Headnote
Abstract
Purpose: This study aims to identify individual and organizational factors impacting dignified relationships between stakeholders covered in the literature and involved in health care, such as patients and health professionals. We propose a scheme of dignified healthcare services that can help managers diagnose the quality of those services regarding dignified relationships.
Originality/value: This paper proposes a scheme for dignified relationships between patients and various healthcare professionals, considering individual and organizational factors impacting these relationships. The scheme aims to help managers diagnose the quality of the services.
Design/methodology/approach: Following the PRISMA 2020 checklist, the results of the studies were mapped and summarised in the Web of Science, SCOPUS, and EBSCO databases. The RSL protocol was developed and registered in INPLASY. A study quality guidance matrix (ROBINS-L) was designed to conduct the RSL. VOSviewer software was used for bibliometric analysis.
Findings: The analysis of 235 studies from 1973 to 2023 produced three thematic groups: "patient-centered dignity," "dignity and health professionals," and "concepts," conceptions of dignity in health." The physical environment, staff attitudes, and the organization's prevailing culture affect the ability to provide dignified care for highly dependent patients. These findings can guide carers and patients towards dignified health care.
Keywords: dignified care, dignity, health, systematic literature review, dignity in health
Resumo
Objetivo: Com este estudo pretendemos identificar os fatores individuais e organizacionais que impactam as relações dignas entre diferentes partes interessadas abordados na literatura e envolvidos na assistência à saú- de, como pacientes e profissionais de saúde, a fim de propor um esquema de serviços dignos de assistência à saúde que possa auxiliar os gestores a diagnosticar a qualidade desses serviços no que se refere às relações dignas.
Originalidade/valor: Proposta de um esquema de relações dignas entre diferentes tipos de pacientes e vários tipos de profissionais de saúde, no que diz respeito aos factores individuais e organizacionais que podem ter impacto nessas relações, de modo a ajudar os gestores a diagnosticar a qualidade dos serviços.
Design/metodologia/abordagem: Seguindo a lista de verificação PRISMA 2020, os resultados dos estudos foram mapeados e resumidos nas bases de dados Web of Science, SCOPUS e EBSCO. O protocolo da RSL foi desenvolvido e registado na plataforma INPLASY. Uma matriz de orientação da qualidade do estudo (ROBINS-L) foi utilizada para conduzir a RSL. O software VOSviewer foi usado para análise bibliométrica.
Resultados: A análise de 235 estudos de 1973 a 2023 produziu três grupos temáticos: "dignidade centrada no paciente", "dignidade e profissionais de saúde" e "conceitos, concepções de dignidade em saúde". A capacidade de prestar cuidados dignos a pacientes altamente dependentes é afetada pelo ambiente físico, pelas atitudes do pessoal e pela cultura prevalecente na organização. Estas conclusões podem orientar os prestadores de cuidados e os pacientes para a prestação de cuidados de saúde dignos.
Palavras-chave: cuidados dignos, dignidade, saúde, revisão sistemática da literatura, dignidade em saúde
INTRODUCTION
Studies have addressed the concept of dignity in health care (Plunkett & Kelly, 2021) in different practice areas, sometimes centered on the patient and sometimes centered on healthcare organizations or professionals, such as end-of-life patient care (Bilgic, 2023; Choi et al., 2022), care provided to older adults (Fuseini et al., 2023; Hartviksen et al., 2023; Heuzenroeder et al., 2022), care and attention in intensive care units (ICU) and accident and emergency departments (Choi et al., 2022), care policies for psychiatric patients (Harper & Fernee, 2022) and obstetric patients (Gulbransen et al., 2022; Rajkumari et al., 2021). Another topic that deserves the literature's attention is barriers to dignity assurance in different countries (Fuseini et al., 2023).
Over time, healthcare dignity models have primarily centered on the patient and less on the stakeholders involved. Errasti-Ibarrondo et al. (2014), in a literature review, identified two theoretical models, Nordenfelt and Edgar (2005), and five empirical models, Baillie (2009), Chochinov et al. (2002), Lin and Tsai (2011), Lin et al. (2011), and Van Gennip et al. (2013).
Despite the extensive literature on dignity and healthcare, research that clarifies what promotes and violates the dignity of healthcare users is necessary, considering the everyday evidence of situations that violate patient dignity (Jacobson, 2009; Fuseini et al., 2023). Furthermore, there is a paucity in the literature regarding a model of dignity in healthcare services that combines patients, healthcare professionals, and the factors that affect the relationship between them.
With this study, we aim to identify individual and organizational factors that impact the dignified relationships between different stakeholders covered in the literature and involved in health care, such as patients and health professionals, in order to propose a scheme of health care dignified services that can help managers diagnose the quality of those services regarding dignified relationships. It also intends to provide a general thematic overview identifying the most addressed issues in studies in order to expand knowledge on dignity in health and identify gaps for future studies.
Zeithaml and Bitner (1996, p. 5) conceptualized services as "Deeds, processes, and performances." Bolton and Drew (1991) defined service quality as the discrepancy between consumers expectations regarding the services offered by a company and their perceptions about the services they received. Healthcare services differ from services provided by specific characteristics that influence their management and operation. The most important characteristics are their importance to life and wellbeing, the urgent nature and immediacy that many health situations require, high technical complexity and multidisciplinary, high risk where health decisions and interventions can lead to complications or failure, strict regulation by government and professional bodies (due to their impact on public health and patient safety), constant and unpredictable demand, high user expectations, among others (Lateef, 2011). This kind of service is a service that clients prefer not to use; in general, they are suffering from pain and illness, perceive a lack of control over their situation, and feel at risk of being harmed. Health care evaluation is a complex task due to the information asymmetry. These conditions could promote the violation of dignity (Jacobs, 2009). In this study, we consider that it is crucial to include dignity in a model of health care services, which means that dignity is a necessary dimension to be included in the evaluation of health care services. It is important to note that despite the literature about dignity in health care services, dignity has deserved little attention as a dimension of quality evaluation (Peičius et al., 2022).
Dignity is about the worth, stature, or value of a human being (Fuseini et al., 2023). Dignity is generally approached in literature from two angles: inherent and contingent. The first defines dignity as intrinsic and inherent to human beings and universal due to the rational nature of human beings and their ability to act morally. Thus, dignity is unconditional, inalienable, and does not belong to exchange logic (Pirson et al., 2023). As contingent, dignity is conditional and attributed to a person by others who judge him/ her as dignified. In this approach, the human being's relational nature is emphasized, and dignity is considered as extrinsic, social (Jacobson, 2007), and merit dignity (Nordenfelt, 2004).
