The recruitment strategy for this case study was appropriate to the aims of the research. All participants were volunteers, although purposely selected, as they were either an inpatient on the surgical ward aged between thirty-four and ninety-two, fifteen men and nine women all from diverse socio-economic backgrounds, or a healthcare professional working on the ward or within the hospital. By purposely selecting the participants, Baillie was able to gain the most wide-ranging actions and answers to her semi-structured questions. This enabled her at a later stage to analyse her research more objectively when producing her findings for the research.
In addition, they could all verbally communicate and speak English. The twenty-six registered nurses and healthcare assistants were observed in practice thirteen of which were interviewed following observation.
Six senior nurses were purposely selected for interview. There were also twelve patients that had stayed on the ward for at least two days who were interviewed following discharge. It was noted that although there were only twenty-two beds on the surgical ward the study was carried out on twenty-four patients, it is unclear why this ambiguity occurred. Prior to the study being carried out, Baillie (2008) gained ethical approval from The Local Research Ethics Committee and the study was registered with the hospital’s Research and Development Office, adhering to governance requirements (DoH, 2005). All participants involved in the case study gave written consent and were advised there was no obligation to take part. For the purpose of this study overt observation was considered to have been best practice as the participants were aware of the ongoing research.
The data for this case study was collected during 2005 by one researcher. This ensured the researcher maintained a consistent approach to the data collected. The research was concerned with patient dignity in an acute hospital setting and therefore Baillie (2008) was justified in her selection of suitable candidates who were all inpatients on the surgical ward. The data was collected by patient observations and interviews whilst on the ward and post discharge in the home. Data for the health care professionals was gathered by interviews immediately following observations of them in practice. Senior nurses were purposively selected for interviews,
“As they could offer insight into factors influencing dignity from a wider hospital perspective” (Ballie, 2008).
The interviews were semi-structured, which consisted of open-ended questions allowing both the researcher and the patients to respond to the area being explored (Britten, 2006). The researcher would ask an opening question, ‘What does the term dignity mean to you?’ Exploring their thoughts and feelings about the subject would follow this up. The advantage to semi-structured questions is that they can be asked in what appears to be general conversation, which encourages two-way conversation and therefore the researcher can gain additional information. A disadvantage can be that, questions may be slightly different for each participant dependant on how the ‘conversation’ evolves.
Patton (1987) outlined that in qualitative interviews questions should be clear to the interviewee, open-ended, neutral and sensitive. He then went on to suggest various types of questions that should be asked. These included experiences or behaviour, values, on knowledge, on feelings, on opinions and demographical or background details.
Baillie in her (2008) case study considered the relationship between herself and the participants and how she could create the most natural and relaxed conditions, ensuring the participants acted ordinarily and without oppression. By wearing a nurse’s uniform in the ward environment, she was able to develop relationships both with the patients and the staff whilst working shifts and prior to any collection of data. Baillie (2008) in recognition of researcher bias maintained a researcher’s diary with reflective observations. Reflexivity is an important self- evaluating tool, as it identifies the researcher’s own values, prejudice’s and behaviour in any given situation and the interpretation of responses (Parahoo 2006). Following her earlier findings, Baillie (2008) later discussed them with the participants to verify they were credible.
The Data collected throughout the study was analysed manually using a framework approach, which is primarily used in health care settings. It is a process, which is flexible in allowing analysis during and also at the conclusion of data collection. By listening to audiotapes and reading transcripts of field notes, the researcher was able to absorb the data and become aware of key ideas and recurrent themes (Ritchie and Spencer, 1994). The author then reduced the data to ‘significant statements’ relating to dignity, coded these statements into a coded framework that enabled her to construct meaningful charts. Using the framework approach for this case study ensured the data analysis was sufficiently rigorous (Ritchie and Spencer, 1994).
Baillie’s (2008) case study concludes with a clear statement of findings. Patient dignity is of paramount importance when in an acute hospital setting. The study has credibility due to a number of reasons. These include the author’s background in relation to the setting of the research, the relevance of the study, the framework of the research together with other factors suggested by (Brewer, 1994).
An area of improvement within Baillie’s (2008) study could have been the incorporation of non-English speaking ethnic minorities from different religious cultures and also lowering the age limit from thirty-four to eighteen. This would have better represented our multicultural society and generated a more diverse set of answers and recommendations to come out of the study. Baillie (2008) in her conclusion does acknowledge this fact and recommends further studies should be carried out in different acute settings such as a city hospital with a multicultural population.
Baillie (2008) stated,
“Dignity is complex and multi-faceted, relating to feelings, control, presentation of self privacy and behaviour from others.”
This is a very broad statement but by no means is it an exhaustive interpretation of the word dignity. According to the Royal College of Nursing
”Dignity is a complex concept but a value and philosophy that is central to nursing. The Royal College of Nursing (RCN) believes it is at the very heart of good nursing care” (RCN, 2008).
The first principle of nursing care specifies that,
“‘Nurses and nursing staff treat everyone in their care with dignity and humanity – they understand their individual needs, show compassion and sensitivity, and provide care in a way that respects all people equally” (RCN, 2011).
