Original Manuscript
Exploring nurses’ personal dignity, global self-esteem and work satisfaction
Nursing Ethics 1–17 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014567024 nej.sagepub.com
Bonnie A Sturm and Jane C Dellert Seton Hall University, USA
Abstract Background: This study examines nurses’ perceptions of dignity in themselves and their work. Nurses commonly assert concern for human dignity as a component of the patients’ experience rather than as necessary in the nurses’ own lives or in the lives of others in the workplace. This study is exploratory and generates potential relationships for further study and theory generation in nursing. Research questions: What is the relationship between the construct nurses’ sense of dignity and global self-esteem, work satisfaction, and identified personal traits? Participants and research context: This cross-sectional correlation study used a stratified random sample of nurses which was obtained from a US University alumni list from 1965 to 2009 (N ¼ 133). Ethical considerations: University Institutional Review Board approval was achieved prior to mailing research questionnaire packets to participants. Participation was optional and numerical codes preserved confidentiality. Findings: Statistical results indicated a moderately strong association between the nurse’s sense of personal dignity and self-esteem (rx ¼ .62, p ¼ .000) with areas of difference clarified and discussed. A positive but moderate association between nurses’ personal dignity and nurses’ work satisfaction (rx ¼ .37, p ¼ .000) and a similar association between self-esteem and nurses’ work satisfaction (rs ¼ .29, p ¼ .001) were found. A statistically significant difference was found (F ¼ 3.49 (df ¼ 4), p ¼ .01) for dignity and categories of spiritual commitment and for nurses’ personal dignity when ratings of health status were compared (F ¼ 21.24 (df ¼ 4), p ¼ .000). Discussion: Personal sense of dignity is discussed in relation to conceptual understandings of dignity (such as professional dignity) and suggests continued research in multiple cultural contexts. Conclusion: The relationships measured show that nurses’ sense of dignity has commonalities with selfesteem, workplace satisfaction, spiritual commitment, and health status; the meaning of the findings has ramifications for the welfare of nurses internationally. Keywords Nurses’ dignity, professional dignity, self-esteem, spirituality, work satisfaction
Corresponding author: Bonnie A Sturm, College of Nursing, Seton Hall University, 400 South Orange Ave, South Orange, NJ 07079, USA. Email: [email protected]
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Introduction Dignity is a concept that is relevant to nursing practice and research and is most often considered in light of preserving the patient’s dignity in practice situations. While there is a growing body of research that examines influences upon patient dignity,1–3 and recent publications examining the concept of professional dignity,4,5 an understanding of the nurse’s own sense of dignity and the potential meaning of this influence is largely unexplored. This implies that there are nurse actions or ways of being/interacting within the interpersonal nurse–patient relationship as well as other workplace relationships, which have the potential to diminish or to preserve the other’s dignity. The dynamic interrelatedness of relationship between the nurse and others is a process with transformative and influential potential. This is consistent with the work of several nurse theorists: Newman’s6 theory of nursing as expanding consciousness, Watson’s7 theory of care, and Eriksson’s8 theory of caring science, which provide a theoretical premise for this exploratory research. This study focuses on the nurse’s sense of personal dignity and supposes that how a nurse views dignity in self will be associated with other attributes of self.
Dignity and nurse perceptions of self It is theoretically posed that nursing behaviors, such as actions supporting or diminishing dignity, are a part of a reciprocal relationship with patients or with colleagues and are moderated by the nurse’s sense of self. From a psychological perspective, Peplau,9 noted seminal psychiatric nurse theorist, consistently emphasized the necessity that the nurse become increasingly aware of the influence of personal motivations and values as these influence the quality and equanimity of the nurse–patient relationship. It is important to examine the nurse’s personal sense of dignity because the nurse’s work with patients, colleagues and the community can be influenced by this perception.10,11 Additionally, the nurse’s attitude and degree of self-awareness has the potential to influence whether the nursing care provided will support patient dignity.12
Dignity in the workplace Professional Nursing Organization codes emphasize the necessity that nurses advocate for and deliver patient care that protects the dignity of patients and also recognize the need for respectful collaborative relationships among colleagues.13,14 The American Nurses Association (ANA) Code of Ethics places respect for human dignity as the first item in the first provision, and while it is common for nurses to assert concern for human dignity, it is generally viewed as a component of the patients’ experience rather than as something necessary in the nurses’ own lives or in the lives of others in the workplace. In recent years, the construct professional dignity has specifically been examined in nursing,5,15,16 uncovering new conceptual understandings of this similar, but not identical, construct; however, this has brought new and important attention to how the dignity of the nurse may be challenged in workplace environments. This is particularly important from a global perspective of dignity in the work-life of nurses, which is heavily influenced by cultural norms, the rights of women, class and segregation, economic power, and poverty. Considering this, however, it is interesting that the dignity of nurses is and remains of current concern in more affluent countries such as the United Kingdom or the United States, as evidenced by ongoing research efforts.
