Patients' Dignity and Its Relationship with Contextual Variables: A Cross-Sectional Study.

Introduction: Dignity is considered as fundamental human needs and recognized as one of the central concepts in nursing science. The aim of this study was to assess the extent to which patients' dignity is respected and to evalutae its relationship with contextual variables.
Methods: This cross-sectional study was conducted on 256 hospitalized patients in the two teaching hospitals affiliated to Zanjan University of medical sciences, Iran. Data were collected by a questionnaire consist of two sections: (a) demographic characteristics, and (b) patient dignity including 32 questions. Data were analyzed by SPSS (ver.13) software using independent t-test, ANOVA and Pearson correlation.
Results: The result showed that the mean (standard deviation) of total score of patient's dignity was 108.17 (25.28). According to the result, the majority of the respondents (76.2%) were not aware of patient's rights. There was a significant difference in mean scores of total dignity between single and married persons, living in city or village, and hospitalization in Moosavi and Valiasr hospital.
Conclusion: Health care systems should take the provision of the patients' dignity into account through using a comprehensive educational program for informing of patient, family members, and health professionals about patients' dignity.

Introduction

Respect for patients' dignity is the long-established principle of health care systems[1] which has gained increased importance over recent years.[2]Care not including dignity would negatively affect patients’ recovery,[3] while preserving dignified care enhances patients’ recovery and promotes emotional comfort.[4]Therefore, respect and dignity are crucial to grant high-quality health care.[5]

Dignity is described as the quality of being worthy of respect or esteem which refers to a personal sense of worth and connected with persons’ self-esteem and perceptions of being respected by other people.[6,7] Thus, respect to each patient’s dignity is important to develop self-worth.[8]

According to the previous studies, maintaining dignity includes respecting patients, protecting patients’ privacy‏, and allowing them to have their autonomy.[9-11]

Moreover, preserving patients’ dignity includes emotional support and telling them the fact about their disease.[9]

Dignity is considered as a fundamental human needs[12] and everybody wants his or her dignity to be preserved irrespective of the position and this includes maintaining dignity in healthcare settings too.[13] Moreover, dignified care is considered as an essential goal of comprehensive care[14] and all nurses are expected to successfully manage situations to make sure continued protection of dignity in delivering patient care.[8] Furthermore, respecting human being rights and preserving dignity are defined as ethical purpose of nursing care, which should not vary due to the patient’s age, race, sickness or handicap, religion‏, gender, or social, political, and economic status.[15]A survey of 398 nurses in Australia showed that preserving patients’ rights and human dignity was one of the ethical concerns to registered nurses.[16]

Whilst dignity has been given main priority, there have been a number of recent studies reporting the lack of respect, privacy and dignity within health care settings.[17] Some studies point out that patients are vulnerable to loss of their dignity in hospitals,[11,18] but what make threats to patients’ dignity has been little investigated.[11]Recognizing of these factors will help nurses to preserve and promote patients’ dignity and provide dignified care at the bedside.[19] Although significance of dignity has been widely documented in literature, there is limited study which examines if dignity is actually preserved in clinical practice or not. Moreover, few studies investigated the relationship between dignity and contextual factors.

Therefore, the aim of this study was to evaluate the extent to which patient’s dignity are respected in the two hospitals affiliated to Zanjan University of Medical Sciences. Moreover, we investigated the relationship between dignity and contextual variables such as age, education, hospitalization time, etc. which has not been studied in previous studies.

Materials and methods

This cross-sectional study was done during the period of June to December 2011. Sample size was calculated based on a previous study‏, and considering the preserving patient dignity in 63% of patients in previous study,[20] a total of 226 patients were calculated to study.