Efforts have been made to clarify the concept of dignified care to serve as an impetus for improvement in care. According to Pirson et al. (2023), dignified care is care that supports, promotes, and does not undermine the patient's self-worth, regardless of any differences in sociodemographic characteristics between the patient and HCPs. Dignified care has also been described as shared decision-making, patient privacy and autonomy, and treatment of patients as one would expect to be treated. (Lin et al., 2011). The provision of dignified care has evolved from recognizing patients' self-worth into a complex endeavor that considers the biopsychosocial makeup of the individual. This systematic review summarizes the diverse types of patients and healthcare professionals covered in the literature and involved in healthcare, factors that have an impact on dignity in health, thematic overview analysis, and offers a set of propositions that allow for the proposal of a schema of dignified relationships in the healthcare services. As a contribution, this study helps develop protocols and practices that ensure patients are treated with respect and consideration, promoting a more humane and patient-centered care experience, as well as helping healthcare professionals adopt a more empathetic stance, and avoiding practices that could be perceived as dehumanizing. It also contributes to formulating public policies prioritizing care quality and equity.
METHODS
The study presents a bibliometric analysis and a Systematic Literature Review (SLR). Following the PRISMA 2020 checklist, the results of researchbased studies from the Web of Science (WoS), SCOPUS, and EBSCO databases are mapped and summarised. Data was collected between 23rd and 24th March 2023. The databases were chosen because of their wide coverage, rigor in content selection, advanced analysis tools, and wide acceptance in the academic community. This ensures the study is based on a robust, validated, widely recognized knowledge foundation. The SLR protocol is developed and registered in INPLASY. Studies will be included if they are: 1. Primary studies relevant to our research topic (if review articles, such as scoping review articles, are potentially relevant, the mentioned and relevant primary articles should be selected and included); 2. Conference paper and literature review; 3. Direct and/or indirect public or private sector participation. The search results and study selection process will be reported in the final scoping review and presented in the PRISMA Extended Scoping Review (PRISMA- ScR) flowchart.
To support the conduct of the SLR, a study quality guiding matrix (ROBINS-L) is selected, excluding commonly designated grey literature. Furthermore, the articles included in the study are subjected to the AMSTAR-2 grid, which guarantees review quality. Figure 1 presents the article search form, selection, and inclusion/exclusion criteria following the PRISMA Flow Diagram for subsequent conduct of the SLR. As a result, 235 studies were selected over 50 years (1973-2023).
RESULTS AND DISCUSSION
Bibliometric analysis
Articles by author and country
Only eight of 628 authors who published on Dignity and Health contributed four or more papers. Table 1 lists the authors with the most publications on the studied subject. It is important to note that, except for Lennart Nordenfelt from Linköping University, all the others are affiliated with British institutions. As for the number of publications, Win Tadd from Cardiff University and Lesley Baillie from The Open University stand out with five papers each. When considering the number of citations, Lennart Nordenfelt and Ann Gallagher from the University of Surrey stand out with 233 and 194 citations, respectively. The predominance of authors from the United Kingdom is possible because the English National Health Service has always focused on health equity.
Citation analysis
Through the analysis of citations between authors (Figure 2), it was found that of the 628 authors of the articles surveyed, 42 had published at least two articles on the studied theme and presented 20 citations or more. Of these, only 16 presented the highest number of citations. This result reveals that only 2.54% of the authors contributed two papers, presented at least 20 citations, and cited each other as part of their theoretical basis. It should be noted that Nordenfelt and Tadd are authors who, in addition to citing each other, are two of the authors with the highest number of citations (233 and 167, respectively) (Table 1).
Co-citation analysis
Among the 9331 authors cited by the surveyed articles, only 24 were mentioned 20 times. Figure 3 shows the co-citation relationships among the cited authors. The 24 authors cited in the surveyed articles were grouped into three clusters. It is interesting to note the high number of lines between these authors, which reveals many co-citation relationships. Thus, these authors were cited together with most others on the map (Figure 3). Again, the authors Nordenfelt, Tadd, and Gallagher stand out, with the highest number of publications and citations. Although not evidenced in Figure 2, in the co-authorship analysis between authors, the author Harvey Max Chochinov holds a prominent place in the co-citation analysis between authors.
Bibliographic coupling analysis
As mentioned earlier, of the 628 authors of the surveyed articles, 58 published at least two studies on dignity and health. From the bibliographic coupling analysis (Figure 4), 55 authors have a greater connection. These were grouped into seven clusters, and, similarly to the previous study, a high number of lines between authors is observed.
In summary, the bibliometric analysis brings important information to light. From the predominant occurrence of authors from the United Kingdom (with the highest numbers of publications and citations), the identification of the most cited authors (Win Tadd, Lennart Nordenfelt, and Ann Gallagher), the clusters formed by the 55 authors who have bibliographic coupling relationships, the level of analysis focusing on patients and hospital institutions and, finally, the high incidence of studies in general hospitals seeking to provide dignified care and protect patient well-being.
Achievement of the study objectives
* Objective: To identify the stakeholders in the literature, those involved in healthcare, and the central locations where the studies were conducted.
Table 2 shows the primary locations where the studies were conducted; 80% were in general hospitals, followed by nursing homes, psychiatric hospitals, and others (11.91%, 4.26%, and 3.83%, respectively). Possibly, the occurrence of most studies focusing on general hospitals is because they are places with the highest concentration of vulnerable individuals (elderly patients with end-stage diseases) or marginalized individuals (HIV patients), where dignity in health care is closely linked to discussions about the services provided and quality of care.
As for the stakeholders of the investigations, they were classified into two groups: (i) patients (unspecified, older adults, parturients, psychiatric, and oncology patients) and (ii) healthcare professionals (unspecified and nursing) (Table 3).
From the total number of studies, 69.36% target patients. Different themes have been developed covering quality care and dignified care, such as artificial intelligence in healthcare and patients' perception of dignified treatment; generalist palliative care; assisted dying, end-of-life care, and patient vulnerability; dignity from the experience of elderly adults with limited molder and bed-ridden; the experience of dignity of patients in voluntary and involuntary inpatient psychiatric care; best practices for safe, dignified, compassionate care in labor; understanding dignity from the perspective of older adults; social dignity of people marginalized by mental illness, substance abuse; cultural factors that prevent maintaining dignity for patients in intensive care units; cancer patient experiences with body changes concerning dignity, amongst others.
