Exploring children’s dignity: A qualitative approach

Background and Objective: Children’s rights to good health care are enshrined in various publications and policy documents. The maintenance of human dignity is recognized as a core value in foundational to human rights. Although it has been studied extensively from adult patients perspective, there are few studies of dignity in relation to school age children, generally or in relation to health care. This paper explores school age childeren,s and parents perceptions of children’s, dignity. Materials and Methods: A conventional qualitative content analysis method was used to explore the meaning of hospitalized childrens’ dignity. Hospitalized children and parents in general medical and surgical pediatric units were eligible to participate. Data were obtained through unstructured interviews. Purposive sampling was used and school age children and parent were recruited until data saturation was reached (n =20, 12 children and 8 parent). Results: Hospitalized children and parents in general medical and surgical pediatric units were eligible to participate. Data were obtained through unstructured interviews. Purposive sampling was used and school age children and parent were recruited until data saturation was reached (n =20, 12 children and 8 parent). Ethical approval for the study was granted by the Ethics Committee of Shiraz University of Medical Sciences. Participants were provided with information about the purpose, reasons for recording interviews, voluntary participation, and confidentiality of data and interviewees. Dignity was reflected in three themes (1) Respect for the child (2) protection of personal privacy (3) family center communication. Conclusion: Hospitalized childrens and parents stated that healthcare services should Respect for the child and protect their personal privacy. Also, they should communicating with the child and their parents to provide dignity. School age is a discrete developmental stage, with specific healthcare needs which must be addressed effectively by healthcare providers.


INTRODUCTION
Maintaining human dignity is detected as a central worth in human interactions (1) and the base of human rights (2,3) .Dignity is important in health care, and nurses should try to promotion and preservat,ion it, considering contextual differences (4).Treating Persons with dignity means treating them as being of worth, in a way that they are respected as valuable people (5).Dignity is rooted in emotions, behavior, and privacy (6) and originates from two Latin words "dignitus" means merit and "dignus" meaning worth (7).In nursing, dignity means to respect for the inherent worth and protecting the patient's privacy and confidentiality of patients (8).Erickson believes in during childhood, between the ages of five and twelve., the child's confidence is formed and It is at this stage that the child's peer group will become a major source of the child's self-esteem.This years are a time of important developmental advances that establish children's sense of identity.Development during this period is driven by basic psychological needs to achieve competence, autonomy, and relatedness.They seek opportunities to make independent decisions and control their own behavior, and to form good social relationships with peers and adults outside the family (9).Hospitalization is a stressful experience for children and their parents and can greatly influence their self-esteem (10).Hospitalization to this age may cause negative changes and endanger the health of children and increase the need for security (11).Several studies have shown that, despite the age and increased mastry, school age children fear and worry about illness, hospitalization and loss of control and self-determination (12).Currently the importance of satisfying children's psychological needs including self-esteem and self-control as well as their physical needs has been emphasized (13).Children's rights to good health care have been documented in various publications and documents (14,15) also the Convention on the Rights of the Child (1989) emphasises the inherent dignity of children (16).The National Service Framework (NSF) for Children, Young People and Maternity Services (DH 2004) recommends respectful approaches and offers options that all coordinate with the promotion of dignity (17).Although Researchers have confirmed Erikson's notion that feelings of competence and personal esteem are very importance for a child's well-being (18,19) but studies have shown that children are not treated with respect, courtesy and sensitivity (20).Reed et al. (2003) studied dignity of children and points out that they are often less valuable than adults.Lack of privacy in hospital, the loss of control of body functions and the risk of exposure in front of others, all of them were identified as threatening children's dignity (21).Several researchers have identified factors such as staying in a single room, give the necessary explanations to the child and give them the opportunity to express their feelings what are most important to them as factors promoting dignity of hospitalized children (22,23).On the other hand, in study of Lerwick (2013), children considered loss of privacy as one of the worst experiences in the hospital (24).Without clarifying the concept of dignity and condition of what is involved and its related factors, respect for dignity is useless (25).Although dignity has been studied extensively from adult patients' perspective (26) there are few studies of dignity in relation to school age children and their parents, generally or in relation to health care (27).
