VOL: 103, ISSUE: 34, PAGE NO: 30-31
Lesley Baillie, PhD, MSc, BA, RGN
Principal lecturer, London South Bank University
This article aims to present the meaning of patient dignity, how patients’ dignity is threatened and how it is promoted, with a particular focus on the effect of staff behaviour
Baillie, L. (2007) The impact of staff behaviour on patient dignity in acute hospitals. www.nursingtimes.net
Background: Nurses have a professional duty to respect patients’ dignity. However, patients are vulnerable to a loss of dignity in hospital. This article aims to present the meaning of patient dignity, how patients’ dignity is threatened and how it is promoted, with a particular focus on the effect of staff behaviour. There is a dearth of research about patient dignity conducted in acute hospital settings. Studies have indicated that staff behaviour and the hospital environment impact on patients’ dignity.
Method: A multi-method case study design was based on one surgical ward. Qualitative data was collected via interviews with patients and staff, participant observation and document examination.
Results: Patient dignity is promoted when staff provide privacy and use interactions that help patients feel comfortable, in control and valued. Individual staff behaviour has a major impact on whether threats to patient dignity actually lead to its loss.
Conclusion: All staff should behave towards patients in a way that promotes dignity during each and every interaction. In the UK, there is increasing emphasis on patients’ rights to be treated with dignity (Department of Health, 2006; 2001a; 2001b; Human Rights Act 1998) and nurses have a professional duty to respect patients’ dignity (NMC, 2004; International Council of Nurses, 2001). However, studies indicate that patients are vulnerable to a loss of dignity in hospital (Jacelon, 2003; Seedhouse and Gallagher, 2002; Matiti, 2002). This article reviews previous research about patient dignity and reports on a study in an acute hospital was conducted. An overview of the findings is given, and findings related to how staff behaviour affects patient dignity are explored in depth. Recommendations for practice are then presented.
Literature review Little research undertaken on patient dignity in general but there is a particular dearth of research conducted in acute hospital settings. Concept analyses of dignity have suggested that dignity is complex and has a range of meanings (Marley, 2005; Jacelon et al, 2004; Jacobs, 2000; Haddock, 1996; Mairis, 1994) but few studies have examined the meaning of dignity from patients’ perspectives. Gallagher and Seedhouse’s (2002) pilot study conducted in three wards for older people indicated that staff behaviour, the environment and resources affected patients’ dignity. Respect and privacy were strongly associated with promoting dignity. Walsh and Kowanko’s (2002) study involved interviews with nine staff and patients who identified that staff behaviour could threaten or promote dignity. Jacelon (2003) studied older people’s hospitalisation in acute settings. Dignity was a core feature and comprised self-dignity (internal dignity based on personal achievement and own behaviour), and interpersonal dignity (being treated with respect by others). In Widäng and Fridlund’s (2003) study, the 17 male patients from acute wards identified that dignity was related to how caregivers treat patients and was about being seen as a whole person, being respected (including providing privacy and listening) and being seen as trustworthy. Matiti’s (2002) study was conducted in acute wards with adults of all ages. She used the term ‘perceptual adjustment level’ to describe how patients adjusted their perceptions of their dignity in hospital. Both privacy and control were important to patients’ dignity being upheld. In summary, the literature review highlighted the possible impact of staff behaviour on patients’ dignity as well as environmental factors.
Aim The study’s aims were to investigate in an acute hospital setting:
- The meaning of patient dignity;
- How patients’ dignity is threatened;
- How patients’ dignity is promoted.
A multi-method case study design was based on one surgical ward in England. The main data collection period was March 2005 to December 2005. Purposive sampling was used and qualitative data was collected from interviews with staff and patients, participant observation, and examination of patient records and hospital documents. The 24 patient participants were aged 34-92 years, with a mean age of 64 years. There were 15 men and nine women. All were white British and from a range of social backgrounds. Twenty had undergone surgery during this admission.
Interviews were conducted with 12 of the patients in their own homes, following their discharge from the ward so that the patients could express their views in the safety of their own environment. They were asked open questions about their perceptions of dignity and factors threatening or promoting dignity in the ward.
A further 12 patients were observed and interviewed on the ward. Each of these was observed for a four-hour episode. Field notes were written based on an open observation schedule including the patient’s condition, the environment and each event (care, interaction) that occurred.