Considering the potential attrition rate and uncompleted questionnaire the sample size increased to 256 patients. In this formula (n= (z2pq)/d2), Z=standard normal deviate (1.96 at 95% confidence level), P = proportion of the subjects having preserved dignity (0.63), and d is the desired precision ((10% of p); n= (1.96)20.63(0.37)/(0.063)2=226. Therefore, a total of 256 hospitalized patients were selected from two hospitals (Ayatollah Moosavi and Valiasr, Zanjan, Iran) by using a cluster sampling method. The wards were considered as the clusters and in each cluster (ward) the participants were selected by random sampling methods. The inclusion criteria for patients were as followings: hospitalized for more than one day, were over 15 years, not mentally ill (according to the past history), willing to participate in the study, and able to give informed consent. Unfilled questionnaire (when a patient have not respond more than 10 questions) were excluded from analysis.

The questionnaire was developed by the researchers and consisted of two parts; 1) Demographical data: This part included questions about sociodemographic data such as age, gender, marital status, educational status, hospital name, date of hospital admission, and other relevant data. Moreover, we added a question about patient’s awareness on their rights: Are you aware patient’s rights (yes or no). 2) Dignity related questions which consisted of 32 questions about patient’s dignity. Responses are scored on a 5-point Likert scale in which indicated never [1], seldom [2], sometimes [3], often [4], and always [5], with an additional neutral answer category: This does not be relevant to me. Therefore, sum of total score ranged from 32 to 160. The results were presented by using means and standard deviation in each items. The higher the score for each question, the better the dignity is preserving. Conversely, a lower score indicated low protection of patients’ dignity. Also the higher the score for sum of all questions, the better the dignity is preserving for the patient.

The questionnaire was designed by the researchers, in line with the Iranian Nursing Code of Ethics[21] and literature,[22,23]in order to emphasize the patients’ dignity by evaluating this topics. Before being used by patients, the instrument was send to 10 experts and was modified according to their comments. Then, it was piloted on 20 patients to evaluate the understandability and suitability of its language, and some corrections were made based on their comments. The piloted patients were excluded from the study. The questionnair showed high internal consistency (Cronbach's α=0.81). The questionnaire was filled by patients or researcher depending on the patient’s literacy (for illiterate participants).

Data were analyzed by SPSS ver.13 software.

The normality of data was evaluated by Kolmogorov–Smirnov test. The independent t-test was used for comparison of dignity mean score between two sexes. We used ANOVA test for comparison of total dignity mean scores based on demographic profiles and its related factors. The correlation between the dignity score and other data such as age, hospitalization days, etc. was checked by Pearson correlation. We used means and standard deviation for presenting the normally distributed data‏.

This study was approved by the research ethic committee of Zanjan University of Medical Sciences, Zanjan, Iran (No. A-10-154-1). All patients received information by researcher about the purpose of the research and patient’s right to not participate. Theferore, participation in the study was completely voluntary and confidentiality of patients was respected. Informed consent form was obtained from all participants in the study.

Results

A total of 256 patients were studied. Table 1 shows the demographical profile and comparison of mean scores of total dignity based on demographic profiles and its related factors. The mean (SD) of participant’s age was 42.64 (20) years (a range of 15–91 years). The results showed that the 54% of patients were female, 30.5% were illiterate, and 63% lived in city. Number of hospitalized days varied from 1–100 days, with mean of 5.62 (9.13) days. Our results showed that most participants (76.2%) were not aware of patient’s rights.

Table 1

Comparison of mean scores of total dignity based on demographic profiles and its related factors

Variable	N (%)	Mean score of total dignity (SD)	Statistics
Gender			t=-0.47, df=222, P=0.63
Male	117(46)	107.33(22.73)
Female	139(54)	108.88(22.73)
Marital status			f=4.49, df=2, P=0.012
Single	45(17.57)	101.52(25.15)
Married	211(82.42)	109.93(24.95)
Educational level			f=1.86, df=4, P=0.11
Illiterate	78 (30.5)	106.97(24.85)
Elementary	49(19.1)	115.22(22.95)
High school	47 (18.4)	110.89(26.73)
Diploma	59(23)	103.14(26.23)
University education	23(8.98)	104.57(23.98)
Live in			t=-2.48, df=254, P=0.01
City	160(63)	105.16(25.36)
Village	96(37)	113.20(24.45)
Awareness of patient’s rights			t= 0.19, df=254, P=0.84
Yes	61(23.8)	108.72(24.21)
No	195(76.2)	108.00(25.26)
Hospital			t= 2.90, df=254, P=0.004
Moosavi	150(59)	112.01(24.46)
Valiasr	106(41)	102.75(25.53)