Objective: This study was conducted to investigate dignity in hospitalized school age children.Research design: A conventional qualitative content analysis method was used to explore the hospitalized school age children's and parent , view of dignity.This method was chosen to collect rich and novel data (28).

MATERIALS AND METHODS
The study sample consisted of 12 children aged between 6 years and 12 years, who were hospitalized due to different diagnoses and eight parents whose children were admitted to the hospital in a university hospital in Shiraz (southwest of Iran) that has four general medical wards and two general surgical wards for children.Purposeful maximum variation sampling was used.This strategy aims at capturing and describing the central themes across a broad range of varied cases (29).Purposive sampling is suitable for qualitative studies where the researcher is interested in informants who have the best knowledge or experience topic or phenomenon of interest (30).Persian-speaking children and parents who consented to participation, who had been followed up in the hospital for at least three days, and who had no communication problems were included in the study.Children who were unconscious, had communication problems, did not have families with them, had pain, and were staying at hospital less than three days were excluded in the study.Also, parents whose children were staying at hospital less than three days and were not willing to participate in the study were excluded in the study.Also, the children and parents would be excluded from the study, if they didn't want to continue interview.Data collection: After obtaining the participants' written consent (in the case of interviews with children, parents granted their consent) data, were collected from children and parents through in-depth and unstructured interviews conducted in a quiet room in the hospital.Interview method selected for data collection because it was anticipated that parent and school age children would have the cognitive and verbal capacity to participate in the research process (31).Purposive sampling continued until data saturation was achieved.Interview with parent lasted 45-60 min and with children 15-30 min.All the interviews were audiotaped, transcribed verbatim and analysed concurrently.
Data analysis: The conventional content analysis, Graneheim and Lundman's method, was done.Because there is little information about dignity in hospitalized children so content analysis that is a systematic method of generating new knowledge about perceptions and feelings was the best method (32).The analysis was performed separately for children and parents.The analysis began with coding the data; the codes were compared and then contrasted to form categories that were based on the childrens' and parents' expressions and the qualitative content of their meaning.Finally, 8 sub-categories and 3 main themes expressing dignity were identified.
Ethical issues: Permission to conduct the research was obtained from the Ethics Committee of Shiraz University of Medical Sciences.verbal and written consent was obtained from children ,their family and parents .The purpose and nature of the research, the time commitment, confidentiality, and the children's and parents' right not to take part were explained verbally and reinforced by a letter to potential participants.The children and parents were interviewed in the quiet room within the hospitals to ensure confidentiality.Care was taken to ensure that the interview process would not weary the children; therefore the interviews lasted between 15 and 30 minutes.http://www.ejgm.co.uk 3 / 9 Rigor: Rigour (reliability of this study) was based on trustworthiness of data, as proposed by Lincoln and Guba (33).Different credibility methods such as maximum variation, prolonged engagement (18 months) and member checking were used.Audit trail and triangulation of time (different shifts), place (different wards), and person (children with different age and sex, parents) were done to achieve the conformability and dependability.For transferability, the written examples of participants' statements and their characteristics were accurately presented.

RESULTS
Eight parent (5 mother and 3 father) who were 32-47 years and twelve children (7 girls and 5 boy) who were 6-12 years in pediatric medical and surgical wards participated in this study.In this study, three main themes and 8 subthemes were emerged.The main themes included "Respect for the child", protection of personal privacy", and "family center communication"."Respect for the child" included three subthemes; i.e., "Respect for the child's autonomy and self-determination", "Respect for the child's personality", and "Respect for religious and cultural beliefs".In addition "protection of personal privacy" also included the following subthemes: "privacy of the body",: "privacy of space" and : "privacy of information".Finally "family center communication" included "Nursing support of the parents" and "Participate Parents in child care" (Table 1).
