This study recruited a total of 18 subjects (14 nurses and 4 family caregivers). The age range of the nurses and family caregivers was 28-54 and 22-41 years respectively. The demographic characteristics of the participants are presented in Table 1.
Data analysis identified three main themes, and constituted of the following categories: the creation of an intimate atmosphere, respect, and comprehensive support. Themes and categories are shown in table 2.
Creation of an intimate atmosphere
One of the most considerable findings of this study, expressed by all participants, was the creation of an intimate atmosphere. From the participants' point of view, providing unique care while maintaining dignity requires creating a cordial atmosphere between the nurse, patient, and his or her family. The nurse provides care involving an emotional closeness through a friendly nurse-patient relationship, as well as dedicating time to the patient which makes the patients feel comfortable and confident with the care along with a sense of respect. From the perspective of the participants, intimacy is a key element of empathy perception to allows the patients to discuss their problems with the nurse. This theme is comprised of categories, empathy, friendly relationship, and dedicating time to the patient.
Empathy
From the viewpoint of caregivers, empathy in burn wards, due to the focus of this specialism and the condition of the patients admitted there, is of great importance. This is because burns patients are affected by multiple health-threatening factors, their health and quality of life are adversely affected and they are hospitalized for a long period. Nurses are therefore more likely to be empathetic to the patients. This type of communication helps nurses understand the patient and make a supportive communication with the patient, as each burns patient needs physical and psychosocial care tailored to their specific symptoms and needs. One participant acknowledged empathy as follow:
A burn patient needs a lot of empathy and emotion, in fact empathy is a complementary treatment. No matter how good the care is provided, it is not useful and effective without empathy… (P1)
From the nurses' point of view, burn patients is less likely to complain of pain when they feel the empathetic expression of the nurse, and in such a scenario, the nurse can effectively help out the patient.
When I put myself in patients' position (burn patient), it helps me a lot to understand their issues and concerns, and subsequently be able to help them more ... (P6)
From the participants' point of view, employing communication skills, such as facial expressions, eye contact, and listening play a major role in healing and reducing patients' suffering and improving patient satisfaction. From the participants' point of view, the expression of emotions and concerns in burn patients can be obtained through appropriate nonverbal communication.
I hold my patient's hand, sit next to him or her, listen to and smile at him or her, which will raise the patient's spirit and allow to talk about his or her worries ... (P8)
Friendly communication
According to the interviews, burn patients need a type of care that is provided with kindness and compassion. In such circumstances, the patient feels valued and believes that his or her dignity is maintained.
I make a friendly connection with my patient to make him or her mentally and emotionally close to me so that the patient feels more valued… (P2)
Participants stated that due to the significant length of stay for a burn patient, patients felt comfortable and ease with caregivers calling, laughing, and being kind to them as their friends.
I am very friendly with them and speak gently. I call them by their first name, and when we call them by their first name, they become happy in a compassionate atmosphere (P14)
Dedicating time to the patient
According to the interviews with the study participants, patients felt intimate and talked freely while caregivers were spending their time with the patient. Also, spending specific time with the patient elevated the patient's cooperation for treatment, whereas ignoring the time allocated to the patient led to feelings of worthlessness and lack of dignity in the patient.
Sometimes I talked to my patient for a long time about their problems and my own experiences ... When the patient realized how much time I was spending with them, they felt valued…(P10)
Respect
From the viewpoint of caregivers, traumatic suffering, experiences of painful hospital treatments, body dysfunction, compassionless communication and pitifulness shown by others lead to loss of dignity among burns patients. Therefore, the nurse may respect the dignity of the burn patients during care by preserving one's identity, maintaining autonomy, and fully involving patients in the treatment procedure. The theme, dignity consists of categories of Respect for human equality, autonomy, respect for human beliefs and values, and avoidance of pity.
Respect for human equality
The participants in this study stated that the worth of all patients is equal. Accordingly, caregivers described burn patient dignity as an equal necessity for all patients regardless of gender, religion, race, economic status and social class. One of the study nurses stated as follows:
Most of the patients here are from the poor areas of the society, but we provide them with complete care in all areas, regardless of their ethnicity and social status… (P9)
A family caregiver pronounced:
When a nurse provides fair care for all patients, no matter what caused the burn injury, motivation for a burn injury, whether self-immolation or an accident, it reflects the preservation of human dignity... (P15)
Autonomy
Participants identified the involvement of the patients in healthcare decision-making and the participation of the patients in the care and treatment process as an expression of respect for the patients' dignity.
It is the worst disrespect to give the burns patient no explanation. I involved my patient in the treatment procedure, which helps the patient to cooperate with me... (P5)
Participants seek to improve the dignity of burn patients by providing information on the treatment process and by introducing similarly treated patients to facilitate effective and fully informed decision making.