As a participant observer, I was aware that my presence could impact upon situations observed and that my interpretations of events could be affected by my own beliefs and values. Following each observation and interview conducted, I maintained a research diary with reflective notes, as the use of reflexivity assists in managing the researcher’s influence on the situation studied (Byrne, 2000). Following observation, each patient was interviewed about their dignity on the ward and their perceptions of the events observed in relation to dignity. Although this method enabled data to be collected in the actual care environment, I was aware that patients might be reluctant to voice concerns. However, due to the rapport developed between myself and these patients during the observation period, patients appeared to speak freely. All participants were also assured of confidentiality.
The 13 main staff member(s) (ward nurses and healthcare assistants) involved in each observed patient’s care were also interviewed about the patient’s dignity on the ward, following the observation episodes. Six senior nurses (both ward and hospital based) were interviewed about the meaning of dignity, factors affecting patients’ dignity and their roles in promoting dignity. The local research ethics committee gave approval for the study.
When recruiting patients to the study, ward staff made the initial approach as it was considered that patients could then decline more easily than if the researcher approached patients directly. All participants were given written information about the study and time to decide whether they wished to take part. It was emphasised that there was no obligation and that care would not be affected should patients not wish to participate. All participants gave written consent and data was anonymised and stored securely. The data was analysed using the framework approach (Ritchie and Spencer, 1994).
Results The findings presented relate to the meaning of dignity and how dignity is threatened or promoted in hospital. The meaning of dignity for patients entailed feelingvalued and psychologically comfortable with their physical presentation and behaviour, their level of control and the behaviour of other people in the environment. Examples of patients’ comments were:
- Feelings: ‘Feeling sort of generally happy with your surroundings and where you are and who you’re with and not feeling embarrassed by whatever’ (Mr A); ‘Feeling that you’re in control of your treatment’ (Mrs Z); ‘Feeling of consequence’ (Mrs Y).
- Physical presentation: ‘Not flaunting everything’ (Mrs X);’The way you dress’ (Mrs W).
- Attitude and behaviour: ‘Respect from other people isn’t it? Respect and people treating you as you treat them, and not making you feel small’ (Mrs V).
Patient dignity was threatened or promoted by the hospital environment, staff behaviour and patient factors. Table 1 summarises these findings. Table 1. Factors that threatened or promoted dignity
|Promotes dignity||Threatens dignity|
|Hospital environment||Conducive physical environment and facilities, including privacy Dignity-promoting ward culture and leadership Support from other patients||
Lack of privacy:
Therapeutic communication making patients feel:
|Breaching privacy Curtness Authoritarianism|
Building good relationships with staff Functional ability and control
Staff behaviour affecting patients’ dignity
Patients’ interviews and observational data indicated that most staff behaved in a way that promoted dignity most of the time. However, some patients identified individual staff members whose behaviour had threatened their dignity or, they perceived that of other patients; patients remembered these experiences vividly. There were two categories of staff behaviour which could threaten or promote dignity: actions relating to privacy, and staff communication.
Most staff were consistently vigilant about providing privacy but a few participants identified that staff occasionally breached privacy. Several nurses commented that staff walked in behind the curtains without warning: ‘People come and peep round the curtains’ (Nurse 1). Mr A described how a staff member entered behind the curtains and talked to the nurse who was carrying out an intimate procedure for him. As he was lying exposed at the time, he felt a loss of dignity. The staff apparently showed no awareness of how Mr A felt about his body being exposed as they talked together.
The ward’s physical environment (five-bed bays with a bathroom) provided a conducive structure for privacy which needed to be combined with appropriate staff behaviour to promote dignity. Most staff were strongly committed to environmental privacy in the ward, pulling curtains and shutting bathroom and side-room doors. When patients described intimate procedures, such as catheter removal, they always mentioned curtains being pulled. For example: ‘Staff always screen me when carrying out procedures’ (Mr B).
Observational data confirmed that staff used curtains during any situation where there was a risk of bodily exposure, including helping patients out of bed. Curtains round a patient’s bed (or a closed door) portrayed the message that the patient was likely to be exposed inside. Therefore care was taken not to enter without warning and not at all by non-healthcare professional staff. However, as previously discussed, Mr A, gave one example where this general ward ‘rule’ was broken.