Relevance to nursing ethics Studying the nurse’s sense of dignity has relevance to the study of nursing ethics because the doing of ethical nursing requires the development of self-awareness, a growth in human understanding, and the feeling for an 2
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ethic of care. Gallagher17 reminds us that ‘‘Doing respect in everyday practice is not, however, always a straightforward matter’’ (p. 366). How will a nurse find an effective way to advocate for improved collegial relations or to constructively address a demeaning comment made in the workplace, without observing and respecting personal interior experiences and reactions? How can a nurse uphold the patient’s autonomy or provide acceptance of a family’s choice to allow death, in a way that also provides a loving presence, if unaware of interior values and the unconscious coloring caused by personal motivations and past experiences? In viewing nursing as a caring science and a relational practice,18 and perhaps in its finest moments a sacred practice, a greater understanding of the nurse’s self-perceptions is relevant. This study is a preliminary step which should encourage continued research, which could focus upon understanding ways to develop ethical competencies in nurses, including moral agency and the nurse’s ability to interact in ethical and effective ways within practice environments that may include patients, colleagues, and others involved in healthcare systems.
Study purpose and plan This study was designed to explore the relationship between the construct nurse’s sense of dignity with the key variables of self-esteem and work satisfaction, as well as with the following personal traits: nurse’s age, years in nursing practice, years in current work setting, level of education, sense of spiritual commitment, perceived ability to advocate, and health status. For purposes of this study, dignity was defined as ‘‘A dynamic, subjective, human sensation in which autonomy, respect, and worthiness occur together and are felt internally as a component of self-esteem’’ (p. 52).19 The purpose of this descriptive study was an attempt to learn more about how nurses perceive dignity in themselves and what factors might be associated with their perceptions. Additional theoretical underpinnings are described in relation to each variable. At the time of this study, no other studies were found to demonstrate any specific statistical associations between the identified variables, although the academic and clinical experiences of the researchers, as well as the publication of some related theoretical literature, did support a reasonable potential for several of the proposed associations. Whether a nurse’s sense of personal dignity is related to self-esteem, work satisfaction, or other personal traits of the nurse is largely unknown. Since ‘‘dignity is also understood as the outcome of relationships of care and a concern for the wholeness and integrity of the person or personhood’’ (p. 138),20 it follows logically that there is merit in exploring the nurse’s personal perceptions of dignity. This first study is exploratory and multiple regressions were not planned for initial data analysis. This article provides a report of the planned bivariate correlations and includes a discussion of these findings in relation to the concept of dignity in nurses.
Background At the time of this study, a preliminary search of the literature published in English utilizing several databases, including CINAHL with Full Text, Academic Search Premier, ERIC, PsycARTICLES, PsycINFO, Health Source: Nursing/Academic Edition, CINAHL, and ScienceDirect from the years 1997 to 2009, produced a variety of studies that focused on the threatened dignity of patients in hospital and nursing home settings and several that suggested nurses could make improved efforts to provide care that preserved patient dignity. When this study was designed, no research studies were found that specifically examined the nurse’s sense of personal dignity. The subject terms (STs) dignity and self-esteem and nursing yielded 6 publications, but none focusing on the nurse. Using the STs nursing and job and/or work satisfaction, and dignity when entered together, rendered 12 scholarly publications. The STs Nursing and work satisfaction yielded 35 publications most of which did not mention the term dignity. A term that has received increasing current interest, professional dignity, was not searched prior to commencing this study; however, additional publications between 2010 and 2014 provide further understandings of professional dignity, a related 3
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concept. Literature published after completion of data collection for this study was reviewed, and those with relevance to the findings are cited in the ‘‘Introduction’’ and ‘‘Discussion’’ sections of this report. A large-scale study examining the concept of dignity in patient care was published in Great Britain by the Royal College of Nursing,21 but there exists no comparative body of research examining the concept in practice environments in the United States. No studies were found that specifically examined the nurse’s sense of personal dignity in relation to the proposed variables.
