Facilitators and Threats to the Patient Dignity in Hospitalized Patients with Heart Diseases: A Qualitative Study.

BACKGROUND: Patient's dignity is an important issue which is highlighted in nursing It is an issue that is highly dependent on context and culture. Heart disease is the most common disease in Iran and the world. Identification of facilitator and threatening patient dignity in heart patients is vital. This study aimed to explore facilitator and threatening patient dignity in hospitalized patients with heart disease.
METHODS: This qualitative content analysis study was performed in 2014 in Kerman, Iran. 20 patients admitted to coronary care units and 5 personnel were selected using purposeful sampling in semi-structured and in depth interviews. Researchers also used documentation and field notes until data saturation. Qualitative data analysis was done constantly and simultaneously with data collection.
RESULTS: Three central themes emerged: a) Care context which includes human environment and physical environment, b) Holistic safe care including meeting the needs of patients both in the hospital and after discharge, c) Creating a sense of security and an effective relationship between patient and nurse, including a respectful relationship and account the family in health team.
CONCLUSION: The results of this study showed that care context is important for patient dignity as well as physical environment and safe holistic care.

INTRODUCTION

Human dignity has always been considered important and its maintenance has been emphasized; it is recognized as the basis for human rights.[1] It is so important that it is a subject long debated in medical professions, particularly nursing, and its maintenance has always been emphasized.[2-4]

Because patients are vulnerable, the need for respect to their human dignity is doubled. Preservation and promotion of patient dignity make them feel more satisfied and that they are valued by their healthcare systems.[5,6]

The word dignity is derived from the Latin words dignitus meaning competence and dingus meaning value.[7] A simple definition of human dignity is the intrinsic value that is given one by virtue of being human and which is formed through one’s individual character and relations with others. Illness, disability, need, reduced power and authority, lack of privacy, medical treatments and hospitalization can affect one’s intrinsic value. Limiting human dignity can affect the body, spirit, morality, and spirituality of clients, and it puts them at risk of stress and discomfort.[8] Human dignity is a major concern of the healthcare system; yet, it is somewhat unknown. Studies have shown that maintaining patient dignity depends on knowledge of the factors influencing it.[9,10] In their 2008 qualitative study, Matiti et al. showed that six factors influence dignity: privacy, confidentiality of information, communication and information, selection, control of and interference in care and respect.[10]

The Royal College of Nursing states” The physical environment, corporate culture and attitude and behavior of staff may affect dignity[11] Numerous studies state that maintenance of dignity in a healthcare setting is influenced by a group of factors such as context, social and cultural background and beliefs.[9-11]

In his study, Turnock at an action research study showed that awareness among the staff and nurses of the factors that promote patient dignity prompts all personnel to better maintain the personal dignity of patients.[12] Manookian at a qualitative content analysis study showed that four themes including persona, communication behaviors, and conduct of the staff are the factors affecting patient dignity.[13]

Various studies have mentioned factors affecting patient dignity, but little research has examined the facilitator and threatening dignity in hospitalized patients with heart diseases. In Iran, like many other countries, cardiovascular disease is the most common cause of death.[10] It influences patients, families, and society and causes social isolation, reduced life quality, and dissatisfaction in patients. It also affects self-care and causes dependence upon caregivers.[14] Studies showed that illness and illness related conditions may lead to loss of dignity.[8] van Gennip in 2013 at a qualitative study showed illness related conditions do not affect the patients’ dignity directly but indirectly they affect the way patients perceive themselves.[8]

Furthermore, studies have shown that respecting the dignity of patients with heart disease increases the satisfaction and confidence in the care, reduces the length of a hospital stay, and increases the patient’s mental health.[15]

Considering the fact that recognition of facilitators and threats the dignity of patients is dependent on the context and also this process is the interaction between persons, it seems that the paradigm of qualitative research for this study is necessary. Therefore, this study investigated facilitator and the factors threatening the dignity of the patients with heart disease in qualitative method.

MATERIALS AND METHODS

The current study is part of a larger study related to a doctoral dissertation which was done as a qualitative approach using conventional content analysis to identify the facilitators and threats to the dignity of patients with heart disease.