Healthcare professionals have also been the focus of investigations (30.64%). Several themes are part of the studies: moral, bioethical, and scientific aspects in decisions made in the context of scarce resources; social representation of death and the effects that its institutionalization has on physicians and nurses; physician and nurse experiences regarding the protection of dignity in end-of-life care; nurse-patient relationships to provide quality care to patients with advanced and terminal diseases; shared decision making at the end of life; nursing professionals' attitude towards death; violation and protection of patients' dignity in the operating room; others.
* Proposition 1: Patients' perceptions of dignity are influenced by their health conditions, respect for autonomy, and treatment conduct, while professionals' perceptions of dignity are impacted by ethical aspects, experiences in patients' end-of-life care, and the possibility of shared decisions with the family.
* Objective: Factors that have an impact on dignity in healthcare.
Table 4 summarises the main variables that influence healthcare dignity. It is important to note that of the 235 studies involved in this SLR, many focused on several factors addressed together and taken as relevant in dignified health care. Twelve influencing factors were identified and mentioned 898 times in the different studies. From the analysis, three factors stand out (respect and person-centered care, communication, and family involvement); however, it becomes necessary to underline that this is not a prioritization index but quantitatively identified elements/factors. In addition, it is important to note that the factors that directly affect patients indirectly influence health professionals.
The studies that mention the factors that impact dignity in health are diverse and are located in different care locations (clinical inpatient units, intensive care units, maternities, operating rooms, accident and emergency departments, nursing homes, home care, psychiatric hospitals, and others).
The themes addressed concern individualized nursing care plans per patient, focused on their specific needs; they reveal the importance of communication between the different stakeholders involved (patient, family, multidisciplinary team) as a way to align the relevant decision-making processes for dignified treatment; they present family involvement as relevant to patient recovery; sometimes they reveal that the structure of services (number of nursing staff), the physical environment (inappropriate for elderly patients, for nursing mothers in the breastfeeding period) significantly impact privacy and care. Moreover, an organizational culture with high values focused on actions aimed at human care recognizes and focuses on these factors to help health professionals establish practical measures to protect and promote patient dignity and provide more dignified care.
* Proposition 2: Factors that impact dignity in health care are related to the place of care, directly affect people who are the most vulnerable or unable to assert their claims to dignity, and indirectly affect healthcare professionals.
* Objective: Thematic overview analysis.
After reading and analyzing the studies in this SLR, the synthesis produced three overarching thematic groups (Figure 5), identified as impacting dignified care and dignity in health care. The themes were stratified into three categories: "patient-centered dignity, with five subthemes: dignified end-of-life care; focus on the older adult; patients admitted to intensive care units and/or accident and emergency departments; and psychiatric and obstetric patients. The second and third categories are "dignity and health professionals" and "concepts, conceptions of dignity in health."
Group 1. Patient-centered Dignity
Dignified end-of-life care
End-of-life care should emphasize the human side, emphasizing human values rather than just the technical skills of health professionals (García- Rueda et al., 2016). Respect for the concept of dignity in health care is significantly changing the clinical relationship and the framework of care involving end-of-life patients in palliative care units, intensive care units, psychiatric hospitals, and others.
Protecting the dignity and well-being of terminally ill patients through dignified and holistic care has become the primary goal of palliative care services (Choo et al., 2020). A "good death" is identified as one that is expected and prepared for, free of pain and suffering, socially integrated, at peace with life and situation, supported by individualized and holistic care, based on professional cooperation and communication, and in a peaceful and private environment (Lang et al., 2022). Patients considered terminal are those for whom there are no effective therapeutic options. In the context of an organized and planned practice involving all professionals involved in the patient's care, a decision is made, hand-in-hand with the family, to withdraw life support measures (González-Méndez & López-Rodriguez, 2019; Puente-Fernández et al., 2020).
The requirement to respect the equal dignity of each person, linked by different anthropological and ethical theories to their autonomy as a rational agent, also refers to their fragile, vulnerable, and interdependent, subjective character, sustained by a complex web of care (Bylund-Grenklo et al., 2019). On the other hand, their vulnerability as others, constituted by the radical appeal of all that affects them socially and emotionally, and their need for recognition and attention, would be pathological if it did not include the drive for autonomy, which, though precarious and connotative, requires dignified and equitable treatment (Terron, 2021).
End-of-life patient care is not only a matter of deontological ethics but also a philosophical and legal issue, as it involves dignity and the principle of autonomy (Möller, 2015). From a legal perspective, terminally ill patients have the right to self-determination, which should involve the right to make explicit and informed choices about available therapies and to decide to discontinue treatment that they consider no longer justified (Díaz-Cortés et al., 2018).
An essential concept behind patient-centered approaches is the need to treat people with and protect their dignity in care settings. People receiving palliative care may have compassionate needs regarding their condition, symptoms, and life expectancy. Dignity is more likely to be violated in hospice settings than in a disease-centred focus (Pringle et al., 2015).
Focus on the older adult
Dignity in older persons is multidimensional and includes several factors such as privacy, independence, inclusion, and autonomy. Several determinants, such as frailty, dependency, sensory and cognitive impairment, and socioeconomic vulnerabilities, tend to compromise the dignity of older people and, consequently, their fundamental rights (Banerjee et al., 2021). Maintaining the dignity of hospitalized older adults is essential to health care and one of the most critical determinants in promoting well-being (Fuseini et al., 2023).
The facilitators and barriers to providing dignified care in the hospital setting are categorized into three domains: "organizational level," "inpatient unit level," and "individual level" (Sullivan, 2015). Inside those levels, the factors that support and undermine dignity in the care of the older adult include "time," "staffing levels," "training," "ward environment," "staff attitudes," "support," "involving family/carers," and "reflection" (Kinnear et al., 2015). Old age is a stage in life when dignity may be threatened due to the vulnerability created by increased disability, frailty, and cognitive decline, combined with a lack of social and economic resources (Semyonov-Tal, 2021). The physical environment of the wards is often poorly designed, confusing, and inaccessible. It may be seen as "not fit for purpose" to treat its primary users, those over 65, with dignity. The factors considered essential for dignified care include promoting autonomy and independence, a personcentered and holistic approach, maintaining identity and encouraging involvement, participation, and empowerment, as well as effective communication and respect (Stevens et al., 2022). Undignified care is associated with invisibility, depersonalization, treating the individual as an object, humiliation and abuse, and narrow and mechanistic approaches to care (Fuseini et al., 2023).
