A case study of patient dignity in an acute hospital

Promoting patients' dignity in
an acute hospital setting
Dr Lesley Baillie
London South Bank University
[email protected]
0207 815 8457
Patients’ dignity must be respected: legislation
(Human Rights Act, 1998), Codes of Professional
Conduct (NMC, 2004; ICN, 2001a, 2001b) and health
policy (DH, 2001a, 2001b; 2006)
However, patients are vulnerable to a loss of
dignity in hospital (Seedhouse and Gallagher
2002; Jacelon, 2003; Matiti and Trorey, 2004).
Lack of research relating to patient dignity and
few studies have explored patients' perspectives.
Most previous research relates to older
people in long-term settings or terminal care.
 Explore the meaning of patient dignity;
 Examine how patients' dignity is
 Investigate how patients' dignity can
be promoted
In an acute hospital setting.
Research design
A holistic research design to explore all the
factors which could affect patient dignity – a
qualitative multi-method case study (Yin,
Local Research Ethics Committee gave
The research was conducted in a district
general hospital of one acute NHS Trust
The study was registered with the Trust’s
Research & Development Office.
Research participants and
Based on one surgical ward, specializing in
Patients’ ages ranged from 34-92 years
(mean = 64 years), 9 women and 15 men,
varying socio-economic backgrounds
Staff participating were ward based
(registered nurses and health care
assistants), visiting staff (specialist nurses,
doctors and allied health professionals) and
senior nurses (ward & Trust-based)
Research methods
Data collection method
12 recently discharged patients
6 senior nurses
Participant observation: 12 4hour care episodes and 12
staff handovers
12 in-patients
26 ward-based staff (nurses and healthcare assistants)
16 visiting staff (doctors, allied health
professionals, specialist nurses)
Informal interviews following
Above 12 in-patients observed
13 ward staff with key involvement in the 12
observed patients' care
Document analysis
Ward/hospital policy documents
Overview of findings
Threats to
patients’ dignity
in hospital:
staff behaviour
patient factors
dignity in
to and from
Promotion of
patients' dignity
in hospital:
staff behaviour
patient factors
Feelings associated with
Feeling comfortable
 Safe
 Happy
 Relaxed
 Not worried
 Knowing your privacy
is not invaded without
 Not feeling
 Well-being
Feeling in control
 Able to cope
 Confident
Feeling valued
 Self respect
 Self esteem
 Of consequence
 Cared about
Patients’ dignity in hospital
Personal feelings –
 'feeling 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
Physical presentation –
 'just not showing your body to other people I think. Just
keeping it covered all the time.‘ (Mrs Y)
Behaviour to and from others –
 'Respect from other people isn't it? Respect and
people treating you as you treat them, and not making
you feel small.‘ (Mrs X)
The meaning of patient dignity
'Patient dignity is feeling valued and
comfortable psychologically with one's
physical presentation and behaviour,
level of control over the situation, and
the behaviour of other people in the
Patient dignity
How patients’ dignity is threatened or
promoted in hospital
Dignity and being in hospital
'It's not a comfortable environment at all, coming here. It
can be pretty uncomfortable. Whatever we do is not nice. It
either hurts or it's unpleasant, or they're put in an
uncompromising position.' (Senior Nurse 4)
'In hospital you expect to be put into situations where you
may feel a certain loss of dignity I suppose.' (Mr A)
'It's [being in hospital] like having to take a step from your
outside world into a totally different one and you kind of
come to terms - before you go in there.' (Mrs X)
'You leave your dignity on the doorstep and pick it up on
your way out. (Mrs W)
'You've got to be cooperative in hospital in a different sort of
way. You've got to submit yourself to things you wouldn't
usually put up with.' (Mr B)
Patients’ vulnerability : impaired health
Loss of function
 'Not being able to do much for herself [Mrs V, postoperatively] at the moment leaves her a bit vulnerable.'
(Nurse 2)
Diagnosis-related intimate procedures
 ‘The very fact that you have a catheter and you were
having your urine bag changed every so often - it's not
dignified.’ (Mr C)
Psychological impact of diagnosis.
 'If you're in the realms of the unknown when you're
desperately ill and you don't know anything about the
illness you've just got to lie back and let them [staff]
deal with it.’ (Mr D)
Patients’ vulnerability: older age
Physical health: 'When you're sort of fairly old
and they've got to come and help you do this and
do that.' (Mr E)
But: no clear cut link between older age and
dependence - health problems were the central
issue, e.g. post-operatively, Mrs V (in her 40s)
was far more dependent than Mr F (in his 90s).