Qualitative content analysis is one of the approaches of qualitative research and also qualitative data analysis.[16] Content analysis method contains a package of techniques for systematic text analysis[17] which was suitable for this research because it is an unobtrusive technique of analysis that can simply accommodate a great amount of data.[18]

Participants in this study were 20 cardiac patients admitted to hospitals related to Kerman University of Medical Sciences in Iran and 5 personnel in 2014. Almost people in Kerman are Muslims. In this city, there are two hospitals related to Kerman Medical University that admitted heart patients. Researchers also used documentation and field notes. Sampling was done using purposeful method with an attempt to observe maximum variations in terms of demographic characteristics and the type of heart disease.

For the purpose of maximum variation in participants, the researchers made an attempt to interview with the participants who could deliver wide insights about the study question.

Inclusion criteria for patients included the ability to speak in the Persian language and admission to the cardiac intensive care unit for more than 48 hours. Exclusion criteria were mental illness confirmed by a physician or the individual patient; also, inclusion criteria for the staff included working in cardiac care units and desire to participate in the study

Data were collected in the form of a semi-structured interview. Interviews were done by a researcher familiar with interviewing technique and conducted by a research team member. Data collection was continued until saturation which occurred when a new category did not appear and until the existing categories were enriched.

Interviews were done after agreement on the location and time between the interviewer and interviewee. Written and verbal consent were obtained by investigators.

At first, the researcher clarified the study aims and explained the benefits of the study for participants. The researchers encouraged the participants to talk about their experiences by starting with an open-ended question: ‘‘What is your perception of ‘dignity’?’’. ‘‘Do you feel dignified and why, or why not?’’ and ‘‘Why do you feel dignified or not dignified?’’

Interviews were conducted at hospital or the researcher’s workplace (School of Nursing and Midwifery, Kerman). Interviews lasted between 30 and 90 minutes with a mean duration of 50 minutes. All interviews were recorded by the researcher, and then the recorded interviews were immediately after completion listened several times and typed verbatim in Microsoft Word, and then analyzed with an inductive style by the research team, using constant comparative method and software MAXQD.

The researchers used a thematic analysis to recognize the themes within the data and find the meaningful categories, and their relation to each other and to the core concept.[19]

Data analysis was performed using the constant comparative method with inductive approach in stage: analysis began with first interview. First, each interview was read several times, important statements were underlined; then we determined the meaning units from the participants’ talks and observations, documentations, and field notes. Codes to determine the similarities and the differences were reviewed and compared. Similar codes were merged and categorized according to similarities and suitability of the categories. Review and comparison of categories were done to ensure the rigor of the codes. Finally, identification of themes associated with facilitator and threatening the dignity of the heart patients.[20]

The researchers continued analysis until all categories were saturated (when there were not new information on the characteristics of the category). Finally three themes were obtained.

The study’s accuracy and reliability of qualitative data, rigor (dependability, transferability and confirm ability) were assessed using the criteria proposed by Guba and Lincoln.[21]

To ensure credibility of the data, interaction and adequate collaboration were established with participants. Also, peer check and constant comparison were used. Data dependability was examined using experts’ views, and revision was done by participants and external observers. The researchers also tried to avoid presupposition and put their previous beliefs aside to obtain sufficient conformability. Transferability was provided by rich explanation of the data.

Ethical Considerations

Before beginning the study, the ethics committee of Shiraz University of Medical Sciences (Code of Ethics k/93/261) approved the study. All participants completed written informed consent forms and were assured that their information would remain confidential.

Study purposes, confidentiality of data, and recording of interviews were clarified to the participants before the interviews, and their verbal agreements were obtained.

RESULTS

Participants in this study were 20 patients and 5 staff. The patients were 12 males and 8 females aged between 27 and 82 years.12 patients had suffered heart disease for more than 5 years and they had been admitted for more than 10 times in Coronary Care Unit (CCU). tables 1 and 2 show the characteristics of the participants. The findings of this study identified three central themes affecting the dignity of the patients with heart disease : a) Care context with subthemes of Human environment, and Physical environment. b) Holistic safe care with two subthemes of meeting the needs of patients in the hospital and after discharge, creating a sense of security. C) Effective communication with two subthemes of respectful relationship and involvement of the family in health team.