Socially, the dignity of nursing home residents depends on the routine and behavior of professional caregivers. Many complaints about the violation of dignity exist, such as long waiting times for care, lack of integrity in care, deteriorated routines, insufficient attention to hygiene, and issues related to nutrition, medication, communication, and privacy (Holmberg & Godskesen, 2022).
Patients admitted to intensive care units and/or accident and emergency departments
Due to the specificities of care types, intensive care units (ICU) and accident and emergency departments are identified as hostile and stressful environments. The need for respect and dignity is likely to be neglected, leading both critically ill survivors and end-of-life patients to suffer mental anguish due to loss of dignity caused by high dependency. Emotional intelligence, empathy, professional values, and training in dignified care are predictors of dignified care (Liang et al., 2022).
Positive experiences are mainly associated with a sense of safety promoted by nurses and the design of a system centered on the dignity of the person (Díaz-Cortés et al., 2018). Negative experiences are usually related to violations of privacy and dignity, lack of empathy, lack of understanding, delay/lack of support, and total control by healthcare staff (Sanson et al., 2021). Professionals should respond positively to the basic principles regarding decision-making, information, family support, spiritual preferences, and pain relief (García-Rueda et al., 2016).
Psychiatric patients
Worldwide interest has grown in promoting patients' rights, especially for psychiatric patients. Psychiatric patients may feel they are treated in an undignified manner, especially during involuntary hospital admissions (Raphalalani et al., 2021), which presents an ethical challenge, especially since the dignity of a person whose freedom and autonomy are restricted is inherently at risk (Plunkett & Kelly, 2021). By understanding the concept of dignity in psychiatric patient care, interventions, and services can be developed to improve family quality of life through dignified care (Anderson et al., 2021).
The construction of a non-ideal theory of dignity in psychiatric institutions is sometimes reflected in (i) avoiding violations of dignity rather than seeking to promote it; (ii) dignity is not a goal to be achieved; it requires ongoing effort; (iii) promoting dignity is a balancing act; and, (iv) dignity can be undermined by organizational and discursive constraints (Plunkett & Kelly, 2021).
Various diagnoses of patients treated in psychiatry reverse the hard-won freedoms and rights most adult human beings enjoy. Deficits in knowledge and decision-making lead to a legitimate reduction in autonomy (Dubljević, 2020). Generally, psychiatric patients may be unable to make decisions themselves, and professionals can decide what is best for them. Unfortunately, in most cases, professionals helping a person with psychiatric help need to make decisions without a clear explanation or consent, making dignity in care a construct by the lived experience of healthcare professionals as well as affected by the culture of organizations and society at the same time (Huang et al., 2020). Shared decision-making aims to facilitate patients' active participation in their care. Care in these institutions is intended to empower patients by increasing their responsibility and self-awareness and helping them to use their resources whenever possible (Beyene et al., 2019). Balancing patients' need for assistance with autonomy while safeguarding their dignity is a challenging process that requires staff to have professional competence.
Established practice in mental health services has tended to be codified into law in paternalistic ways, seeking to make decisions for patients that presume "best interest" and ultimately placing power in the hands of the medical authority (Dubljević, 2020). There are profound challenges in legislative reform, but a human rights framework offers the potential for a paradigm shift in how people are treated in services and explores alternative practices that promise a more humane and dignified future for mental health care.
Obstetric patients
Appreciation of maternity care includes respect for autonomy, dignity, feelings, privacy, and consideration for personal preferences, including the choice of companionship during maternity care (Rajkumari et al., 2021). Positive experiences of parturients include 1. empathic interactions between the healthcare provider and woman and timely information sharing, 2. an enabling environment characterized by the improved physical environment, availability of equipment, and provision of staff incentives, 3. supportive leadership demonstrated by staff commitment, ensuring guidelines and policies are available, and 4. attitudes and behaviors characterized by professional values through communication (Mdoe et al., 2021).
In contrast, factors identified as a lack of dignity include unqualified staff, lack of privacy, and lack of basic hygiene infrastructure (Hameed et al., 2021). The determinants identified for disrespect were sociocultural factors, including age, socioeconomic status, caste, parity, women's autonomy, comorbidities, and environmental factors, including infrastructural issues and overcrowding (Ansari & Yeravdekar, 2021). Training healthcare providers, written policies and procedures that describe the responsibilities of healthcare providers in the process of respectful maternal care, improved facility infrastructure, provision of supplies, regular supportive supervision, and mentoring and motivation of high-performing staff have the potential to improve respectful maternal care (Mihret et al., 2020).
The need for dignified obstetric care should ensure that all women receive high-quality, equitable maternity care in all healthcare facilities (Hameed et al., 2021; Mihret et al., 2020).
* Proposition 3: Patient-centered dignity has different approaches depending on the stage of life and/or type of illness.
Group 2. Dignity and Healthcare Professionals
Most important to the dignity of caregivers is to provide good care for their patients and to protect their dignity (de Voogd et al., 2021). Several studies point out that healthcare providers report that the physical environment of the hospital institution influences the provision of dignified care (Díaz-Cortés et al., 2018). Person-centered care is often described as an ideal way to protect the well-being and dignity of vulnerable people and an essential component of quality care (Helgesen et al., 2020).
Insufficient training in patient-centered care leads healthcare workers to experience situations of great stress and frustration, resulting, on many occasions, in the resort to avoiding certain situations, thus preventing care with dignity (Puente-Fernández et al., 2020). However, understaffing, primarily in nursing, influences care by assigning insufficient time to bring dignity to care (Morton et al., 2020). Nursing has a proactive and reactive role in ensuring that patients remain safeguarded, providing care with dignity, and taking appropriate action if abuse or neglect is suspected (Stevens et al., 2022).
Dignity-centered care is associated with maintaining mutual dignity between the patient and healthcare professionals. By maintaining mutual dignity, dignity-centered care increases mutual trust and satisfaction, mutual understanding, and effective communication, and improves the quality of care delivery (Helgesen et al., 2020).