There was a significant difference in mean scores of total dignity between single and married persons (P=0.012), living in city or village (P=0.013), and hospitalization in Moosavi and Valiasr hospital (P=0.004). But there was no significant differences between male and female gender (P=0.63), educational levels (P=0.118), and aware of patients’ rights (P=0.84) regarding the preservation of dignity. Also we could not find any correlation between demographic profiles and mean scores of total dignity (P>0.05) (table 1).

Table 2 summarizes the responses to various issues related to patient’s dignity. In term of patient dignity, the most respected items of dignity which patients responded that these items were preserved in always time included question No. 6, 27 and 17 respectively, as: 68.4% of patients answered that “staffs always avoid sitting on their bed” (question No.6), 55.5% said that “during the discussion of personal matters medical staff always ensure sufficient privacy” (question No.27), and 53.9% felt that “medical staffs always respect their request on having a caregiver in their room” (question No.17).

Table 2

Respect to the each item of patient's dignity from the patients' viewpoint

Items related to patient's dignity	Never N (%)	Seldom N (%)	Sometimes N (%)	Often N (%)	Always N (%)	No case N (%)
Did medical staff ask your permission before entering your room?	80(31.3)	50(19.5)	33(12.9)	39(15.2)	48(18.8)	6(2.3)
Did medical staff introduce themselves to you at your first meeting in hospital?	93(36.6)	49(19.1)	43(16.8)	33(12.9)	33(12.9)	5(1.96)
Did medical staff ask your permission before performing care procedures on your body?	65(25.4)	38(14.8)	40(15.6)	48(18.8)	60(23.4)	5(1.96)
Did medical staff ask your permission before moving your personal belongings?	17(6.6)	17(6.6)	29(11.3)	42(16.4)	119(46.5)	32(12.5)
Did medical staff respect your request about personal space and selecting desired room or bed?	90(35.2)	39(15.2)	32(12.5)	33(12.9)	58(22.7)	4(1.6)
Did staff avoid sitting on your bed?	27(10.5)	9(3.5)	19(7.4)	22(8.6)	175(68.4)	4(1.6)
Did staff avoid disturbing your sleep or your rest?	28(10.9)	25(9.8)	42(16.4)	63(24.6)	95(37.1)	3(1.2)
Did male staffs take care of male patient and female staffs take care of female patient in the ward?	18(7.03)	25(9.8)	41(16.4)	51(19.9)	116(45.3)	5(1.96)
The male staff was not allowed to enter female patient room and vice versa?	27(10.5)	20(7.8)	33(12.9)	70(27.3)	100(39.1)	6(2.3)
Did medical staff take care to cover the parts of your body when doing a procedure?	10(3.9)	19(7.4)	33(12.9)	63(24.6)	107(41.8)	24(9.4)
Did medical staff take care to cover the private parts of your body at the end of each procedure?	39(15.2)	15(5.9)	27(10.5)	46(18)	110(43)	19(7.4)
While undergoing medical procedures which required the exposure of private parts of your body, did the door of your room remain closed?”	98(38.3)	26(10.2)	37(14.5)	37(14.5)	41(16)	17(6.6)
Did medical staff take care to use curtains around your bed before doing a procedure?	144(56.3)	27(10.5)	17(6.6)	14(5.5)	28(10.9)	22(10.2)
To what extent has the necessary facilities for your worship and prayer prepared?	32(12.5)	19(7.4)	34(13.3)	42(16.4)	92(35.9)	37(14.5)
To what extent has the staff respond to your request promptly?	27(10.5)	30(11.7)	46(18)	56(21.9)	82(32)	15(5.9)
Did medical staff treat you with care and caution during painful procedures for you?	10(3.9)	20(7.8)	48(18.8)	57(22.3)	105(41)	16(6.3)
Did medical staff respect your request on having a caregiver in your room?	6(2.3)	10(3.9)	19(7.4)	65(25.4)	138(53.9)	18(7.03)
Did medical staffs ask your problem and concern and try to resolve them?	78(30.5)	42(16.4)	36(14.1)	30(11.7)	53(20.7)	17(6.6)
Did medical staff do greeting before doing any medical procedures?	19(7.4)	21(8.2)	51(19.9)	49(19.1)	104(40.6)	12(4.7)
Did medical staff refer to you using your name rather than the number of your bed?	27(10.5)	26(10.2)	39(15.2)	46(18)	105(41)	13(5.1)
Did medical staff interact with you using a kind and warm tone?	9(3.5)	12(4.7)	28(10.9)	60(23.4)	134(52.3)	13(5.1)
Did medical staff listen to you carefully?	13(5.1)	20(7.8)	46(18)	72(28.1)	95(37.1)	10(3.9)
Did medical staff response to you correctly?	13(5.1)	31(12.1)	35(13.7)	70(27.3)	97(37.9)	10(3.9)