Respect for the child: All participants indicated the importance of respecting childrenss.Related themes included: Respect for the child's autonomy and self-determination, Respect for the child's personality and Respect for the child's religious and cultural beliefs a) Respect for the child's autonomy and self-determination: For school age children, Maintaining autonomy and selfdetermination are very important.They tend to be self-controlled and preserved their independence.
Autonomy means paying attention to the child's priorities and perspectives regarding care and treatment.Also Parents believed that nurses should pay attention to the child's priorities and perspectives.
Father: Nurses can listen to the child's request and apply their opinions to the point where they are not at risk.Mother: Sometimes my priorities are different with my child.For example, in the afternoon, my son, I had to go to the game room while I preferred to rest in the bed.Eventually the nurse agreed with my child (Boy 9 years): I'm afraid of injections and don't like it.I told the nurse to give me oral medication, but they dont listen.
(Girl 8 years): I asked the nurse to inject a drug in my left hand so I could paint with my right hand.She accepted, and I was pleased that he was paying attention to my request.
(Girl 7 years): during changing the dressing, the nurse wants me to remove the adhesive.She says, needs my help.Mother: My son looked at me gladly after helping the nurse.He had a very good feeling.The children experienced lack control over matters such as waking time, sleeping time and time of eating food.The children reported having to go to sleep at a certain time and being woken at a certain time.
(Girl 9 years): I have to eat my dinner every hour they want, although I'm not hungry at that time.I wish the nurses were listening to me.
(Boy 10 years): I wake up many times.I can not sleep right here.Nurses should do what they can when we wake up.b) Respect for the child's personality: Parents said that respect for the child's personality leads to a rise in self-esteem and the maintenance of his or her dignity.Children and parents believed that when nurses greet the child and take their words and emotions seriously and give them time, that is, they respect the child's personality as a human being.c) greeting: Greeting with children and introducing yourself to them means that they are respected.Mother: At the start of the shift, the nurse should introduce her to the child and greet with her.This is how the child feels to respect her.
School-age children evolve cognitively and they want to be treated with respect.(Boy 12 years): "The nurse should not talk with us childishly.We grew up."d) Take children seriously: children dignity is preserve by taking their expressions, emotions and concerns seriously and not rejecting them as delusions or as Childish imaginations.
In these situations, childrens were not being met as credible people having the ability to describe their own experiences.
(Boy7 years): I saw a bad dream last night, it was very scary.Oh, I was scared.The nurse said me, "What are you afraid of?"Someone came from space to take me with himself.The nurse laughed me and said, "Why did not he do that?"You are here now.He mocked me Mother: My son was very painful two days after the operation.I told the nurse.But the said that now there should not be severe pain.He probably exaggerats.I was very upset.It's kind of Disrespect to myself and to my child.e) Nurses dedicate personal time to children: When nurses see that children are sad, they give them personal time by sitting down with them and finding out what is wrong.Hospitalized childrens' dignity is preserve when nurses perceive their situation and emotions and try to ansower their questions.
(girl 10 years): I was very sad and afraid.I did not know what I was going to do.The nurse sat next to me and explained what was going to happen and answered my questions.
f) Respect for religious and cultural beliefs: The Respect for religious and cultural beliefs subtheme refers to nurses' respect for childrens' beliefs and culture in their nursing care.
Attention to the religious and cultural beliefs of the hospitalized child increases the child's human dignity.Father: children have different religious and cultural beliefs.These differences should not discriminate in care.The nurse must adhere to justice (girl 12 years): My nurse is very respectful to me.He speaks with my accent.
Mother: It was a cloth of shrine of the king that close to my son's hand because to be treated earlier.When I told the nurse she accepted and let me it close to my child's wrist g) protection of personal privacy: Privacy is the dominant component of dignity for childrens Which includes 'privacy of the body', 'private space' and 'privacy of the information.