The constant pressure to complain about clinical practice has severe consequences for physicians and patients. Professionals respond with defensive and costly practices, and the system sometimes marginalizes and overlooks higher-risk patients. Hence, the need to defend the dignity of the medical profession is increasingly damaged by the organizational dynamics imposed on it by many political decision-makers (Portugal, 2012).
* Proposition 4: Healthcare providers perceive that dignified patient care is mainly about organizational factors such as an adequate physical environment, sufficient training in patient-centered care, enough staffing, and bioethical reasoning and scientific knowledge when facing decisionmaking regarding resource allocation.
Group 3. Concepts, conceptions of dignity in health
Health and human rights defenders suggest that dignity may explain the relationship between promoting and protecting human rights and health status. The literature abounds with appellations such as fundamental, human, social, and personal dignity (Nordenfelt, 2004; Chochinov et al., 2002).
Jacobson's (2007) study portrays human dignity, based on several authors, as the inherent and inalienable value that belongs to every human being simply because they are human (Pullman, 2001), a value that cannot be measured or weighed, or destroyed; nor is it contingent, conditional, contextual or comparative (Gewirth, 1992), the version most often associated with Kant and neo-Kantian philosophy where the meaning of dignity is grounded in the rationality of human beings and their ability to act as moral agents (Nordenfelt, 2004) and, at the collective level, provides justification for sociopolitical ideals of equity and justice (Jacobson, 2007). As for social dignity, it is portrayed as a consequence of human dignity (Szawarski, 1986); however, social dignity is contingent, comparative (thus scalable or measurable), and contextual (Nordenfelt, 2004) and can be lost or earned, threatened, violated or promoted (Jacobson, 2007).
The term dignity in health care is very much linked to discussions about the services provided, especially to vulnerable or marginalized individuals, such as older adults (Holmberg & Godskesen, 2022), the mentally ill (Plunkett & Kelly, 2021), parturient women (Mihret et al., 2020), end-of-life patients (Lang et al., 2022) amongst others, of which the purpose of the studies is to find ways to provide care that maintains the integrity and selfesteem of both patients and health professionals. General guidelines for professional practice are included in the codes of ethics of different healthcare professionals and are widely explored in nursing (Heuzenroeder et al., 2022; Helgesen et al., 2020). There are relevant studies examining social dignity in health care and how dignity is threatened or maintained through social interaction in specific health-related situations (Jacobson, 2007).
Several authors have developed conceptualizations aimed at understanding the meaning of dignity in health, developing mechanisms that can assist in promoting dignity and identifying factors that threaten or promote dignified care. Based on what the authors referenced, it is possible to observe a variety of conceptions of dignity in health. Dignity is treated through different prisms, sometimes focused on the patient, sometimes on health professionals, and sometimes on the reciprocal relationship between patient, family, and health professionals. Factors that affect or promote dignity are also of concern, but there is no consensus among them regarding the defined factors. Table 5 presents a synthesized outline of the different conceptions of dignity in health.
Table 5 Different conceptions of dignity in health
A fundamental aspect observed after the extensive literature review is that dignity in health care depends on the stakeholders involved and their interaction, sometimes more relevant for patients and sometimes more evident among professionals. Family interaction is also relevant, considering it can assist in the patient's recovery with good communication. In patients' cases, other factors that must be considered are their health condition, degree of dependence, emotional state, and the social situation they find themselves in. In summary, one should not limit the factors that promote or impact dignity in health, because human needs, although generally conceptualized, have specificities and individualities that do not allow us to "standardize" the concept of dignity in healthcare.
Proposed Health Care Dignity Scheme of the Interrelationships
The content analyses of the 235 articles in the SLR made identifying the main stakeholders involved in dignity in health possible. Figure 6 presents the diagram of the interrelations of dignity in health resulting from the qualitative content analysis of the studies explored in the SLR. In this diagram, it can be seen that for patient-centered dignity, the stage of life or type of illness influences the degree of perceived lack of dignity in health care, such as dignified end-of-life care (Lang et al., 2022), focusing on the older adult (Fuseini et al., 2023); patients admitted to intensive care units and/or accident and emergency departments (Liang et al., 2022); psychiatric patients (Plunkett & Kelly, 2021) and obstetric patients (Ansari & Yeravdekar, 2021).
A close interaction occurs between patients and healthcare professionals. In turn, the factors influencing the perception of dignity in health care by professionals include teamwork (Helgesen et al., 2020); training aimed at improving attention to patient-focused care (Puente-Fernández et al., 2020); structure of services reflected in the physical facilities (Stevens et al., 2022), and the number of professionals available for good care (Morton et al., 2020); the work developed with ethics and focused on values that build dignified care and effective communication (Helgesen et al., 2020).
Through textual analysis, twelve factors that impact dignity in health were identified, and their relationship with the stakeholders contemplated in the literature and involved in health care was established. After analyzing the extensive literature, it can be inferred that defining dignity in the health sector is arduous. In the first instance, one needs to mention the complexity surrounding the sector. For example, in hospitals, services such as hotel, hygiene, cleaning, nutrition, dietetics, and maintenance work for patients' direct and indirect care. However, they are all involved in maintaining patient dignity. Moreover, each individual is unique and has different perceptions and needs that must be met.
Regarding patients and health professionals, what is important to one individual may not be so relevant to another, independently of the individual or organizational level. Among the most important aspects are respect and person-centered care (Sufrin, 2021); communication (Mdoe et al., 2021); family involvement (Mihret et al., 2020); shared decision-making between patients, family, and healthcare professionals (Dubljević, 2020); structure of services (Hameed et al., 2021); personal attitude of the patient (Anderson et al., 2021); privacy (García-Rueda et al., 2016); physical environment of hospital facilities (Reddy, 2019); maintaining the patient identity and personalized care (Mdoe et al., 2021); autonomy (Plunkett & Kelly, 2021); staff shortages, especially nursing staff (Sanson et al., 2021) and; organizational culture of the hospital institution (Huang et al., 2020). However, there may be others, depending on the location of the healthcare services in which the studies were conducted, such as patients in intensive care units (who may feel low in dignity due to mental distress and vulnerability caused by high dependency) or those admitted to psychiatric institutions (dignity may be undermined by organizational constraints, due to the patient's clinical condition).