Table 1

Characteristics of participants in the study (patients with heart disease)

Participant	Gender	Age	Education	Hospitalization Reason	Occupation	Number of hospitalizations
P1	Male	42	Bachelor’s degree	MI	Employee	1
P2	Male	54	Diploma	Heart failure	Self employed	1
P3	Male	72	Illiterate	Heart failure	Farmer	More than 10 times
P4	Male	28	Bachelor’s degree	ACS	Employee	1
P5	Male	48	Diploma	ACS	Employee	3
P6	Female	66	Illiterate	MI	Housewife	3
P7	Male	61	Diploma	ACS	Retired	More than 10 times
P8	Male	51	Diploma	Heart failure	Employee	3
P9	Female	49	Bachelor’s degree	ACS	Employee	1
P10	Female	49	Diploma	ACS	Self employed	4
P11	Male	40	Master’s degree	ACS	Employee	2
P12	Female	52	Diploma	MI	Housewife	4
P13	Female	46	Associate degree	ACS	Housewife	1
P14	Male	41	Bachelor’s degree	MI	Self employed	3
P15	Female	35	Diploma	ACS	Employee	1
P16	Male	59	Illiterate	Heart failure	Self employed	5-6
P17	Female	47	Diploma	ACS	Self employed	2
P18	Male	43	Bachelor’s degree	MI	Employee	1
P19	Female	70	Illiterate	Heart failure	Housewife	6
P20	Male	36	Diploma	ACS	Self employed	1

MI=Myocardial infarction; ACS=Acute Coronary Syndrome

Table 2

Characteristics of participants in the study (staffs)

Participant	Gender	Age(year)	Job	Working experience(year)	Education
P1	Female	46	Head nurse	19	Undergraduate
P2	Female	29	Nurse	8	Post graduate
P3	Male	49	Nurse	21	Undergraduate
P4	Female	24	Nurse	2	Undergraduate
P5	Male	56	Cardiologist	20	Professor

1. Care Context

Care context is an environment where heart patients are taken care of and cured. This context is not only a physical environment, but also a human environment.

Based on their experiences, participants described the environmental conditions that affected their human dignity, including human and physical environments.

1-1. Human Environment

Human environment in hospital includes nurses, physicians, other patients and staff. Regarding the human environment, participants pointed to the conditions of the nurses’ personal and professional lives and the patient’s individual beliefs. One participant reported, “A few days ago, nurses were speaking in the ward with each other, and I heard them. I heard that they were not satisfied with their salary and that they had very low income. One of them worked in the shift of another one, the night before. How could I ask them to come and help me? If they become angry. … they are right; they are tired and living has costs and they live as we do,” (Participant 5).

Another participant said, “If one is respected, he will respect others as well, and nurses will respect them as well. Despite the fact that I have diabetes and my foot has to be bandaged every day, I respect nurses, so they respect me and treat me well,” (Participant 7).

Participants stated that the lack of resources is threatening human dignity of heart patients, such as the shortage of nurses, and the shortage of homogeneous nurses. A nurse said, “At night I was in CCU. We were two nurses with a dozen heart patients. We have a patient with heart arrest. We spent the whole night with him. Other patients were forgotten.”

Individual circumstances of each person are the conditions that promote or threaten the dignity of patients. These include the type of the nurses’ character and personal problems.

A nurse said “Some nurses are inherently kind and others are generally cranky”.

There are some conditions that would threaten the dignity of heart patients in nursing. For example, lack of job motivation. A nurse said “I do not like nursing; I do not have any motivation to work. So when I come to the hospital, I’ll just do my job and I only want to finish the shift. I work because it is my duty”

Experience of nurses is one of the facilitators of the dignity of heart patients. Nurses said that those with more experience respect heart patients better.

