18 subjects (14 nurses and 4 family caregivers) participated in the present study. The age ranges of the nurses and family caregivers were 28-54 and 22-41 years respectively. The demographic characteristics of the participants are presented in Table 1.
Data analysis yielded three main themes: creating a friendly atmosphere, showing respect, and providing comprehensive support. The themes and their categories are shown in Table 2.
Creating a friendly atmosphere
One of the most important findings of the study, referred to by all participants, was creating a friendly atmosphere. From the participants' perspective, providing high-quality care to patients while maintaining their dignity requires a cordial atmosphere between nurses, patients, and patients' families. By being kind to patients and giving their time to them, nurses can build emotional intimacy with patients and impart a sense of comfort, trust, and respect to them. From the participants' perspective, intimacy with patients is the key to sympathizing with them and allows patients to discuss their problems with their nurses. This theme is comprised of 3 categories: empathy, friendly relationship, and dedicating time to patients.
Empathy
From the viewpoint of the caregivers, empathy is of great importance in burns departments due to the special nature of burn injuries and the condition of the patients. Since burn patients' health and quality of life are usually very seriously affected by their injuries and they are hospitalized for longer periods, nurses have more time to be empathetic to the patients. This type of relationship helps nurses understand patients better and support them more effectively. Every burn patient needs physical and psychosocial care tailored to his/her specific needs. Regarding showing empathy for burn patients, one participant stated that:
"A burn patient needs a lot of empathy and emotional closeness; in fact, empathy is complementary to our treatment. No matter how good the care we provide is, it is not going to work without empathy…" (P1).
From the nurses' point of view, burn patients are less likely to complain of pain when they realize that nurses empathize with them and, thus, nurses can help patients more effectively.
"When I imagine myself in his [a burn patient's] position, it helps me a lot to understand his issues and concerns, and then I can help him more ..." (P6).
From the participants' point of view, good communication skills, including speaking clearly, using facial expressions, making eye contact, and listening attentively, play a major role in healing and reducing burn patients' suffering and increasing their satisfaction. Also, the participants believed that burn patients can express their concerns more freely when nurses establish an effective non-verbal communication with them.
"I hold my patients' hands, sit next to them, listen to and smile at them, all of which will raise their spirits and allow them to talk about their worries ..." (P8).
Friendly relationship
According to the interviews, burn patients need care which is combined with kindness and compassion. This kind of care makes the patients feel valued and believe that their dignity is being maintained.
"I start a friendly relationship with my patients and try to make them feel emotionally close to me. This makes them feel they are valued…" (P2).
The participants stated that, due to burn patients' prolonged length of stay, the patients feel more comfortable with the caregivers who call them by their first names, laugh with them, and treat them like a friend.
"I am very friendly to them and speak gently with them. I call them by their first names, and when we call them by their first names, they become happy and a friendly atmosphere is created" (P14).
Dedicating time to the patients
According to the interviews with the study participants, burn patients feel more intimate and talk more freely when caregivers spend time with the patients. This also motivates patients to cooperate in their treatment. On the other hand, nurses' failure to spend quality time with their patients creates feelings of worthlessness and indignity in the patients.
"Sometimes, I talk to my patients for a long time about their problems and my own experiences .... When the patients realize how much time I am spending with them, they feel valued…" (P10).
Showing respect
From the caregivers' viewpoint, the traumatic experience of having a burn, painful hospital treatments, body dysfunctions, and expressions of pity from others cause burn patients to feel that they are not treated with dignity. Nurses can preserve the dignity of burn patients during care by showing respect for their identity and autonomy and by involving the patients in their treatment plans. The theme of showing respect consists of the categories of respect for human equality, respect for autonomy, respect for beliefs and values, and avoidance of pity.
Respect for human equality
One of the major challenges of preserving the dignity of burn patients while providing care to them is cultural differences. The population of Iran is comprised of various racial and ethnic groups. The majority of the population is Fars, but caregivers are likely to meet burn patients from Baloch, Azeri, Turk, Kurd, Lur, or Arab minorities. The existence of varieties in patients' cultural, ethnic, and social backgrounds can affect the sense of value of the patients and their families.
The participants of the present study stated that all patients are equal. Accordingly, caregivers must preserve the dignity of all patients, regardless of their gender, religion, race, ethnicity, economic status, and social class. One of the nurses stated that:
"Most of the patients here are from the poor classes of the society, but we give them all the services they need, regardless of their ethnicity or social class …" (P9).
A family caregiver said:
"When a nurse provides care fairly to all patients, no matter what the cause of burn, be it self-immolation or an accident, this reflects the preservation of human dignity..." (P15).
Autonomy
The participants identified patients' participation in the decision-making and treatment process as an expression of respect for the patients' dignity.
"It is the worst kind of disrespect to give a burn patient no explanation. I involve my patients in their treatment plans, which makes them want to cooperate with me..." (P5).