Theoretical perspectives on nurse’s sense of dignity The nature of reciprocity in the psychodynamic relationship between nurses and others means that the nurse’s self-perceptions of dignity will likely play a part in the nurse’s work with patients or colleagues. Because of this, it is important to consider the influence of reciprocity in situations in which the nurse cares for the welfare of another and to clarify that the reason for considering the nurse’s sense of dignity is not only to justly preserve the nurse’s humanity but because the nurse’s actions carry the potential to influence patient well-being and work culture. Being able to be aware of how one functions while in the midst of working with a patient is evidence of the positive development of the nurse.9 While this care is directed toward the other, it requires an awareness of oneself in action which includes one’s feelings toward self. In short, the nurse’s sense of dignity is linked with what virtue or feeling of care might arise from within and does then include the other. The caring relationship involves responsiveness and reciprocity,22,23 constituting a form of mutual exchange that requires the nurse to experience sensitivity for the other’s position and to reciprocate with respect for the other’s views, needs, and wishes. Mutual exchange would also require simultaneous awareness of self, which would include consciousness of the needs and values of the nurse. It has been suggested that a singular focus upon the patient’s experience in the exchange may be partly responsible for the lack of attention given to the nurse’s experience of self.24 Therefore, the active cultivation of respect for human dignity (within the nurse) is central to actions identifiable as ethical behavior in nursing;13,24 however, what are the traits and qualities of a nurse who can provide this type of relationship? While it is beyond the scope of this study, the question of how these qualities may be supported and refined naturally arises. The nurse has the potential to foster the dignity of the patient and of one’s colleagues, but the awareness of the need to do so may, in fact, only be recognized by a nurse who personally values similar experiences in self.
Theoretical background: key study variables This study was designed to explore whether a relationship exists between nurses’ sense of dignity (in self), and several other key variables and personal demographic traits. These potential associations with the primary variable, nurse’s sense of dignity, have not been previously researched in this way. Theoretical definitions, rationales of linkages, and operational definitions of the three key variables follow. Dignity. There exist theoretical definitions of dignity in the literature which provide an introductory understanding of the concept. A selection (far from exhaustive) is included here. Wiegman’s19 research posits that ‘‘dignity is a dynamic, subjective, human sensation in which autonomy, respect, and worthiness occur together and are felt internally as a component of self-esteem. It is highly valued among people and has a universally shared meaning’’ (p. 52). Conceptual research from Jacelon et al.25 led to defining dignity as ‘‘an inherent characteristic of being human; it can be subjectively felt as an attribute of the self, and is made manifest through behaviors that demonstrate respect for the self and others’’ (p. 82). Nordenfelt26 notes that dignity includes both objective and subjective components. Edlund et al.27 state, ‘‘Dignity is a 4
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concept that is only applicable to human beings and implies being whole as a human being, as an entity of body, soul, and spirit’’ (p. 858). This study examines the nurse’s perceptions of dignity in self. The concept dignity was operationalized with a modified version of The Dignity Instrument (DI), developed by Wiegman19 and is based on her definition of dignity. Self-esteem. The concept of ‘‘global self-esteem’’ is theoretically defined as The way in which one perceives one’s self; holding a positive or negative viewpoint towards oneself; constituting an overall sense of one’s worth or value. People desire high self-esteem and this signifies a positive self-regard, which is not explained as egotism. Self-esteem is considered to be one component of the self-concept.28