CONCLUSIONS
Dignity cannot be compartmentalized as just one component of the ethics of the multidisciplinary team but rather is inextricably connected to the entire practice of patient care. Recognizing the "value of the other" is the only foundation necessary for the existence and maintenance of a health service in any society. The culture of care is complex and influenced by many factors, some of which overlap with other issues, such as staff attitudes and behaviors. The culture of care is also, in part, a product of the broader institutional culture, which is influenced by government agendas. The physical environment, staff attitudes, and the organization's prevailing culture affect the ability to provide dignified care for highly dependent patients.
Over the past 50 years, delimited by this study (1973-2023), the concept and conceptions of dignity in health care and dignified patient care have undergone different transformations, evolving and enriching the literature. It is hoped that this SLR has contributed to the epistemological advancement of the topic. A distinctive aspect of the findings of this study is the importance that patients place on the need to create a respectful environment. As a limitation, the search by keywords ("dignified care, dignity, health") is identified; searching using only the keywords "dignity" and "health" would undoubtedly bring many more articles to be analyzed.
As contributions, dignity research helps develop protocols and practices that ensure patients are treated respectfully and carefully, promoting a more humane and patient-centered care experience. Dignity studies elucidate how practices that respect patients' autonomy and values can improve this relationship, leading to better clinical outcomes. In addition, understanding the importance of dignity helps healthcare professionals adopt a more empathetic stance and avoid practices that could be perceived as dehumanizing. Research into dignity in health services contributes to formulating public policies prioritizing quality and equity in care. It influences and stimulates managers in general and specialized hospitals and public and private clinical institutions to create regulations and guidelines that guarantee respect for patients' rights in different care contexts, impacting their satisfaction. Dignity in healthcare is not limited to the clinical context; it also involves considerations about the care environment and communication. It presents important results for healthcare professionals to improve social interactions within healthcare services.
Suggestions for future research are presented: (i) focus on different medical specialties (e.g., oncology, pediatrics) where there is the possibility of patient vulnerability; (ii) studies that develop the application of professional forums that assist in greater awareness of clinical practice. Which address the development of training programs for medical professionals to ensure adequate services; and (iii) development and validation of outcome measures for interventions that aim to increase the dignity of health professionals and patients and enable the implementation of strategies to improve health literacy and expand communication.
Sidebar
References
REFERENCES
Anderson, J. G., Bartmess, M., Hundt, E., & Jacelon, C. (2021). "A little bit of their souls": Investigating the concept of dignity for people with dementia using caregivers' blogs. Journal of Family Nursing, 27(1), 43-54. https:// doi.org/10.1177/1074840720975216
Ansari, H., & Yeravdekar, R. (2021). Respectful maternity care during childbirth in India: A systematic review and meta-analysis. Journal of Postgraduate Medicine, 66(3), 133-140. http://doi.org/10.4103/jpgm.JPGM_648_19
Baillie, L. (2009). Patient dignity in an acute hospital setting: A case study. International Journal of Nursing Studies, 46(1), 23-37. http://doi.org/10. 1016/j.ijnurstu.2008.08.003
Banerjee, D., Rabheru, K., Lima, C. A. M., & Ivbijaro, G. (2021). Role of dignity in mental healthcare: Impact on ageism and human rights of older persons. American Journal of Geriatric Psychiatry, 29(10), 1000-1008. https:// doi.org/10.1016/j.jagp.2021.05.011
Beyene, L. S., Severinsson, E., Hansen, B. S., & Rørtveit, K. (2019). Being in a space of sharing decision-making for dignified mental care. Journal of Psychiatric and Mental Health Nursing, 26(9/10), 368-376. https://doi.org/ 10.1111/jpm.12548
Bilgic, S. (2023). The meaning of death for nursing students and their attitudes toward dignified death principles. OMEGA-J, Death and Dying, 86(4), 1388-1401. http://doi.org/10.1177/00302228211009754
Bolton, R. N., & Drew, J. H. (1991). A multistage model of customers' assessments of service quality and value. Journal of Consumer Research, 17(4), 375-384. https://www.jstor.org/stable/2626833
Bylund-Grenklo, T., Werkander-Harstäde, C., Sandgren, A., Benzein, E., & Östlund, U. (2019). Dignity in life and care: The perspectives of Swedish patients in a palliative care context. International Journal of Palliative Nursing, 25(4), 193-201. http://doi.org/10.12968/ijpn.2019.25.4.193
Chochinov, H. M., Hack, T., McClement, S., Kristjanson, L., & Harlos, M. (2002). Dignity in the terminally ill: A developing empirical model. Social Science & Medicine, 54(3), 433-443. http://doi.org/10.1016/s0277-9536 (01)00084-3
Choi, H. R., Rodgers, S., Tocher, J., & Kang, S. W. (2022). Nurse's, physician's and family member's experiences of withholding or withdrawing life-sustaining treatment process in an intensive care unit. Journal of Clinical Nursing, 32(15-16), 4827-4842. http://doi.org/10.1111/jocn.16556
Choo, P. Y., Tan-Ho, G., Dutta, O., Patinadan, P. V., & Ho, A. H. Y. (2020). Reciprocal dynamics of dignity in end-of-life care: A multiperspective systematic review of qualitative and mixed methods research. American Journal of Hospice and Palliative Medicine, 37(5), 385-398. http://doi.org/10.1177/ 1049909119878860
de Voogd, X., Willems, D. L., Torensma, M., Onwuteaka-Philipsen, B. D., & Suurmond, J. L. (2021). Dignity of informal caregivers of migrant patients in the last phase of life: A qualitative study. BMC Palliative Care, 20(1). http://doi.org/10.1186/s12904-021-00721-6
Díaz-Cortés, M. D. M., Granero-Molina, J., Hernández-Padilla, J. M., Pérez Rodríguez, R., Correa Casado, M., & Fernández-Sola, C. (2018). Promoting dignified end-of-life care in the emergency department: A qualitative study. International Emergency Nursing, 37, 23-28. http:// doi.org/10.1016/j.ienj. 2017.05.004
Dubljević, V. (2020). Disease and wellness across the lifespan: A global perspective on the mental health burden of dementia. In D. J. Stein & I. Singh (Eds.), Global Mental Health and Neuroethics (pp. 225-235). Academic Press. http://doi.org/10.1016/B978-0-12-815063-4.00014-9
Enes, S. P. D. (2003). An exploration of dignity in palliative care. Palliative Medicine, 17(3), 263-269. https://doi.org/10.1191/0269216303pm699oa
Errasti-Ibarrondo, B., Garcia, M. M., Varcárcel, A. C., & Solabarrieta, M. A. (2014). Dignity Models: Contribution for the end-of-life care. Cuadernos de Bioética, 25(84), 243-256. https://pubmed.ncbi.nlm.nih.gov/25329414/
Fuseini, A., Rawson, H., Ley, L., & Kerr, D. (2023). Patient dignity and dignified care: A qualitative description of hospitalised older adults perspectives. Journal of Clinical Nursing, 32(7/8), 1286-1302. http://doi.org/10. 1111/jocn.16286
García-Rueda, N., Errasti-Ibarrondo, B., & Arantzamendi Solabarrieta, M. (2016). The nurse-patient relationship in advanced and terminal illness: A literature review and conceptual analysis. Medicina Paliativa, 23(3), 141-152. http://doi.org/10.1016/j.medipa.2014.01.003
Gewirth, A. (1992). Human dignity as the basis of rights. In M. J. Meyer & W. A. Parent (Eds.), The constitution of rights: Human dignity and American values. Cornell University Press.