The participants mentioned that, to preserve the dignity of burn patients, they provide them with information on the treatment processes and introduce them to similar patient cases which can help them make informed decisions.
"Some patients resist skin grafting; then I show them patients who have had skin grafting and introduce them to some of the patients who have been treated successfully. In fact, by giving them this information, I help the patients make better decisions about their treatment..." (P7).
Respect for beliefs and values
According to the participants, burn patients tend to become interested in mystical, spiritual, and religious practices. By providing prayer services, arranging meetings with a priest for them, and providing access to prayer books, caregivers can show respect for patients' dignity. One participant said:
Many patients here believe in praying. To respect the dignity of these patients, we've provided them with a bookshelf full of prayer books and this has really helped with their recovery ..." (P5).
Avoidance of pity
The caregivers in the present study mentioned that, though burn injuries can cause serious changes in burn patients' physical functions and appearances, the patients should be treated as ordinary people and the treatment team should avoid pitying behaviors. Showing undue pity for a burn patient is regarded as undermining the patient's dignity.
"Burns patients do not need to be pitied, and yet some nurses pity them. For instance, they say stuff like "Oh, poor thing!"... This can make the patient feel disrespected ..." (P5).
On the same note, the experiences of the family caregivers underscored the importance of avoiding pitying behaviors in the preservation of the patient's dignity.
"Burn victims are scared of being pitied by the people around them; this is disrespectful to these patients ..." (P16).
Comprehensive support
The findings of the study indicate that comprehensive support is an important contributory factor in maintaining the dignity of burn patients. Comprehensive support consists of the following categories: pain relief, emotional support, psychological support, and social support.
Pain relief
The majority of the interviewed nurses referred to pain as the most important physical cause of complaint amongst burn patients. The slightest movement and the implementation of various treatment procedures can increase patients' pain. The participants stated that, since burn patients may suffer from multiple injuries and functional disabilities, relieving the intensity of their pain using different methods and regular evaluations of the efficacy of the measures taken to manage their pain demonstrate respect for the dignity of the patients. According to a nurse:
"We have a lot of patients who have lost their organs or suffered spinal cord injuries due to electrocution, and most of them are constantly complaining of pain. Replacing a burn dressing is a really painful experience. We use partial anesthesia when we want to replace a patient's dressing. After the procedure, if the patient is still in pain, painkillers are administered. We may use non-pharmacological interventions, too ..." (P12).
Psychological support
From the perspective of the study participants, burn injuries not only affect the patients' bodies, but affect the psychological health of the patients and their families. Burn patients desperately need the support of the people around them: because the treatment procedures are relatively long, are implemented in stages, and can be very painful, the patients may suffer depression, isolation, anxiety, humiliation, and loss of dignity. One of the most important aspects of nursing burn patients is providing them with the emotional and psychological support required to preserve their dignity and facilitate their recovery.
"Once, 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 to change his mind .... After the patient saw her family members, she felt very valued and recovered quickly…" (P1).
Based on the experiences of the caregivers of burn patients, it is important to consider the origin of the patients' mental distress and make an effort to resolve it toward maintaining their dignity.
"We have patients here who are scared of death. Family visits can help them a lot to cope with this fear. For these patients, we assign a round-the-clock companion…" (P4).
Other measures which can help preserve the dignity of burn patients are: evaluating their mental and emotional well-being, providing them with counseling services, and ensuring collaboration between the members of the burn care team and the patients' families.
"Drug Addiction, family problems, and fear of alienation from the family and society are leading psychological problems in burn patients. We try to reduce the patients' psychological distress by raising their awareness, arranging counseling sessions for the patients and their families, removing the gaps between the patients and their family members, and facilitating cooperation between the treatment team and the patients' families ..." (P11).
Another nurse stated:
"After a patient is discharged, we introduce him or her to a counseling center where they and their families can receive counseling services ..." (P13).
Social support
According to the information gathered from the interviews, another major problem for burn patients is the social issues which they may encounter after the incident. Divorce, family disintegration, the society's negative attitude towards these patients, and the patient's consequent decision to quit school or work are among the social harms which undermine burn patients' dignity. According to the experiences of the caregivers, the distressful nature of burn injuries and the associated complications may damage the ego of the victims.
A participant stated:
"We've had many patients who resigned from their jobs because of the inappropriate behaviors of their co-workers ..." (P12).
From the viewpoint of the caregivers interviewed in the present study, the financial support provided by insurance companies, charity institutes, and social welfare organizations is quite limited and burn patients view their nurses and family caregivers as the main sources of support for them. Therefore, nurses and social workers seek to preserve the patients' social dignity by helping them learn job skills and find jobs and by referring them to charity centers to help them pay their treatment costs.
"We had a patient here whose spouse separated from her because of her facial burn marks and then she had no source of income and came to us. Here, the personnel try and help out these people any way they can: we introduce them to charities, find them jobs, buy their medication for them ...." (P10).