The concept global self-esteem is measured utilizing the Rosenberg Global Self-Esteem Scale (SES).29 Dignity and self-esteem (rationales for association). One aim of this study was to discover the degree to which dignity and self-esteem are related for professional nurses. Wiegman19 documents that the concepts measured as dignity and self-esteem are not equivalent. The concepts of dignity and self-esteem appear to share certain components, but this conceptual relationship requires further investigation and description. How nurses behave toward and with other nurses is likely to impact the nurse’s sense of self (which may be an aspect of dignity or of self-esteem or of both), supporting the need for further exploration. Work satisfaction. The Revised Nursing Work Index (NWI-R), developed by Aiken and Patrician,30 has been used to measure characteristics of professional nurse practice environments thought to affect patient care outcomes and nurse–physician relationships. Aiken and Patrician report that this instrument has been sufficiently tested to allow its use with survey research techniques to study samples of nurses working in varied healthcare environments. The NWI-R was used to operationalize the concept nurse work satisfaction in this study.30 Dignity and work satisfaction (rationales for association). The dignity of the nurse may be compromised by human interactions in the workplace, financial restrictions, or cultural climate. Workplace environments are influenced by the presence or absence of respectful collegial interactions.31 The dignity of the nurse as experienced in the workplace has been referred to as professional dignity, and the importance of valuing it, as well as its potential impact in the workplace environment has been noted.16 It is not uncommon for nurses in the workplace to experience criticism delivered with disrespectful and pejorative tenors, particularly in situations where nurses may challenge the actions of a physician or supervisor. This may include prolonged and targeted bullying behaviors or may be limited to simple untargeted negative criticism by an inconsiderate colleague or superior. Bullying and negativity in nursing workplace settings are not uncommon and impact negatively on the workplace climate.32–34 It is proposed that workplace satisfaction may be associated with nurses’ sense of dignity because the quality of workplace relationships has the power to compromise the dignity of the nurse, particularly if the nurse is belittled or embarrassed in front of others. When these types of feelings are internalized, negative projections (such as anger or resentment) can be displaced into the work environment and create a cultural climate wherein the dignity of the nurse is overlooked and the nurse becomes unaware of the impact of his or her behaviors on the culture of the work environment and on the quality of patient care. Additionally, a financially restrictive healthcare environment can present nurses with ethical dilemmas in which they can feel their professional dignity is compromised, leading to a loss of work satisfaction, where some may seek transfers, new employment, or even leave nursing.35 5
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Theoretical background: dignity and personal traits of nurses In this study, certain personal traits were measured under demographics, and correlations between these and nurse’s sense of dignity were proposed as worthy of exploration, but which lacked published supporting findings as to these relationships. The rationales for proposing these relationships follow. Inner spiritual commitment. This term was meant to capture whether a nurse felt committed inwardly to a belief and responsibility to something larger than oneself or to some nature of higher spiritual being. It was purposely non-religious and was an attempt to capture a sense of accountability beyond one’s own personal desires, which is why it can be viewed as a marker for ethical values. Since the concept of dignity has been noted to include spiritual dimensions such as holiness, caring, respect, wholeness, and service for the greater good,8 it was reasonable to explore the potential relationship between spiritual commitment and sense of dignity. Ability to advocate. This personal trait was chosen because it is reasonable to propose that nurses with a higher sense of personal dignity might perceive themselves to be workplace advocates. Most nurses value advocacy and believe they will advocate for patients,36 but there are also studies that show that nurses may choose to advocate in accordance with organizational objectives over patient needs.37,38 Therefore, wanting to advocate for others can be different from the actual doing of advocacy and worth examining further. The item measuring advocacy was constructed to try to ascertain the nurse’s advocacy actions, rather than their beliefs. Health status. No published research was found to support a relationship between sense of personal dignity and health status, but dignity is an expression of worthiness, and this sense of worthiness can be inherent or influenced by the way one is treated or by what one can engage with. A loss of physical capacity or function can diminish autonomy, decreasing what Nordenfelt26 terms dignity of identity, negatively impacting the nurses’ sense of self-worth. Therefore, it is reasonable to examine a possible association between sense of dignity and health status. The item measuring health status was constructed to capture the nurses’ perception of their general health and function.