Staff prevented patients’ bodies being exposed by ensuring hospital gowns (used post-operatively and for men with catheters) were fully pulled round patients, covering patients with blankets when they were sitting in a chair or lying on the bed, and by encouraging patients to wear dressing gowns. Mrs U described how staff prevented bodily exposure by covering her up, saying that staff had ‘gone above and beyond’ to ensure that she kept her dignity when she was very unwell post-operatively. While staff were behind curtains with patients carrying out personal care, they kept patients’ bodies covered as much as possible. For example, Nurse 2, while bedbathing Mrs T, covered her with a towel when she removed her gown and helped her on with a new gown on as soon as she had finished washing her front so that she was covered when she turned over.
Nurse 1 defined dignity as: ‘Knowing your privacy is not invaded without invitation,’ highlighting the importance of gaining consent to invade privacy. Staff specifically checked with patients before exposing them behind curtains, for example, Nurse 3 was observed saying to a patient: ‘Is it alright to take back the covers?’ Two senior nurses referred to providing privacy for body products too, for example disposing of urine discreetly and covering catheter bags with clothes. However, no patients referred to this aspect.
Senior Nurse 1 expressed that there was strong awareness of confidentiality within the ward. A few other nurses emphasised the importance of confidentiality, saying that hospital staff must talk quietly so that patients do not overhear conversations. Curtains were drawn when private information was discussed, for example during an admission interview. However, staff acknowledged that curtains were poor at maintaining auditory privacy.
Staff communication threatening patients’ dignity
|Curtness: a lack of kindness and courtesy||‘brusque’, ‘off-hand’, ‘couldn’t be bothered’, ‘stand-offish’, ‘having a lack of conversation, doing a job in amatter-of-fact way and not bothering much about it’. (Mr C)|
|Authoritarianism: Controlling; not offering choices or respecting requests||‘One or two of them you sort of feel a bit annoyed at being bossed around.’ (Mr A) ‘Feeling everything’s being taken out of your hands - makes you feel small, almost invisible.’ (Mrs Z)|
Half the patients interviewed described a staff member communicating in a curt manner which threatened their (or another patient’s) dignity, mainly displayed through non-verbal communication rather than what was actually said. When patients were vulnerable, such staff behaviour compounded their situation. For example, Mr D felt that, by some nurses’ attitudes, his incontinence ‘put their backs up’. Some patients identified that an authoritarian approach threatened their dignity. Mrs Z, who was terminally ill, said that a few staff said, when she requested painkillers: ‘You’re obviously not in that much pain at the moment - I don’t think you need it, why don’t you wait a bit?’ She said that this ‘Can be very hurtful’.
Nearly all patients and staff identified interactions that they felt promoted patients’ dignity. Therapeutic communication promoted dignity by making patients feel comfortable, in control and valued. Mr B’s description of the nurse who cared for him during the observation period included all these categories: ‘Nurse 4 [first name] is sensitive, explains what she’s going to do before she does it, she’s cheerful, she has a sense of humour, she appears interested in me as an individual, she has a caring approach, appears to enjoy her work, doesn’t appear as though it’s a chore’. He added that all these attributes promoted his dignity. Table 3 presents how interactions made patients feel comfortable, in control and valued with example quotations.
