Being treated with dignity

In line with previous studies (Pound, Gompertz and Ebrahim, 1994; Tyson and Turner, 1999) patients within the current study were satisfied that they were treated with dignity. This was the statement with the highest level of satisfaction. However, the current study identified that 18.5% (n= 25) of respondents did not feel they were treated with dignity. This is a similar finding to that of Pound et al (1999) who found that 10% of their respondents did not feel they were treated with dignity. Alarmingly, this figure has increased during the 13 years interlude between these studies. This finding indicates that there remains a proportion of patients within stroke rehabilitation who are not treated with dignity and this number is increasing.

Previous research has concluded that not being treated with dignity can lead to a negative emotional reaction within the patient including anxiety, anger, humiliation and embarrassment (Griffin-Heslin, 2005; Clark, 2010) which can impact upon motivation and participation with therapy (Reynolds, 1992). In turn this can limit the functional recovery made during rehabilitation. Therefore, despite a limited number of patients not being satisfied with the dignity they felt they were treated with, this could be impacting their recovery from stroke, which should not be acceptable. To not be treated with dignity is a breach of basic human rights (Amnesty

International, 1948; WHO, 1994) and against professional ethical practice (Jacobs, 2001; Shotton and Seedhouse, 1998; International Council of Nursing, 2006; RCN, 2003) and should not feature in modern health care.

Dignity is a subjective concept (Becker, 2001; Moody, 1998; Pullam, 1996) and different people may experience dignity in different ways (Clark, 2010; Bolton, 2007; Fenton and Mitchel, 2002). Within the current study the oldest group of patients, over 80 years, were the most satisfied with the extent they were treated with dignity. This is in agreement with previous studies which found that younger patients are less satisfied with the dignity they felt they were treated with (Chochinov et al, 2002; Kathol et al, 1990; Noyes et al, 1990). This may be due to older patients generally expressing higher levels of satisfaction (Fakhoury et al, 1997; Lecouturier et al, 1999; Jenkinson et al, 2002), potentially due to low expectations and reluctance to express dissatisfaction (Mangset et al, 2008; Owens and Batchelor, 1996). This finding that older patients are more satisfied with the level of dignity they experienced may also be due to recent reports in the press highlighting lack of dignity in the care of the elderly, along with national reports such as the Healthcare Commission's Caring for Dignity (2007). This emphasis may subconsciously influence health care staff to be more aware of how they are treating older patients.

Interestingly, the severity of stroke did not impact on patient satisfaction with being treated with dignity, which is contrary to previous studies identifying an association between poor subjective health and decreased satisfaction (Asplund, 2009). Elements of dignity have been suggested to include a deterioration in appearance (Chochinov et al, 2002), pain (Chochinov et al, 2002), a sense of being a burden to others (Chochinov et al, 2002) and a persons ability to exercise competence (Seedhouse and Shotton, 1998). All of these features could be associated with a more severe stroke and therefore could be expected to feel less dignity in their care. However, the more severe

stroke would impact the patient’s ability to participate in the current study. Whilst patients with severe strokes were not excluded from the current study they are more likely would require

assistance to complete the study questionnaire. This may bias the response received as the person facilitating completion of the questionnaire may not be present during personal care or witness individual interactions throughout the patient's care.

The current study did not explore specific features of treatment possibly contributing to the patient's feeling of being treated with dignity. If a patient is not seen as having individual value but being part of a group, if their privacy is not respected or if the patient is humiliated can result in a loss of feeling of being treated with dignity. As individual features of dignified care were not explored in the current study no conclusions can be drawn regarding the causes of dissatisfaction in this area therefore specific recommendations for service improvement can not be identified. However, these possible causes of a loss of dignity are strong causes for concern regarding how stroke rehabilitation patients are treated.

The opinions of staff regarding the delivery of dignified care were not sought in the current study. In previous research nursing staff have reported that a lack of staffing can be a barrier to delivering dignified care (Bagheri et al, 2012). The association between staffing levels and patient perception being treated with dignity was not explored within the current study. However, staffing levels were highlighted by staff within the current study as a barrier to delivering intensive levels of treatment therefore may also be a factor in delivering dignified care. Previous research has also identified that the levels of dignity that healthcare staff themselves feel they receive whilst at work can in turn impact upon the level of care they give to patients (Lawless, 2010). The current study did not explore whether staff felt they were treated with dignity therefore conclusions can not be drawn regarding the potential impact of how staff are treated and their subsequent treatment towards

patients.