The most three important item which subjects responded that these items never have been preserved by medical staff included followings: 56.3% of patients answered that medical staff never take care to use curtains around their bed before doing a procedure (question No.13), 38.3% stated that the door of their room never remained closed while undergoing medical procedures (question No.12), and 36.6% said that medical staffs never introduce themselves to them at their first meeting in hospital (question No.2).

The results showed that the mean score of total patients’ dignity was 108.17 (25.28) (the range of total score varies from 32 to 160) and the minimum and maximum scores were 32 and 156, respectively.

Discussion

This study aimed to evaluate the extent to which patients’ dignity has been respected and its relationship with contextual variables. This study showed that only 23.8% of patients were aware of the patient’s right. Patient’s awareness about their right is different in other countries according to the health care facilities and financial resources. The previous studies showed that 25.2% of patients in turkey[24] and 25.2% of patients in Saudi Arabia[25] were aware of the patient’s right. These findings are consistent with our result. But in other developed country such as Malaysia, almost 90 % of patients were aware of their right.[26]

Dignity represents the fundamental basis for nursing care and, nurses are professionally responsible for preservation, provision, and promotion of every patient’s dignity, while taking into consideration of contextual differences.[19,27] Moreover, the performance of nurses and other healthcare professionals may have an effect on delivery of dignified care.[28]

Approximately 56% of patients in this study commented that medical staff never uses curtains around their bed before doing a procedure. It is noticeable that using curtains around the bed is the simple method which helps to preserve patient’s dignity. In this regard, Oxtoby argues that the preservation of a patient’s dignity is crucial to nursing care and it involves using curtains around a patient’s bed and respecting the patient’s beliefs and values.[29] Henderson et al., believes that nursing staff usually attempt to preserve the physical environment to maintain dignity by drawing curtains and covering patients where suitable. But, sometimes this was not undertaken successfully because of the urgency of the position.[8] Previous studies have shown that bodily exposure due to undressing and uncovering patient’s body threaten their dignity.[11,30,31]

In a study in Iran, Litkouhi et al.,[32] found that having a curtain around the patients’ bed is the main preference of the Iranian patients. In this regard, they also showed that girls more than boys preferred to have curtains around their beds, but we could not find such differences.

Many patients have strong spiritual or religious beliefs that must be respected by medical professionals. Respecting their values and beliefs and interacting them with dignity are important for having a good relationship between medical staffs and patients.[26]

Our findings is line with Matiti et al.,[13] view that the patients’ dignity is not well preserved in health care settings. It is now broadly recognized that the quality of care is dependent not only on the care received, but also on the manner the treatment is delivered and how the health care providers interact with clients.[33]

In a study on patients, it was found that patient involvement in decision making was associated with positive outcomes such as patient satisfaction and adherence to the treatment.[34]

According to the result, only 18.8% of participant said that medical staffs always ask their permission before entering the room. This result is not in line with Bhaskar et al., study.[35] In their study, almost 65% of participants commented that medical staff always asks their permission before entering the room.