1-2. Physical Environment

Physical environment is the part of the environment that includes purely physical factors (as soil, climate, and water supply). Participants referred to organizational culture and comfort requirements in the physical environment and mentioned characteristics such as hospital conditions, physical and entertainment facilities. Clean environment, Comfort equipment, Green hospital and Silence in the intensive care unit are facilitators of the patient dignity and the failure of these factors is threatening the dignity of patients. For example, one participant said, “The sounds of the air conditioner and the utility room are not good for those who suffer from heart disease. Some put up with it, but some don’t. I myself get very annoyed, but nobody cares. This shows that the hospital does not think about the patients very much. It doesn’t care about our comfort. The workers come with bad temper, clean the room a bit, and go. Yesterday I spilled tea; we asked several times until someone came and cleaned it” (Participant 9).

2. Safe Holistic Care

A system of broad or total patient care reflects the physical, emotional, social, economic, and spiritual needs patients. Safe holistic nursing is a system of comprehensive care without harm to the patient and without error. It is the modern nursing practice that states the philosophy of care. Based on their experiences, the participants of this study considered holistic care an important factor affecting the dignity of meeting the patients’ needs in the hospital and after discharge; a sense of security was placed on this category.

2-1. Meeting the Needs of Patients in the Hospital and After Discharge

Patients have physical, psychological, social, and spiritual needs. Addressing the physical psychological, social, and spiritual needs of patients facilitates the patients’ dignity and negligence of needs is threatening the dignity of heart patients.

Meeting physical needs includes pain relief, considering the needs of the body system, and self-care training. A participant stated, “I was admitted into this hospital last night. They take care of patients. In another hospital, you should search for a doctor. Yesterday, 7 or 8 staff members came to me; one of them performed an electrocardiogram, one took my blood pressure; one gave me a pill and lowered my pain. This demonstrates that they respect human life, and in my opinion they affect dignity,” (Participant 1).

Another participant said, “I wasn’t allowed to leave the bed and go to the restroom. They give patients a bedpan. It is very important. Imagine who is ready to help you with it? Nobody! Nobody would do it. What faith, belief and virtue one should have to do this,” (Participant 14).

Another participant said, “When I am discharged, I need to know what to eat and where to go when I have pain. They should tell me this or write it and give it to my companion. No one will call and ask me if I’m alive or dead or how it is going. When we are discharged, the nurses’ responsibilities are also finished,” (Participant 16).

Participants referred to meeting psychological needs as predicting the needs of patients, emotional support for patients and their families, and respecting the will of the patient. One participant said, “I come from a long way. My daughter came with me. They told her to go and sit outside. Having visitor is not permitted in this ward. How sad I am. Where will my daughter sleep tonight? I’m upset. No matter how many sleeping pills they give me, they don’t work. I’m so uncomfortable; they should comfort me,” (Participant 6).

Participants referred to being accepted in society as one of their social needs and considered attempting to resolve the problem as a factor affecting the patient’s dignity. For example, one participant said, “The community needs to understand what it means to be a heart patient and what it’s like for one who has had a heart attack. Some advantages should be defined for them. They should pay more attention to them. For example, once I went to a bus stop, no one offered me a seat. I was drenched in sweat and got tired, and then a young girl said, ‘You are sick; come and sit in my place.’ It is better to place some seats for patients in bus stations. Of course, I know it’s too much to expect, but radio and TV should educate the public,” (Participant 10).

Respect for religious duties, training in religious issues, and spiritual tranquility are factors that participants considered, and they mentioned that fulfilling such needs are among the factors affecting the patient’s dignity. One participant reported, “When I speak to God, I feel comfortable. It is very important for me to say my morning prayer on time. I have never delayed my prayer in my life. Now, in the hospital, my morning prayer is delayed. I am asleep. No one awakens me,” (Participant 11). Another participant said, “I have never been hospitalized before. I don’t know the religious orders about saying prayers for a man who lies in bed. I cannot get out of the bed; one should teach me what the religious orders for me as a patient are,” (Participant 13).

2-2. Creating a Sense of Security

Security is all actions that nurses and physicians do for heart patients to be safe in the hospital from any risk and medical error.

A sense of security, including physical and mental and spiritual security, is another contributor to patient’s dignity, according to the participants.