González-Méndez, M. I., & López-Rodríguez, L. (2019). Organ donation after controlled cardiac death under Maastricht category III: Ethical implications and end of life care. Enfermeria Clinica, 29(1), 39-46. http://doi. org/10.1016/j.enfcli.2017.10.009
Gulbransen, K., Thiessen, K., Pidutti, J., Watson, H., & Winkler, J. (2022). Scoping review of best practice guidelines for care in the labor and birth setting of pregnant women who use methamphetamines. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 51(2), 141-152. http://doi.org/10.1016/j. jogn.2021.10.008
Hameed, W., Uddin, M., & Avan, B. I. (2021). Are underprivileged and less empowered women deprived of respectful maternity care: Inequities in childbirth experiences in public health facilities in Pakistan. PLoS ONE, 16(4). http://doi.org/10.1371/journal.pone.0249874
Harper, N. J., & Fernee, C. R. (2022). Unpacking relational dignity: In pursuit of an ethic of care for outdoor therapies. Frontiers in Psychology, 13. http://doi.org/10.3389/fpsyg.2022.766283
Hartviksen, T. A., Aspfors, J., & Uhrenfeldt, L. (2023). Dignity at stake - relatives' experiences of influencing dignified care in nursing homes. BMC Health Services Research, 23(1), Article 194. http://doi.org/10.1186/s12913- 023-09175-3
Helgesen, A. K., Fagerli, L. B., & Grøndahl, V. A. (2020). Healthcare staff's experiences of implementing one to one contact in nursing homes. Nursing Ethics, 27(2), 505-513. http://doi.org/10.1177/0969733019857775
Heuzenroeder, L., Ibrahim, F., Khadka, J., Woodman, R., & Kitson, A. (2022). A Delphi study to identify content for a new questionnaire based on the 10 Principles of Dignity in Care. Journal of Clinical Nursing, 31(13), 1960-1971. http://doi.org/10.1111/jocn.15462
Holmberg, B., & Godskesen, T. (2022). Dignity in bodily care at the end of life in a nursing home: an ethnographic study. BMC Geriatrics, 22(1), Article 593. http://doi.org/10.1186/s12877-022-03244-8
Huang, Y. C., Lei, R. L., Lei, R. W., & Ibrahim, F. (2020). An exploratory study of dignity in dementia care. Nursing Ethics, 27(2), 433-445. http:// doi.org/10.1177/0969733019849458
Jacobson, N. (2007). Dignity and health: A review. Social Science & Medicine, 64(2), 292-302. http://doi.org/10.1016/j.socscimed.2006.08.039
Jacobson, N. (2009). Dignity violation in health care. Qualitative Health Research, 19(11), 1536-1547. http://doi.org/10.1177/1049732309349809
Kinnear, D., Victor, C., & Williams, V. (2015). What facilitates the delivery of dignified care to older people? A survey of health care professionals geriatrics. BMC Research Notes, 8(1), Article 826. http://doi.org/10.1186/ s13104-015-1801-9
Lang, A., Frankus, E., & Heimerl, K. (2022).The perspective of professional caregivers working in generalist palliative care on 'good dying': An integrative review. Social Science and Medicine, 293, Article 114647. http://doi. org/10.1016/j.socscimed.2021.114647
Lateef, F. (2011). Patient expectations and the paradigm shift of care in emergency medicine. Journal of Emergencies, Trauma, and Shock, 4(2), 163-167. http://dx.doi.org/10.4103/0974-2700.82199
Liang, A., Gao, C., Xu, W., Shen, Y., Liu, C., Lu, Z., & Yang, Y. (2022). Individual factors in dignified care: A cross-sectional study of critical care nurses. Journal of Nursing Management, 30(7), 3286-3294. http://doi.org/ 10.1111/jonm.13765
Lin, Y., & Tsai, Y. (2011). Maintaining patients' dignity during clinical care: A qualitative interview study. Journal of Advanced Nursing, 67(2), 340-348. http://doi.org/10.1111/j.1365-2648.2010.05498.x
Lin, Y., Tsai, Y., & Chen, H. (2011). Dignity in care in the hospital setting from patients' perspectives in Taiwan: A descriptive qualitative study. Journal of Clinical Nursing, 20(5-6), 794-801.<http://doi org/10.1111/j>. 1365-2702.2010.03499.x
Mdoe, P., Mills, T. A., Chasweka, R., Nsemwa, L., Petross, C., Laisser, R., Chimwaza, A., & Lavender, T. (2021). Lay and healthcare providers' experiences to inform future of respectful maternal and newborn care in Tanzania and Malawi: An Appreciative Inquiry. BMJ Open, 11(9), Article e046248. http://doi.org/10.1136/bmjopen-2020-046248
Mihret, H., Atnafu, A., Gebremedhin, T., & Dellie, E. (2020). Reducing disrespect and abuse of women during antenatal care and delivery services at Injibara General Hospital, northwest Ethiopia: A pre-post interventional study. International Journal of Women's Health, 12, 835-847. http://doi.org/ 10.2147/IJWH.S273468
Morton, L., Cogan, N., Kornfält, S., Porter, Z., & Georgiadis, E. (2020). Baring all: The impact of the hospital gown on patient well-being. British Journal of Health Psychology, 25(3), 452-473. http://doi.org/10.1111/bjhp.12416
Nordenfelt, L. (2004). The varieties of dignity. Health Care Analysis, 12(2), 69-81. http://doi.org/10.1023/B:HCAN.0000041183.78435.4b
Nordenfelt, L., & Edgar, A. (2005). The four notions of dignity. Quality in Ageing and Older Adults, 6(1), 17-21. https://doi.org/10.1108/1471779 4200500004