Tadd et al (2002) in their paper ‘Dignity In Healthcare’ noted the word ‘dignity’ is becoming all too widespread and generalised across the healthcare environment, to the extent it is being used as an expression or idea that is no longer effective because of its overuse.
In Baillie’s (2008) case study the patients and staff views on dignity were very similar, in so much both patients and staff not only recognised, but maintained that feeling comfortable within their environment, being in control and feeling safe were essential to their own sense of dignity. Phrases such as feeling valued, feeling cared for, self-respect and self esteem were common place and the word ‘respect’ was considered to be closely related if not interdependent on ‘dignity’.
Chochinov (2007) based on his personal experience and observations, noted that qualities such as kindness, humanity and respect are essential values of medicine, but are only made available if time and circumstances allow. He argues that all medical staff can have a deeply felt influence on how patients perceive their illness and sense of dignity. Although Chochinov specialises in palliative care, where maintaining patient dignity is a fundamental requirement, together with a team of experts, they have developed ‘dignity therapy’, a four-part guide that can be applied to most situations by all health professionals. This could range from a simple outpatient visit, a period spent in an acute hospital setting or to a prolonged period in a hospice for the ‘terminally ill’. Chochinov’s (2007) ABCD guide relates to: Attitude, Behaviour, Compassion and Dialogue and provides a framework, for educating and guiding healthcare professionals in maintaining patients’ dignity. In an accompanying editorial to Chochinov’s (2007) paper in the British Medical Journal (BMJ), Higginson, Hall (2007) a palliative care doctor and psychologist at King’s College London suggest that,
“Chochinov’s ABCD should be the first mnemonic we teach all professionals entering health and social care, even before Airway, Breathing, and Circulation.”
The Department of Health (DoH, 2010) Essence of Care report, defines dignity as:
“Quality of being worthy of respect.”
The report highlights general issues and best practice for respect and dignity. Factors including attitudes and behaviours, personal identity, privacy and confidentiality, personal boundaries, space, communication and modesty are all equally important (DoH, 2010).
In Baillie’s (2008) study the patients referred to ‘dignity’ in various forms. Both the patients and staff’s opinions were similar in that they expressed ‘feelings’ as being significant to the meaning of dignity. ‘Feeling comfortable, in control and valued’ was crucial to maintaining their dignity. When questioned the patients asserted that when they felt safe, happy, relaxed and not worried, they felt comfortable and had a sense of well being. Four patients and two staff members felt strongly that feeling in control was essential to their dignity. Being treated as they themselves would treat others and ‘mutually respectful behaviour’ was another consideration by about a third of the patients. It is incumbent on all healthcare professionals to remember that every patient is an individual and should therefore be treated as one. The NMC (2008) code of professional conduct states that nurses must:
“Make the care of people your first concern, treating them as individuals and respecting their dignity”.
Matiti (2002) put forward 11 categories for maintaining dignity, all of which were mentioned by patients when interviewed and were subsequently supported by nurses. Matiti’s proposed categories of: privacy, confidentiality, need for information, choice, involvement in care, independence, form of address, decency, control, respect and nurse-patient communication, highlights the varied opinions on what dignity means to the individual.
Baillie (2008) identified Patient factors affecting dignity, which ranged from the extent of the illness, i.e. the seriousness of it and how in turn that illness/condition affects the individual patient in personal care to factors such as bodily exposure. Although attitudes towards bodily exposure differed between the age groups it appeared that younger patients were as concerned with their dignity as older patients.
Baillie (2008) also discussed the impact of the hospital environment on dignity. The layout of the ward being five bedded bays sharing one bathroom was considered by two patients to breach both their privacy and therefore their dignity. Mixed sex wards were also considered to be sometimes undignified due to bodily exposure and a third of the patients and the majority of the staff identified this as being a threat to dignity. The close proximity of beds with only curtains to maintain privacy was also an issue due to the fact that other patients on the ward could hear what was being said between the staff members and the patient. The attitudes of staff also had an effect on patients’ dignity. Half the patients interviewed described how one member of staff had a curt manner, which could be interpreted as being ‘off handed’ or even rude. The most important aspect of maintaining patient dignity was privacy, i.e. pulling curtains around beds and avoiding bodily exposure. All the ward staff, five of the six senior nurses and half the patients that were interviewed, agreed and confirmed this.
As healthcare professionals we are all morally bound to upholding patient dignity. We are regulated by the Nursing Midwifery Council (NMC, 2008) code of conduct, but the overriding principles of dignity, humanity and equality are legislated for under the Human Rights Act 1998 and the Equality Act 2010, (Jackson, 2011).
Conclusion
In 2010 the Care Quality Commission (CQC) carried out their annual survey. More than 66,000 patients who were discharged between June and August of that year from 161 acute and specialist trusts took part. Approximately 2,000 (3%) of these patients revealed they were not treated with dignity and respect whilst in hospital and a further 12,000 (18%) said they had been treated with dignity and respect “sometimes” but not always. This survey showed there had been no improvement since 2002 (Stephenson, 2011).
Although steps are being taken to educate healthcare professionals regarding patient dignity, it never the less remains an important issue at the core of NHS values. Dignity remains an often-overused phrase but underperformed action within the healthcare environment. ‘Patient dignity’ is a right, not a concession that health care professionals can hand out when it best suits them.
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