Table 3. Staff interactions which promoted patients’ dignity
|Interactions that made patients feel comfortable||Use of humour Reassurance Friendliness Professionalism||‘The staffwere all a good laugh, which helped all the way round, basically’ (Mr E) ‘They always did come and check on you even if nobody was calling, you’d always see one of them come round just to make sure everyone was alright and that made you feel a bit safer’ (Mrs S) ‘They’re friendly, they put you at ease’ (Mrs X) ‘The staff were all very professional, all got on with their job’ (Mr F)|
|Interactions that made patients feel in control||Explanations and information giving Offering choices and gaining consent Promoting independence||‘Telling you exactly what’s going on - that is very helpful in a hospital when you’re worried and concerned about what’s going to happen to you - that makes you feel more able to cope’ (Mrs V) ‘How much we get their consent, respect their feelings, take their opinions into account’. (Nurse 5) ‘She said: ‘Would you like your paracetamol now?’ Not ‘Here’s your paracetamol’ or ‘Here’s your tablets’ without telling me what they are’ (Mrs Z) ‘Stafflet you do things for yourself as much as possible’ (Mr G)|
|Interactions that made patients feel valued||Helpfulness Consideration Showing concern for patients as individuals Courteousness (politeness, form of address, greetings, a respectful approach)||‘If you say you can’t get to the toilet they’ll bring you a commode, never make a fuss’ (Mrs Z) ‘She [ward manager] was brilliant. Very considerate, very kind, very understanding. If you wanted to ask a question she’d always stop’ (Mr H) ‘Staff were always concerned about you. As much as they have 20 other odd patients but they did always enquire how you were’ (Mrs S) ‘From the cleaner to the sister, I got the same respect and reaction, which was nice’ (Mrs Y) ‘It wasn’t assumed that I wanted to be known as my Christian name’ (Mrs Y).’Staff who smile and introduce themselves - say who they are and say they’re looking after them, say goodbye at the end of the shift’ (Senior Nurse 2)|
In situations where dignity was threatened, staff communication could prevent dignity being lost. For example Mr D related that when he was incontinent of urine, some staff promoted his dignity by reassuring him ‘It’s not your fault’ while promptly changing his bed and nightclothes. Mr J said that the student nurse who inserted his suppositories (a procedure that he felt could have threatened his dignity) ‘did it nicely’ so he did not lose his dignity. Mrs Z identified that she could have lost her dignity in the bathroom but her ‘bath had been handled well’ because she had been given choicesthat promoted her dignity (Box 1). She said that if she had felt weaker she would have been happy to be bathed and that Nurse 4 had offered to help her and to wash her hair and it was ‘nice to be offered these things’.
Box1. Promoting dignity in the bathroom by offering choices (Observation fieldnotes)
|‘Nurse 4 asked Mrs Z if she’d like her to push her to the bathroom in a chair but Mrs Z wanted to walk. We walked with her slowly to the bathroom. In the bathroom we shut the door and Nurse 4 asked her if she wanted to use the bath hoist to get in and out but Mrs Z said no, she wanted to step in. Nurse 4 asked her to check the temperature of the water and Mrs Z said she wanted a bit more cold in so Nurse 4 put the cold tap on a bit more. Mrs Z then took her nightdress off and stepped into the bath. I passed her a face flannel and soap. Nurse 4 asked her if she’d like her to wash her back for her but she said she could manage. Nurse 4 also said, ‘Do you want me to wash your hair?’ but Mrs Z said ‘Not today’. Nurse 4 then said would you like us to stay or would you like us to leave you for a bit and you can ring when you’re ready? She said we could leave her so I handed her the call bell.|
The research findings indicated that staff behaviour strongly influenced whether patients’ dignity was threatened or promoted. Patients are particularly vulnerable to a loss of dignity during intimate care but appropriate staff behaviour could instead promote dignity in these situations (Baillie, 2007). Although dignity-threatening behaviour by staff was uncommon, such situations were vividly remembered.
Jacelon (2002) also found that unfortunately nurses who were memorable to patients tended to be those who were unpleasant in their interactions. The study’s findings supported previous research identifying that staff behaviour can threaten patients’ dignity (Öhlén, 2004; Gallagher and Seedhouse, 2002; Matiti, 2002; Walsh and Kowanko, 2002). Although staff were strongly committed to preventing bodily exposure, occasional breaches of privacy occurred. Staff entering curtains without warning patients has been previously reported (Arino-Blasco et al, 2005; Woogara, 2004; Lai and Levy, 2002; Walsh and Kowanko, 2002; Bauer, 1994). However, most patients in this study felt that staff were attentive to their privacy, which was confirmed by observational data.
The ward had strong leadership and a generally dignity-promoting culture. In contrast, Woogara (2004) reported a distinct lack of leadership and good role-modelling on the wards he studied, where standards of privacy were poor. Provision of privacy alone was not sufficient for dignity to be promoted; therapeutic communication was also essential. However, as in previous research, some patients experienced individual staff members communicating in a curt manner. Brusqueness (Öhlén, 2004), harshness (Calnan et al, 2005) and ignoring patients (Enes, 2003; Matiti, 2002; Walsh and Kowanko, 2002) have been previously identified.Such behaviour infers a lack of respect or care for patients.
A few patients referred to staff behaviour that conveyed that they were just doing a job and similarly, Jacelon (2002) found that staff threatened dignity by communicating that getting the job done was more important than focusing on the person as an individual. That some staff use an authoritarian approach which threatens dignity has also been previously identified (Woolhead, 2005; Öhlén, 2004; Reed et al, 2003; Huckstadt, 2002; Jacelon, 2002). Several patients expressed that they needed to feel confident in staff as professionals, supporting previous research (Matthews and Callister, 2004; Widäng and Fridlund, 2003; Lai and Levy, 2002).