Physical safety is highly regarded by participants. Care must be taken to keep them safe and not to impose mental or physical injury on them. One participant said, “I trust the nurses. They care for me, and they don’t do anything to hurt me. At least they are careful about my body, though it would be better if they pay attention to my mental status as well. For example, they should do something to make me relaxed. Let my companion stay with me. However, I know that what they do is for my good,” (Participant 15).

Emotional security includes observing the privacy of the patient, considering his autonomy, and keeping his/her secrets. A participant reported, “I wanted to be comfortable. I’m addicted, but my family does not know. My wife does not know anything. When I came to the hospital, I was so afraid that they would tell my wife that I’m addicted. I told the nurses that I don’t want my family to know about it; they accepted my request and did not say anything,” (Participant 18).

Spiritual security includes meeting the spiritual needs of patients, being admitted to any hospital with any religious beliefs and practices and being allowed to do what helps them spiritually. For example, a participant said, “When I’m dying, I want the hospital to bring a priest to give me peace. I am so afraid of death. I want someone to come so that I can ask him what happens after my death or what I can do to make God accept me better,” (Participant 17).

3. Effective Communication

Effective communication between the patient and the nurse was another reported issue that affects the patients’ dignity, and many participants consider it important in promoting human dignity. Having a respectful relationship with the patient and his/her family is a factor in this group; factors such as working conditions, health staff, patient’s number, patient’s culture, the culture of nurses, and culture and family are also involved.

3-1. Respectful Relationship

The suitable relationship between heart patients and staff that is based on mutual respect makes patients feel satisfied about hospitalization.

Respectful communication and dialogue is considered important by many participants. For example, one participant said, “They talked nicely with me, and they didn’t let me feel strange. They did what I needed. They were like my family. They listened to my confabulation. Even when they were busy, they treated me well. I reciprocated with respect to them. If you respect others, they will respect you in return,” (Participant 3). Another participant said, “Doctors have no time to speak with us. They ignore us. Nurses are better. At night when they are not busy, they come and speak with us. It does my heart good. How much should I see these curtains? No one comes to speak. If they speak with me, it is better than a hundred sleeping pills. I have no patience. Some speak more, but younger nurses speak little with me,” (Participant 19).

3-2. Involvement of the Family in the Health Team

Involvement of the family in the health team and communication with respect are two important subjects at patient dignity

Communication with the patient’s family and accepting the family as a member of the treatment group was the factor always considered by participants. Many of them complained that their spouse is not allowed to be with them in the hospital; because of that, after discharge, he could not be helpful. For example, one participant said, “My spouse came from a long way. The old man heard that I’m sick and he came all this way just to visit me. But they didn’t let him in the CCU. They told him, ‘Visiting is forbidden in the CCU; go and come during visiting hours.’ They didn’t even tell him about my condition. They don’t allow us to bring cell phones so we can inform our family about us. They didn’t tell me that my uncle had come. If they had let him visit me for a minute, it would have been very good for me, and he would be more comfortable, too,” (Participant 20).

DISCUSSION

This exploratory study provides important visions that are extremely relevant to facilitator and threats to the human dignity of heart patients, broadly considered to be one of the essential principles of ethics. Firstly, it provides useful information to clinicians and researchers about what the facilitators and threats to human dignity of the heart patient are.

Secondly, medical care is based on preserving the patient’s dignity. If the facilitators and threats to the patient dignity are identified, medical staff can better observe the patients’ dignity. The results of this study presented a new insight toward facilitators and threats to the patient dignity and human dignity of heart patients. The researchers have chosen heart patients, because these patients constitute a large group of patients in Iran and in the world. The majority of heart patients suffer from other chronic diseases such as chronic kidney disease, multiple sclerosis, high blood pressure, diabetes, stroke, psychiatric diseases and … . Since heart disease is a chronic disease requiring frequent hospitalization, respecting these patients improves their quality of life.

In this study, participants considered their experiences and presented the factors that were effective in maintaining the patient’s dignity. They referred to categories such as care context, holistic safe care, and effective communication and considered them to be the major factors in patient dignity. considering this factors promotes dignity and lack of respect is a threat.