Some patients resist skin grafting, then I talk to them about patients who have had skin grafting and introduce them to some of the successfully treated patients. In fact, by giving such information, I help the patient to decide to continue the treatment ... (P7)
Respect for beliefs and values
According to the participants' viewpoints, burns patients tend to follow mystical, spiritual, and religious practice frameworks, thus providing prayer services, recruiting a spiritual counselor in the ward, and providing spiritual material packs was shown to considerably improve religious practices, and paying attention to these issues reflected the respect for patient's dignity. As such, a participant said:
Many patients believe in prayer and say prayers. To maintain the dignity of these patients, we provided them with spiritual material packs, incorporating requirements for religious worship, such as holy prayer books, that effectively improved their health status... (P5)
Avoid pity
The caregivers in the present study revealed that burns injuries may cause serious damage to one's appearance and performance, leading to unusual changes in presentation. Therefore, they should be treated in a normal and rational way, and the treatment team and those surrounding them should avoid displaying any pitiful behaviors. The expression of pity for a burn patient is regarded as disrespectful for the patient's dignity.
Burns patients do not need pity, and some nurses pity them. For instance, they say "oh how miserable"... In this case, the patient feels disrespected ...(P5)
The experience of family caregivers significantly underscored the important role of avoiding a pitiful behavior on the preservation of the patient's dignity.
The burns victims are scared of being pitied by the people around them, which is considered as disrespectful for these patients ... (P16)
Comprehensive support
The findings of this study indicate that, comprehensive support is one of the important factors to create and enhance the dignity of burn patients. Comprehensive support is constituted of pain relief, emotional support, psychological support, and social support.
Pain relief
The majority of nurses reported pain as the most important physical complaint amongst burn patients. Pain intensity is increased by the slightest movements and by various treatment procedures. Participants stated that burns patients suffer from multiple injuries, and functional disabilities, thus relieving pain intensity using different methods and evaluation of the efficacy of multiple pain-reduction therapies demonstrates preservation of dignity in patients with burn injuries. Accordingly, a nurse stated:
We have a lot of patients who have lost their organs or have spinal cord injury due to electrocution, and most of them complain of pain. Wound dressing is a really painful experience for burn patients. Therefore, sedation techniques are used during the wound dressing removal. After this procedure, if dressing removal is painful, painkillers are administered. Non-pharmacological treatments can be also used instead of chemical medications ... (P12)
Psychological support
From the perspective of the study participants, burn injuries not only affect the patient's body, but it also affects the mental health of the patient and his or her family. The patient who has suffered a burn injury desperately needs the support of the individuals surrounding them, because the treatment process is relatively long, sequential and painful, leading to depression, isolation, anxiety, humiliation and loss of dignity. One of the most important aspects of nursing burns patients is the emotional and psychological support required to preserve burn patients' dignity and improve their recovery.
We had a patient who was seriously ill and her husband would not allow her family to visit her. I did my best to convince her husband ... after the patient saw her family members, she felt very valued and recovered quickly… (P1)
Based on the experiences of burns caregivers, it is important to pay attention to the origin of the mental distress, and make an effort to resolve them in a way that their dignity is maintained.
We have patients who are scared of death. Visiting by family during hospital stay helps them alleviate this fear. For these patients, we provide 24-hour dedicated attendant…(P4)
Other major measures to improve the patients' dignity include: evaluate and control their psychological status, provide psychological counseling services, and collaborate between members of the burns team and the patient's family.
Drug Addiction, family problems, anxiety about being rejected by the family and society are among the leading psychological problems in burned patients. We attempt to reduce the patient's psychological distress through providing the patient with healthcare guidance, conducting multiple psychotherapy sessions for the patient and his or her family, facilitating collaboration between patients and their family members, and enhancing their cooperation with members of the burns team ... (P11)
Another nurse pronounced:
After the patient was discharged, we introduced him to a counseling center where he and his family could receive counseling services ... (P13)
Social support
According to the interviews, post-accident social issues is another major problem for burn patients. Divorce, family disintegration, people's negative thoughts towards these patients, and consequently the patient's decision to leave school or quit work, were social harms that adversely affected the burns patients' dignity. According to the experiences of the caregivers, the devastating nature of burning and associated complications may cause existential issues among burn victims.
A participant stated:
We had many patients who resigned from their job because of inappropriate behavior ... (P12)
From the viewpoint of caregivers in this study, the financial support provided by insurance, charity, and social welfare organizations is limited, and nurses and family caregivers were known as the main source of support for burns patients. Therefore, nurses and social workers seek to preserve the patient's social dignity by helping them acquire skills and find jobs, paying treatment costs, and referring them to charity centers.
We had a case whose spouse had separated from her due to facial burn wounds, and now she has no source of income. Here the personnel can help out these types of patients in many different ways, including referring them to charities, finding them a job, accessing medications etc. ... (P10)