Every individual, irrespective of gender, race and culture is born with equal right to respect, in order to maintain dignity. A person strives to be respected and valued throughout their life. However, in environment where we live, sometimes we as a human being intentionally or unintentionally breaks this basic principle of respect and split individual dignity into spatial elements. What happens if a person is mentally ill and faced disrespect in front of others? Have we ever seen or realized the impact of this act on an individual self-esteem? It might be that we have seen them many times but have failed to ever realize their impact. Similarly, on my clinical visit, I encountered a patient, Ms. X, 40 years old, was a bedridden patient diagnosed with Schizophrenia. Currently, she was suffering from severe diarrhea, and due to her condition she was unable to perform her hygiene care herself and therefore needed assistance. At that point it came under my observation that the staff of the institution was not only neglecting her, but also degrading her and adding injury to her self-esteem. While I was interviewing the patient, I observed that a staff entered the room and started to verbally abuse the patient by saying that, “She was not worth their time as they were not here to clean up her mess or to solve her issues all the time”. Furthermore, she exclaimed, “Her parents left her on our mercies and we don’t have enough time to do this work rather we have to look after other patient’s as well”. At that time, other patients were also listening to this conversation. All of which were disregarding the respect and dignity of a patient.
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Respect is defined as “To show deferential regard for; to be treated with esteem, concern, consideration or appreciation; to protect an individual’s privacy; to be sensitive to cultural differences; to allow an individual to make choices.” Furthermore, dignity is defined as “To be treated with esteem, honor, and politeness; to be addressed in a manner that is not patronizing or condescending; to be treated as an equal; to be treated the way any individual would like to be treated” (Ray, 2010, p. 1). In other words, if a person gets respect, person feels dignified. Moreover, respecting person it means we are respecting their right and this cannot be attained without one another.
In above scenario, the first ethical principle, respect and dignity of a patient have been violated by the staff in front of others. Moreover, staff verbally abused the patient although it was her duty to take care of patient. “Respect for persons represents the clinician’s ethical obligation to regard the ill individual fully, genuinely, intrinsically” (Roberts, 2003, p.340). It is our responsibility to give respect to all individuals equally to maintain dignity. Even then, I encountered the case of disrespect. Do these incidents happen because psychiatric patients are perceived as not deserving respect? Do their mental conditions deprive them of respect and dignity which is the basic right of all humans? These are the questions which emerged in my mind while reflecting on it and led me to choose this issue.
The principle of respect and dignity applies everywhere in our daily lives and every person deserves to be treated with respect. (Kazim, 2007). However, to discuss this principle in mental health is significant because these patients are at risk of losing respect and dignity at all times. “People with mental disorders are, or can be, particularly vulnerable to abuse and violation of rights.” (Freeman, & Pathare, 2005, p.1). Also, most often society does not respect the mentally ill patient as they respect others. In many countries mental patients are still kept in chained, beaten, parts of their bodies burnt. Even they are treated worth than local animals (Pridmore & Pasha, 2004). Moreover, “People who suffer from mental health illnesses are often excluded from social society.” (Santegoeds, &Tekeer, 2006, p.3). Psychiatric patients lack social support because they often excluded from society. Similarly, in my case patient was insulted in front of others and was verbally abused and labeled as ‘mental.’ If my patient was suffering from diarrhea only then there would be any difference in giving respect? Study revealed that health professionals frequently hold negative attitudes and behavior towards mental ill patients (Kapungwe, Cooper, Mwanza1, Mwape, Sikwese, Kakuma, …Flisher, 2010). Alike, as my patient was suffering from diarrhea and the likelihood of a physical complaint has been overlooked due to negative attitude towards mental illness by verbal abuse which may impairs the mental well-being of patient. Otherwise, there would be a huge difference in dealing diarrhea of normal patient. As, my patient had disturbed thought process so, does we have right to break the principle of respect which is equal for all? According to Islamic bioethics, “Patient must be treated with respect and compassion and that the physical, mental and spiritual dimensions of the illness experience be taken into account” (Kazim, 2007, p.72). It means, all human beings are worthy of equal, regardless of any factor like differences in social status, gender, mental status are an important to the identity and give meaning to their lives. And if society continues behaving like this, as a result, other members of society might do the same and this act will continue rather being stopped. Also, violation of this principle would increase at great extent by affecting the whole society. However, it is the key principles of the Human Rights Act. When a person’s dignity is compromised and no respect is afforded them, it is an abuse of their human rights (Gostin, & Hodge, 2003).
There are numerous factors which are involved in violation of this principle. Firstly, in mental health settings, “younger and well educated staffs have mainly found their work to be more stressed and emotionally exhausted” (Valimaki, Scott, Lahti, & Chambers, 2007, p.8). It is evident in my case that due the exhaustion, staff ventilates their anger or verbally abuses the patient, rather understanding the patient’s condition. According to a study, patients experience of violation of rights in Kenya as “It is apparent that the nurse’s verbal impoliteness constituted violations of dignity and not merely rudeness.” (Ojwang, Ogutu, & Matu, 2010, p.106). Also, words play a key role in the mental health settings, may affects patient dignity to a great extent. “Using respectful language and gestures promotes dignity.”(Cass, Robbins, & Richardson, 2009, p.92). However, psychiatric patients are at risk of disrespect and losing dignity in hospitals. “Staff behavior and the hospital environment impact patients’ dignity, and threats to patients’ human needs can lead to loss of dignity.” (Ojwang et al., 2010, p.104). Alike, in above scenario due to staff behavior patient’s right to respect violated which may threaten patient’s dignity.