Staff use of humour helped patients to feel comfortable and reduced embarrassment and patients considered that staff humour made them feel relaxed and happy. Humour has only been explicitly linked with promoting dignity in two studies in terminal care (McClement et al, 2004; Dean, 2003). Two staff explicitly referred to the need to be sensitive when using humour, also emphasised by Olsson et al (2002) but no patients commented on ward staff using humour inappropriately. Over half the patients identified reassurance and friendliness in staff interactions. References to reassurance and friendliness, as ways in which staff can promote dignity, were previously identified in a study with older people (Jacelon, 2002) and a study in maternity care (Matthews and Callister, 2004). However, in this study, patients from all age groups and both genders identified reassurance and friendliness as interactions that promoted dignity.
Interactions that made patients feel in control included explanations and information giving, offering choices, gaining consent and promoting independence. The findings supported Matiti’s (2002) work in a similar setting, from which she proposed that control impacts on all other aspects of dignity. Several other studies identified that giving explanations and information promote dignity (Bayer et al, 2005; Enes, 2003; Jacelon, 2002; Lai and Levy, 2002).
Information is essential for patients to make choices and give their consent, which are also linked with patients feeling in control. Staff offering choices was referred to by a small number of patients and slightly more staff as a way of promoting dignity. For one patient, who was terminally ill, retaining control through choices was crucial for her dignity, thus supporting research in terminal care which emphasises choice (McClement et al, 2004). This patient’s examples of where choices were offered illustrated how choice in everyday care, such as bathing, can impact positively on a patient’s dignity. This patient was physically quite incapacitated but being able to make decisions was important to her dignity. Gaining consent prior to procedures, identified as important for dignity by a few participants, was strongly adhered to by the staff. The findings indicated that staff being helpful, considerate and courteous, and conveying that they were concerned for patients as individuals, promoted dignity.
That feeling valued is important for patients’ dignity has been previously reported (Chochinov et al, 2002; Jacelon, 2002; Matiti, 2002) and similar interactions, such as courteousness, helpfulness and consideration were identified in these studies. Courteousness includes treating patients with respect and was identified as being important for promoting dignity by over half the patients in the study. Form of address, in relation to dignity, was referred to by just four patients and only one staff member.
Previous studies reported strong feelings expressed about use of first names and endearments being disrespectful (DH, 2006; Woolhead, 2005; Woogara, 2004; Matiti, 2002). Tone of voice and accompanying non-verbal communication may be as important as what form of address is used. One patient in this study expressed that he did not mind what he was called provided staff were polite. Staff invariably smiled, made eye contact and greeted patients politely, for example: ‘Good morning’ when addressing patients.
Individual staff behaviour has a major impact on whether threats to patients’ dignity, such as aspects of the hospital environment and patients’ impaired health, actually lead to a loss of dignity. The hospital environment could be highly conducive to dignity but the behaviour of individual staff with individual patients will still strongly influence these patients’ experiences of dignity. Staff behaviour has a particularly strong influence over whether patients lose dignity or not during intimate care. While provision of privacy is important for patients’ dignity, therapeutic communication is also essential. For patients to feel that their dignity is promoted, staff should communicate in a way that helps patients to feel comfortable, in control and valued.
Recommendations and implications for practice
All practice staff should behave towards patients in a way that promotes dignity during each and every interaction.
- Staff must provide privacy within the environment, by closing curtains fully, not intruding without warning and consent, and minimising bodily exposure.
- Staff should use interactions that make patients feel comfortable (humour, reassurance, friendliness and professionalism); in control (explanations and information giving, offering choices, gaining consent and promoting independence) and valued (helpfulness, consideration, showing concern for patients as individuals and courteousness).
- Staff should not use interactions that are curt or authoritarian nor breach patients’ privacy.
- Experienced staff should role model behaviour that promotes dignity to more junior staff.
- Staff should take appropriate action if they consider a patient’s dignity is at risk due to the environment or staff behaviour.
- Staff should be extra vigilant in situations where a loss of dignity is more likely, for example, during intimate procedures and when patients are unable to take steps to promote their own dignity.
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