Boys emphasized the privacy of information, while girls point to private space h) privacy of the body: Children feel that their privacy is compromised if a nurse touches them without permission.
(girl 12 years): My nurse is very good.He allowed and then examined my stomach.
(girl 11 years): The nurse wanted to change my clothes.I was very worried that I was embarrassed by another child in the room, but the nurse took the curtain around the bed and I was very happy.
i) private space: childrens believed that nurses should get permission before entering the child's room (girl 11 years): The nurse wanted to change my clothes.I was very worried that I was embarrassed by another child in the room, but the nurse took the curtain around the bed and I was very happy.j) 3 privacy of the information: Privacy also involved being able to speak to the nurse and doctor alone on issues she or he did not 'feel comfortable saying in front of other children.
(boy 10 years): The nurse asked me to talk about what worried me, but i did not want to talk in front of other.Mother: I do not want information about my child's illness to be shared with other parents.m) Family -center communication: The children trust the nurses when they respects the parents and communicate with them.
According to childrens communication particularly valued the trustworthy and respectful that was extended to their parents.
n) Nursing support of the parents: informational support mother: I need the nurses to give me some information such as the child's illness, treatment, and care; and about parental rights and responsibilities during the my child's hospitalization.
father: I wish nurses give us information about the child's behavioral and emotional responses and needs.This will increase our confidence.o) Emotional support (girl 10 years): Ms. ....is a good nurse.She respects me and my parents.My mother was very upset.She was worried about my illness and cried.The nurse listened to my mother and talked to her. http://www.ejgm.co.uk 5 / 9 Mother: I'd expect some respect for the parents.We don't really have to be here.We're here because we love our children and worry about them mother: Nurses can help parents cope with the child's illness and the other aspects of their lives that are impacted by the illness.p) Participate Parents in child care: Child: The nurse wanted to change my dress.She asked my mom to help her, so I was less afraid.Mother: If I do nothing for my child, I feel incapacitated.Instead, when I help the nurse for care of my child, my confidence increases and I feel so good.

DISCUSSION
Parents who have their children admitted to the hospital expect their children to be able to put into the hands of nurses who will care for them in a dignified way.
The findings of our study showed that nurses can preserve hospitalized school-age children's dignity by Respect for the child, protection of personal privacy and family center communication.Most children and parents who participated in the study mentioned to respect and privacy.They indicated respect for the child in pediatric ward includes Respect for the child's autonomy and self-determination, Respect for the child's personality and Respect for the child's religious and cultural beliefs.Autonomy depends on patient's ability to make independent choices, on his or her adequate knowledge, and on correct information received (34).Children participate in decision-making can be seen as one step in a child's development (35).In this study, children and parents believe that involvement of them in the care and treatment can improve their autonomy.although in other studies as our study the children expressed the need to be involved in their care, so they can prepare themselves for procedures and they should be encouraged to be active partners in decisions about their health and care (36) However, in most cases at school age, parents are final decision-makers (37,38).
Even though young children are not capable of making most medical decisions, they can participate in these decisions and, if given the opportunity, can voice their concerns, their opinions and their preferences.In a separate publication, the same authors (39).In addition, the children participating in the study also referred to autonomy as self-control.Children said that they felt that they didn't have control on their body, daily activities like sleep and feeding time and it violated their autonomy.They believe that the hospital rules in relation to these activities restrict them.One study mentioned that hospitalized adolescents feel that they can't have control over many issues and most don't agree with some hospital rules (40).With regard to respect for the child personality, parent said that when nurses greet with their babies and taking their emotions and concerns seriously and give them personal time, they respect the child personality .These results are consistent with those of other studies indicating that Considering patients as a human, Let them talk, engage them in their care, Spending time for patients and paying attention to them leads to maintaining and improving the status of patients (41)(42)(43)(44).Respect for religious and cultural beliefs was another subtheme of the present study.Parents who participated in our study believed that Nurses should respect the cultural and religious beliefs of child and family and with this action increases the child's human dignity.