Now, considering the patients view, if the principle of right to respect violates, does this act adds further injury to one’s self? Would it be painful for an individual? Does the dignity of patient get affected? Does this act helps her to cope or further deteriorates her health? These are the question that arouse in my mind at that point and time.
When patient gets respect, feels dignified. “Dignity entails the positive feelings that the individual has for the self, including respect, self-esteem, self-worth, trust, valuing self, and honoring self” (Ojwang, et al., 2010, p.103). In other words, dignity makes an individual to think positive which promotes mental health. On the other hand, when dignity and respect are absent from care, patient feel devalued, ashamed and embarrassed. They may also lack confidence, unable to make decisions for themselves, and feel disgraced. (Chambers, & Ryder, 2009). According to a Jacobson, “…dignity may be a link that explains the relationship between the promotion and protection of human rights and health status.” (Jacobson, 2007, p.292). As, patient feels dignified, it shows improvement in mental health status and recovery rather deterioration in mental health. According to Declaration of patient organization on mental health care, if patient gets no respect then, ultimately leads to an outbreak of psychic problems. (Santegoeds, & Tekeer, 2006). Similarly, if I kept myself in patient shoes, I felt very bad about it, felt lack of confidence and worthlessness.
According to human dignity framework, (n.d.), dignity is a subjective concept, referring to an inner sense of self-worth. Second, dignity is influenced by a host of psychological, cultural, and social factors. Third, human dignity belongs to each individual; it is constructed by and dependent on relations of the individual with others. Fourth, there is a sense that human dignity is also a holistic concept; that it is always more than the sum of the rights that constitute it. In addition, the core of dignity consists of three basics: the essential worth of all human beings, to respect each other’s worth, and to protect and fulfill everyone’s worth. On the contrary, in my case, patient felt disrespect which affects worth of a patient. It influenced by social factors and has negative impact on health. Moreover, psychiatric patients are considered to be the vulnerable. It raises questions for those persons who are unable to communicate the incident of mistreatment either psychological or physical. So, this framework helps to analyze the experience related to human rights and to recognize its vulnerability. In same way, this framework can help in my case because my patient was unable to communicate her feelings to anyone rather thinking on it.
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In western countries, patient dignity has been well researched, but only one study has examined this topic in an Asian country that is Taiwan. Through American Nurses Association 2001, Canadian Nurses Association 2002, Australian Nursing and Midwifery Council 2003, London Nursing and Midwifery Council 2004 organizations, maintenance of patient dignity and respect for differences in personality, gender, race, age, culture, economic status and lifestyle has been promoted. Similarly, nurses in Taiwan are required to respect patient’s individuality dignity, religion, customs, values and cultural differences. Currently, clinical practice education in Taiwan does not indicate dignity in care (Lin, Tsai, & Chen, 2011).
For this, some fruitful interventions should be done in order to prevent the further violation of this basic principle and to promote mental health of psychiatric patient. During clinical, we have observed and identified the need of teaching on ethical principles, its importance and to discuss some alternative interventions through sharing practical examples. So, in our forthcoming clinical we will give teaching on these principles. The purpose of this teaching would be to provide awareness and to realize the importance of ethical principle while caring with psychiatric patient.
The psychiatric workforce needs collaboration between individual health care provider, organizations and government to promote the dignified care to great extent (Hung, 2008). According to Baillie, Gallagher and Wainwright (2008) proposed recommendation on three levels i.e.: micro, meso and macro level. Micro level includes individual responsibility and accountability in care. Being in a nursing profession it is our primary responsibility to give respect to our patient as we have taken oath and if we neglect this responsibility it means we are not sincere with ourselves and as well as with our profession. However, according to BBC News, “Nurses have a duty to treat patients with dignity at all times by giving respect.”(Carter, 2008). So, we as an individual must take some initiative on our part to prevent disrespect and work as a change agent for those patients who are facing disrespect. For that, individual nurses must develop their understanding of dignity in care through awareness sessions and role modeling. For this, in 2004, standards for better health established its core standard that staff must treat all patients with respect and dignity (Baillie, Gallagher and Wainwright, 2008). Moreover, individuals should be reflective and invite feedback from others regarding their performance. Furthermore, staff must integrate dignity framework to understand its significance and recognition of vulnerability. Also, individuals must report the cases in which principle violates. Meso level includes role of organization. Organization must provide environment, in which patients are valued and respected in care setting. Furthermore, “It has been shown that multiple organizational and social interventions have a positive effect to health care staffs work satisfaction, moral and well-being and further the quality of patient care.”(Gilbody, 2006, p.10). Moreover, organization must keep an eye over staff and avoid taking young staff in mental health setting because it requires patience. Also, those organizations which are already working to maintain respect and dignity of patients so, they must continue their work without neglecting. Institution must take serious action where principle violates. Macro level includes the role of government. Government must take serious steps in delivering dignified care and policies should be made to stop violation of this basic principle. Nurse and patient ratio must be appropriate so that it may not hinder in care. Also, in east, research has been done in Taiwan only. For this, further studies should be done in mental health settings to explore the differences in respect of patient.
In conclusion, treating each other with respect and dignity is everyone’s responsibility. Nobody should be forced to listen to bad language in front of others in any way. We must treat psychiatric patients as we would want to be treated ourselves if we were in a similar situation.
Hence, Government, NGO’s, civil society, must work together to face this challenge head on and to improve the quality of life by giving respect to psychiatric patients. “All human beings are born free and equal in dignity and rights” (The Universal Declaration of Human Rights).
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