Peičius, E., Urbonas, G., Harrison, W. D., Urboniene*, A., Kuznecoviene*, J., Butkevičiene*, R., Astromske*, K., & Kale*diene*, R. (2022). Dignity violations and barriers to dignity assurance for terminally Ill patients at the end of life: A cross-sectional analysis. Medicina, 58(2), 294. https://doi. org/10.3390/medicina58020294
Pirson, M., Piedmont, R. L., Nagy, N., & Hicks, D. (2023). Establishing a dignity scale - Measuring intrinsic value within social contexts. Humanist Management Journal, 8, 97-112. https://doi.org/10.1007/s41463-023-00 147-7
Pleschberger, S. (2007). Dignity and the challenge of dying in nursing homes: The residents' view. Age and Ageing, 36(2), 197-202. https://doi. org/10.1093/ageing/afl152
Plunkett, R., & Kelly, B. D. (2021). Dignity: The elephant in the room in psychiatric inpatient care? A systematic review and thematic synthesis. International Journal of Law and Psychiatry, 75, Article 101672. http://doi. org/10.1016/j.ijlp.2021.101672
Portugal. Physicians' Order. (2012, April 15). Governo não respeita dignidade dos profissionais de saúde. https://www.dn.pt/arquivo/diario-de-noticias/governo-nao-respeita-dignidade-dos-profissionais-de-saude.html
Pringle, J., Johnston, B., & Buchanan, D. (2015). Dignity and patient-centred care for people with palliative care needs in the acute hospital setting: A systematic review. Palliative Medicine, 29(8), 675-694. http://doi.org/ 10.1177/0269216315575681
Puente-Fernández, D., Lozano-Romero, M. M., Montoya-Juárez, R., Martí- García, C., Campos-Calderón, C., & Hueso-Montoro, C. (2020). Nursing professionals' attitudes, strategies, and care practices towards death: A systematic review of qualitative studies. Journal of Nursing Scholarship, 52(3), 301-310. http://doi.org/10.1111/jnu.12550
Pullman, D. (2001).Universalism, particularism and the ethics of dignity. Christian Bioethics, 7(3), 333-358. https://doi.org/10.1076/chbi.7.3.333. 6876
Rajkumari, B., Devi, N. S., Ningombam, J., & Ingudam, D. (2021). Assessment of respectful maternity care during childbirth: Experiences among mothers in Manipur. Indian Journal of Public Health, 65(1), 11-15. http:// doi.org/10.4103/ijph.IJPH_430_19
Raphalalani, S., Becker, P. J., Böhmer, M. W., & Krüger, C. (2021). The role of mental health care act status in dignity-related complaints by psychiatric inpatients: A cross-sectional analytical study. South African Journal of Psychiatry, 27, Article 1602. http://doi.org/10.4102/sajpsychiatry.v27i0.1602
Reddy, B. V. (2019). Maathru Samman Pants: An initiative towards Respectful Maternity Care. J. Family Medicine and Primary Care, 8(6), 1821-1823. https://doi.org/10.4103/jfmpc.jfmpc_326_19
Sanson, G., Lobefalo, A., & Fascì, A. (2021). "Love can't be taken to the hospital. If it were possible, it would be better": Patients' experiences of being cared for in an intensive care unit. Qualitative Health Research, 31(4), 736-753. http://doi.org/10.1177/1049732320982276
Semyonov-Tal, K. (2021). Honor thy father and thy mother: the contribution of verbal concerns to the understanding of elderly patients' satisfaction. Quality in Ageing and Older Adults, 22(2), 95-105. http://doi.org/10.1108/ QAOA-02-2021-0022
Stevens, E., Price, L., & Walker, L. (2022). Just because people are old, just because they're ill..." Dignity matters in district nursing. The Journal of Adult Protection, 24(1), 3-14. http://doi.org/10.1108/JAP-07-2021-0024
Sufrin C. (2021). Reproductive health care for incarcerated pregnant, postpartum, and nonpregnant individuals: ACOG Committee Opinion Summary, Number 830. Obstetrics and Gynecology, 138(1), E24-E34. https:// doi.org/10.1097/aog.0000000000004429
Sullivan, M. P. (2015). Eldercare. In J. D. Wright (Ed.), International encyclopedia of the social & behavioral sciences (2nd ed., pp. 335-341). Elsevier. https://doi.org/10.1016/B978-0-08-097086-8.28029-X
Szawarski, Z. (1986). Dignity and responsibility. Dialectics and Humanism, 2(3), 193-205.
Terron, J. M. M. (2021). Vulnerable dignity, dignified vulnerability: Intertwining of ethical principles in end-of-life care. International Journal of Environmental Research and Public Health, 18(2), 482. http://doi.org/10.3390/ ijerph18020482
Thompson, G. N. & Chochinov, H. M. (2008). Dignity-based approaches in the care of terminally ill patients. Current Opinion in Supportive and Palliative Care, 2(1), 49-53. https://doi.org/10.1097/SPC.0b013e3282f4cb15
Van Gennip, I. E., Pasman, H. R. W., Oosterveld-Vlug, M. G., Willems, D. L., & Onwuteaka-Philipsen, B. D. (2013). The development of a model of dignity in illness based on qualitative interviews with seriously il patients. International Journal of Nursing Studies, 50(8), 1080-1089. http://dx.doi. org/10.1016/j.ijnurstu.2012.12.014.
Wilson, P. M., Longley, K., Muon, S., Rodgers, W. M. & Murray, T. C. (2006). Examining the contributions of perceived psychological need satisfaction to well-beingin exercise. Journal of Applied Biobehavioral Research, 11(3-4), 133-287. https://doi.org/10.1111/j.1751-9861.2007.00008.x
Zeithaml, A. V., & Bitner, M. J. (1996). Services Marketing. McGraw Hill.