Dignity is a cultural concept.Defining and preserving it based on the culture of individuals.People's expectations of maintaining dignity are based on the values and faculties of different people.Care based on culture is a care that takes into account the values and beliefs of the patient and creates a feeling of comfort, respect and trust (45).
In some cultures, children are expected to speak only when adults address them.Therefore, during child care, attention should be paid to their cultural context.Even Non-verbal aspects of communication may be affected.For example, children from Latin America and Asia may avoid eye contact with adults in authority as a sign of respect (46).Health care providers with considering these cultural areas can take care of the child with respect.One of the themes emerged in this study was protection of personal privacy.This point has been raised in several studies.In study of Wechter, children stated the lack of privacy in the hospital environment as one of the worst experiences they had in the hospital (47).Although significant developmental characteristic of school-age children is the increase in the importance of the concept of privacy but it can be ignored in hospitalized children due to the factors such as inappropriate physical conditions, high number of patients, and false attitudes of healthcare personnel (24).In this study, we explored privacy of the body', 'private space' and 'privacy of the information that are essential for children's dignity.A similar study also reported that these are among the important aspects of privacy (48).Privacy of the body in this research referred to protecting children's' privacy by getting Permit before touching child's body during Procedures and by drawing curtains to prevent exposure.Indeed, privacy means limited accessibility of others to your body, thoughts, and feelings, and it often has to do with the confidentiality of patient information (49).The participants of the study, especially parents, emphasized that they want information about their child's illness is kept confidential and in this regard children said did not want to talk about their feels in front of other.Study of Jamali and et al. in line with our study emphasizes the patient's physical and informational privacy (50).Family center communication is another aspect of dignity in our study.Different communication styles between nurses and patients can improve dignity of the patients (42,51).
According to children's ideas dignity is diminished when healthcare providers care them without paying attention to their parents.The study of Smith et al. confirms our study findings: A fundamental need for hospitalized children is that their family is included in their care provision (52).Parent in our study had expressed that they need to be supported by nurses in terms of information and emotions and taken into account in child care.Denney also believes Nurses are in a significant position to support parents as they provide care to their sick child, as they are in regular contact with parents during the child's hospitalization (53).Despite the fact that school-age children are cognitively at a stage that can well communicate with adults, they are still heavily dependent on parents (9).Regardless of whether parents are physically present, their influence is pervasive.Parents are therefore central in pediatric care.The health and well-being of children are inextricably linked to their parents' physical, emotional and social health, social circumstances and child-rearing practices (54).In the present study both children and parents noted that caregivers, in addition to having a relationship with the child, should also have a good relationship with their parents.In this case, it can be said that caring for the child is a dignified care.These results were consistent with finding of other study which states children particularly valued the friendship and courtesy that was extended to their parents they referred that communication is an important component of family-center care that facilitated treatment with dignity and respect (55).Sensitive communication with children and their families was considered essential to promote dignity.If the parents are ignored and not support, they lose their self-esteem and self-respect, allowing their children to be exposed to disrespectful treatment (56).
However, are parents participating in decisions concerning their child's care?Some studies show that nurses believe they involve parents in care (57), and some suggest that parents are only partly involved in decisions concerning their child's care (58).

CONCLUSION
Overall, hospitalized children and parent mentioned that children could feel dignity if healthcare providers respect for them while protecting their personal privacy and communicate with their parents.Children can be vulnerable to diminished dignity in health care and so caregivers must actively promote dignity in this environment.Caregivers can do much to promote dignity through their own behaviour with children.In pediatric wards, healthcare providers should be aware about the children's views of dignity and must be sensitive to this important issue.Also, more qualitative research in other places and cultures and in relation to other ages children is needed to explore.

Table 1 :
Themes and sub-themes of children dignity Participate Parents in child care http://www.ejgm.co.uk