Upbringing: 'I'm a man who was brought up in
the innocent age if you want to call it that and
your body being touched and played with by
women and that kind of thing is a bit difficult.' (Mr
How the hospital environment
threatens dignity: lack of privacy
'You don't know what to experience in a
hospital. I mean the privacy was - it's quite a
shock to see people considerably worse off
than you.' (Mr D)
Privacy provided by curtains is easily
'Other patients can hear [what's happening] even
with the curtains round. Curtains are a visual but not
a hearing barrier.' (Nurse 13)
A mixed sex environment and risk of bodily
exposure in hospital further threatened privacy
Mixed sex environment
The ward was mixed with single sex bays but due to bed
shortages, ward staff were sometimes pressurised into
mixing bays:
 'The staff are very well aware that we do not mix the
bays. And I do have fights sometimes with the managers.
And I don't like it.' (Senior Nurse 1)
Patients felt uncomfortable in mixed bays:
 ‘With all girls here, patients might not always pull the
curtains round if they are getting out of bed but with a
man here, the curtains have to be pulled.’ (Mrs U)
Bodily exposure in hospital
Occurred due to hospital procedures - was an
issue because the ward was a public place and
patients were surrounded by strangers.
Urology patients: 'They're in for treatment of their
private genitalia area so that they're always that
bit self conscious - that bit aware of the bits that
are exposed that shouldn't be exposed.' (Senior
Nurse 3)
[wearing a hospital gown] 'was one of the worst
bits, to be absolutely honest - that was one bit
where you hadn't got any dignity.' (Mr E)
How the hospital environment threatens
dignity: Hospital systems
Bed management: 'I went in three different beds before I
ended up in urology because they didn't have room
anywhere - but being trundled around like that … you
feel a bit helpless.' (Mr C)
[if] 'you were treated more like a human person than on
a conveyor belt that would be very nice.' (Mrs X)
'Sometimes people aren't taken as individuals, they're
taken as a sort of en masse really.' (Senior nurse 4)
Workload: 'I felt in hospital that the question of dignity
doesn't necessarily come into question when doctors
and nurses and auxiliary staff are flat-out doing what
they have to do’. (Mr H)
How staff behaviour threatens
patients’ dignity
‘brusque’, ‘off-hand’, ‘curt’, ‘stand-offish’.
'having a lack of conversation, doing a job in a
matter-of-fact way and not bothering much
about it.' (Mr F)
'One or two of them you sort of feel a bit
annoyed at being bossed around.' (Mr A)
'It's like you're a thing in a bed and I'm coming
round. You have to have all these tablets
whether you want them or not.' (Mrs Z)
How staff behaviour threatens
patients’ dignity
Breaching privacy
 A few participants identified that staff
occasionally breached privacy, e.g. 'people
come and peep round the curtains' (Nurse 2).
 Mr A explained how during a bladder washout,
a staff member intruded and chatted to the
nurse carrying out his procedure, which caused
'a certain loss of dignity'.
Promotion of patient dignity in
hospital: patient factors
Attitude: rationalisation, humour, acceptance
 ‘Encroaching on the body’s modesty when
undergoing treatment is a necessity – it’s just
part of their (staff’s) job’ (Mr J)
 ‘If you look on everything light heartedly and you
can have a laugh and a joke with the staff that's
half the battle (Mr E)
 'In some ways I suppose I've lost my dignity but
I've accepted it.' (Mrs T)
Promotion of patient dignity in
hospital: patient factors
Relationships with staff:
 ‘I know it's hard in hospital because obviously you are in
pain, and you are suffering, but it doesn't cost much to
be nice to people’ (Mr K)
 'I didn't do anything about it. I didn't want to upset
anybody because I don't want anybody taking it out on
me. [Laughs] Not that they would but you know what I
mean' (Mr A)
Ability & control:
 I didn't sort of suffer with anything like that as such. I
suppose it's because I was sort of younger and fitter
than a lot of chaps that were in there' (Mr E)
Promoting patients dignity in
hospital: environment
Conducive physical environment and
A clean, well-maintained environment makes patients
feel valued
 ‘This ward has more open space - it's clean and
new - it makes you feel better’ (Mr L)
The ward layout (small bays with a bathroom) were
popular with almost all the patients
 ‘It makes it easier doesn't it to sort of manoeuvre
about - you don't have to go walking down a long
corridor with your frock [gown] flapping in your
bottom' (Mr A)
 'There's only five beds in a bay, so you can talk to
everybody' (Mr E)
Promoting patients’ dignity in hospital: Dignitypromoting ward culture and leadership
Almost half the patients referred to aspects of ward culture
and leadership which promoted their dignity.