The results of this study showed that care context is a facilitator or threat to human dignity. In fact, it includes an environment in which dignity is shaped, consisting of human, social, and physical contexts. Studies have shown that since the human environment is comprised of the individual characteristics of nurses and patients, it is a facilitator or threat in this field. Manookian, in a qualitative study done in 2013 in Tehran, considered the characteristics of the personnel as an effective factor in human dignity, and he believed that if one respects oneself, he will respect others, as well.[13] Laschinger in 2005 showed that nursing shortage is threatening the patients’ dignity.[22]

The patients’ character and individual circumstances are among the factors affecting human dignity.[23] Hall in 2014 also considered that the patients’ character was important for patient’s dignity.[24] Of course in the current study, the human environment consisted of the personal situations of patients and nurses and the professional conditions of nurses. Other environments such as physical and social ones that include the patients’ environment and consider the health and comfort requirements were also considered important by the participants. Feris (2014) also considered the importance of the physical environment and environmental health in promoting human dignity and stated that a multifaceted approach is required to create a healthy physical environment to maintain the dignity of patients.[25] Baillie in 2009 said that social supports promote dignity in acute setting hospitals.[1] Webster (2009) in a qualitative study showed that environment and cleanliness promote dignity in hospitals.[26]

Safe holistic care is another facilitator, according to the findings of this study. A patient who refers to a hospital expects to receive perfect care, but the care should be in the light of physical, emotional, and psychological security. Meeting the patients’ needs is the basic demand of them, and this should not be limited to hospitals; it should also be brought to patients’ homes to further maintain their independence. Statistics show that heart patients who have had a myocardial infarction will suffer the second infarction within the first month after treatment. Thus, the importance of care and meeting the patients’ needs after discharge are doubled.[27] Indeed, comprehensive care is based on the patient being the central concern. Studies have shown that this type of care enhances human dignity.[28] This care should allow the patients to feel entirely safe. Gibson et al., in a study conducted in 2012, found security to be a key point in promoting dignity. The study participants also believed that the care environment should be safe. They divided security into three categories: physical, psychological, and ontological.[29]

Effective and mutual communication and conversation between the nurses and medical staff and the patients and the feedback they receive are other factors considered by participants of the current study. The education of the patient and the patient’s family is formed through effective communication. Dialogue with respect promotes dignity in both patients and nurses. Effective and respectful communication allows patients to easily express their concerns, and as a result, their anxiety is reduced.[30] In a study by Matiti et al. conducted in 2008, one factor affecting dignity was found to be effective communication.[10] The relationship doesn’t always include discussion, but it includes any other communication methods. Communication in which the patient and his family are informed as to what the patient’s sickness is, why certain treatments are performed, and any other information that the patient needs maintains the patient’s autonomy. Hall et al., in a study to determine the factors affecting the dignity of people living in care homes, considered communication an effective factor in maintaining dignity.[24] Borhani et al. also showed if nurses have moral sensitivity, the relationship between the nurse and the patient will be better.[31]

The findings represent facilitator and threats to human dignity of heart patients. In this study, the strategy of triangulation was used in data collection and analysis. Constant contact with the data and deep interviews yielded reliable and valid results.

Researchers’ effort was to certify accuracy and reliability of qualitative data, but this study had all qualitative research limitations in generalization of results. Therefore, it is essential to repeat the study in different patients. The results of this study highlighted the facilitator and o threats to human dignity of heart patients.

CONCLUSION

Generally, experiences of heart patients explicated facilitator and threats to patient dignity. This study showed that care context is important for patients’ dignity and includes human and physical environments; also safe holistic care is one of the important aspects affecting the dignity of heart patients. If the staffs pay attention to care context and safe holistic care, but they don’t perform effective communication, the dignity of patients is not well observed. Thus facilitator and threat to patient dignity is under the influence of these three factors. No doubt, respect for dignity of heart patients enhances the quality of life and quality of care provided to them. Identification of the factors facilitating and threatening the dignity of heart patients helps the staff to better respect their patients.