Previous studies have indicated that the physical care environment has a significant influence on patient’s dignity.[3,11,36] In this regard, approximately one-third of patients commented that while undergoing medical procedures, the door of their room never remained closed.‏ This result is not consistent with Ferri et al., work in Italy.[23] In their study, 66% of patients stated that nurses close the door of their room when they undergo medical procedures. In a study by Randers et al.,[37] caregivers firmly stated that the staff must close the door when enters in patient’s room, because the patients would not want others to see them. These discrepancies can be explained by the differences of healthcare systems in term of police regarding patients’ right and healthcare facilities in Iran and other developed countries.

Although Granger[38] argues that healthcare staff must properly introduce themselves to the patients, but almost a third of the participants (36.6%) in our study reported that medical staffs never introduce themselves to the patients. Our result is not in line with Ferri et al.[23] In their study 74% of patient stated that medical staff never introduce themselves to the patients.

Previous research have showed that disease can decrease a person’s ability to maintain privacy and dignity, however all people wish that they dignity have preserveed properly even in undesirable situations.[39,40]According to Lindwall & von Post,[41] caring can be delivered as dignified for the patients when staffs endeavor to achieve a sense of human value. Morover, Jacobs suggested that respecting human dignity is not merely a task of nurses but is fundamental to nursing care.[42] In a study conducted by Beach et al.,[34] patients who reported higher level of dignity were more likely to report higher levels of satisfaction, receipt of optimal health services, and adherence to the treatments. In contrast, the lack of dignity may cause poorer health quality.[23] and could negatively impact on patients’ recovery.[43]

Our findings indicated that the mean score of dignity preservation in single persons was less than married ones. This result seems to be logical with regard to cultural issues in Iran and sensitivity of single persons to the dignity issues. Also the mean score of dignity preservation in patients who live in cities was less than patients live in villages. It seems that patients who live in cities are more aware of patient right, have more expectations and demands high quality of dignified care as compared with people who live in villages.

Our result showed that the mean score of dignity were similar in both male and female genders. This result is similar to the result of Borhani et al., study.[44] In their study, the mean score of dignity was not significantly different in male and female groups.

In the present study, the mean score of patients hospitalized in Valiasr hospital was less than patients hospitalized in Moosvi hospital. This can be explained by the large number of patients whom are admitted to Valiasr hospital. Also this hospital admits the patients with internal disease and this is a busy and crowded hospital, so a large number of patients are hospitalized within the wards and it provides the situation for violation of patient’s dignity.

It seems that medical staffs such as physicians and nurses have little knowledge of patient’s dignity. In the United Kingdom, Woogara[45]‏ found that medical and nursing staff had little knowledge about patients‏’ privacy. So, it is recommended that education on human rights, dignity, and privacy should be integrated into healthcare curricula.

One of the limitations in the study was the selection of participants from one city which may decrease the generalization of the results. However, we tried to select the large sample size of patient. We conducted the study on patient and we did not assess the medical staff’s views. So, it is recommended to investigate medical staffs view in the future studies.

Conclusion

In conclusion, dignity is an important patients right and any threat to this may deteriorate the therapeutic relationship between heath care providers and patient and negatively affect the quality of care. The study showed that most patients were not aware of patients' rights and there was not good condition in some measures of dignity‏. Therefore, more attention of heath care authorities for planning to respect the dignity in all areas of health systems is seems necessary. Furthermore, the comprehensive educational programs are needed to inform patient, family members, and health professionals about patients’ rights and their dignity.

Acknowledgments

The authors thank all patients who participated in the study, and research deputy of Zanjan University of medical science for providing the financial support.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.