While environment and resources are important factors, all staff working in practice should take individual responsibility for promoting patients’ dignity as just one individual's behaviour in a team can lead to a distressing experience for patients. Staff in this study were often unaware of how interactions affect dignity and there was some lack of attention to privacy. Therefore, staff education at all levels should emphasise the impact of their interactions and patients’ vulnerability. All staff should reflect on their own behaviour with patients and take action if they consider a patient's dignity is at risk due to the environment or staff behaviour. Staff must recognise patients’ vulnerability to their dignity being threatened in hospital and be extra vigilant in situations where a loss of dignity is more likely, for example intimate procedures and when patients are unable to take steps to promote their own dignity. Staff should also be aware of potential power imbalances between patients and themselves.

Conducting further case studies in different acute settings is recommended, in particular, a city hospital with a multi-cultural population would contrast with the rural setting studied here. Action research could enable study of how practice might be changed, incorporating the study of dignity-promoting cultures. The impact of other patients on dignity has been little studied and further research of this dimension should be considered.

To conclude, while the hospital environment should provide the physical and managerial structure for promoting patient dignity, each individual staff member must promote dignity in their behaviour with patients and be aware of their impact on vulnerable patients’ dignity during each and every encounter.Conflict of interest

There is no conflict of interest relating to this paper.Funding

There was no funding for the study.Ethical approval

The study was approved by the Local Research Ethics Committee.