'There's a very caring, respectful approach. The ward is
friendly - there's a nice feel about the place. People on this
ward are sensitive to making you feel dignity is promoted
all the time' (Mr M)
'I think that goes down to the sister that was on the ward. I
think she was brilliant with her staff - everybody has a
massive amount of respect for her’ (Mr H)
'We're quite a good team. We're here for the patients. Want
to deliver the best for them. I like to think we're quite
patient focused and like to treat the patients as individuals’
(Senior nurse 4)
Promoting patients’ dignity in hospital:
Support from other patients
Camaraderie between the patients who understood what
each other was going through and supported and helped
each other.
the comfort of being on a ward with patients with
similar conditions: 'all in the same boat'
‘Everybody realises there's something going on
behind those curtains but - so what - they're all in the
same boat' (Mr C)
'The patients are quite respectful in this ward - they
were quite friendly’ (Mr G)
'Everyone [other patients] seems to root for everyone
else’ (Mrs S)
How staff behaviour can promote patients’
dignity in hospital: providing privacy
Providing environmental, body and auditory
‘The nurses there were straight round with the curtains
as soon as anything happens' (Mr K)
'The staff who bring the water round know not to go in if
the curtains are round' (Nurse 1)
‘You should never expose any more of the body than
absolutely necessary when carrying out care’ (Nurse 1)
‘You have to be aware that voices carry’ (Nurse 15)
When Mrs V was too unwell 'couldn't be bothered' to
maintain her own dignity, ‘staff stepped in and
straightened me up' saying things like 'you don't want
the men seeing you’
How staff behaviour can promote patients’
dignity: Therapeutic interactions
Interactions that make patients feel comfortable : use
of humour, reassurance, friendliness and
the staff: 'were all a good laugh, which helped all the way
round, basically'. (Mr E)
'They're [nurses] friendly - they put you at ease’ (Mrs U)
A professional manner portrayed efficiency and competence
and inspired confidence in patients, making them feel safe
and comfortable.
Mr G talked of the nurse's approach while taking his catheter
out saying that:
'she did it very nicely without any bother or fuss or
How staff behaviour can promote patients’
dignity: Therapeutic interactions
Interactions that made patients feel in control:
explanations and information giving, offering choices,
gaining consent and promoting independence:
 ‘She [Nurse 14] 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)
 'Telling you exactly what's going on - if people say
what's going to happen that makes you feel more
able to cope'. (Mrs X)
How staff behaviour can promote patients’
dignity: Therapeutic interactions
Interactions that made patients feel valued:
helpfulness, consideration, showing concern for
patients as individuals and courteousness
'From the cleaner to the sister, I got the same respect,
which was nice' (Mrs W)
'If you say you can't get to the toilet they'll bring you a
commode - never make a fuss'. (Mrs Z)
'Staff were always concerned about you. As much as
they have twenty other odd patients but they did
always enquire how you were'. (Mrs R)
'It wasn't assumed that I wanted to be known as my
Christian name' (Mrs W).
Feelings are central to dignity: physical
presentation and behaviour to and from others
affects patients’ feelings
Patients are vulnerable to a loss of dignity in
hospital due to their health condition which led
to their admission
The hospital environment and staff behaviour
may increase or decrease patients’
vulnerability to a loss of dignity occurring.
Patients' use their own strategies to counteract
threats to dignity, with varying success.
Promoting dignity in an acute
hospital setting
Fundamental structural environmental aspects needed
Bed management: a single sex environment, minimal
transfers and patients with similar conditions sharing their
A dignity promoting leadership and a whole ward culture
and commitment to patients' dignity.
Staff all have individual responsibility to behave towards
each patient in a way that promotes dignity during every
Many patients place strong emphasis on their own role in
promoting their dignity, using rationalisation and building
relationships to make them feel more comfortable
But not all patients are able to promote their own dignity
and they are more vulnerable
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