Aim The aim of this study was to explore potential relationships between the nurse’s sense of dignity and selfesteem, the nurse’s sense of dignity and work satisfaction, and the nurse’s sense of dignity with several personal traits. The rationale is that through knowing more about the nurse’s personal sense of dignity, it may become possible to recognize and develop the characteristics needed to provide sensitive, individualized, ethical, and respectful patient care and to develop the skills required to ethically and effectively navigate workplace settings. This exploratory descriptive study is an attempt to learn more about how nurses perceive dignity in themselves and what factors might be associated with their perceptions.
Research questions A number of questions were posed to examine the concept of dignity in professional nurses: 1. To what extent are the nurse’s sense of dignity and self-esteem related? 2. Is there a relationship between the nurse’s sense of dignity and work satisfaction? 3. Is there a relationship between the nurse’s sense of dignity and the following personal traits: nurse’s age, total number of years in nursing practice, number of years spent in the same current work 6
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setting, level of education, spiritual commitment, perceived ability to advocate (for another person’s needs in area of practice)?
Method Following receipt of University Institutional Review Board approval, this cross-sectional correlation study utilized research questionnaire packets that were mailed in June 2009 to a sample of registered professional nurses; 566 packets were prepared and mailed to obtain an adequate study sample. A postcard was sent to all 566 names 2 weeks after the initial mailing in an effort to improve the response rate. The postcard reminded the recipients of the packet previously sent, thanked them for their assistance, and requested them to complete and return the questionnaires if not already done.
Sampling procedure A sample was randomly selected from the alumni list of a well-established College of Nursing in a major mid-Atlantic US Catholic University. It was determined that a sample of 180 respondents would provide power of .80 with medium effect for a study with nine variables.39 The alumni list contained 4554 names of graduates between 1965 and 2009 in alphabetical order according to zip code. A stratified random sampling technique was used to assure that the subject pool would be representative of the graduates of the college living throughout the United States.39 Of 566 mailed packets, 11 were returned undelivered, and 133 usable questionnaires were returned and analyzed for a respectable response rate of 24%.
Instruments Participants in the study responded to three questionnaires: (a) the DI developed by Wiegman and modified with permission for a sample of professional nurses, (b) the SES, and (c) the NWI-R, as well as a set of demographic items (including one Likert-type question each for the following items: spiritual commitment, ability to advocate, and health status). Two open-ended questions were included which asked for descriptions of situations that impacted the nurse’s sense of personal dignity; content analysis of these responses will be discussed in a future publication. DI. The DI was developed, tested, and revised by Wiegman19 to measure dignity in adults. The DI was developed using samples of English-speaking, community-living, working, or retired male and female adults 18 years and older recruited from colleges, church groups, and military veterans organizations, making it appropriate for use with an adult population living in the community. Face, content, and construct validity were established by Weigman19 for the current 24-item scale, which has been previously shown to have a reliability of .91. The DI measures factors of Autonomy, Self-Respect/Self-Worthiness, OtherRespect, and Other-Worthiness and produces a single-scale score. The five response options for each item range from ‘‘almost always’’ to ‘‘almost never,’’ with the range of scale scores from 24 to 120 and lower scores indicating higher level of dignity. In the current sample, the DI modified for a nurse sample demonstrated a Cronbach’s alpha of .88. Although the DI has not been widely used, it was developed using robust psychometric approaches with community-dwelling adults 18–79þ years of age. Other instruments have been developed to study dignity in long-term care patients,40 palliative care patients,41–46 or the elderly.47 Since this study explored the concept of dignity in a sample of nurses rather than patients, it was more appropriate to use the DI. 7
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SES. The SES is a 10-item instrument that produces a single measure of global self-esteem and has been validated in adolescent, adult, and geriatric populations. Half of the items are worded negatively and are reverse scored for analysis. Item response options range from ‘‘Strongly Agree’’ (1) to ‘‘Strongly Disagree’’ (4). Scale scores can range from 10 to 40, with lower scores indicating higher self-esteem. Reliability indexes ranging from .77 to .88 have been reported.29 In this study, the SES had a Cronbach’s alpha of .82. NWI-R. The NWI-R was developed and tested by and Patrician, and content and criterion validity of the instrument were established.30 The instrument produces a single total score and has sub-scales for autonomy, control, and relationships with physicians. There are 52 items in the total scale. Response options range from ‘‘Strongly Agree’’ (1) to ‘‘Strongly Disagree’’ (4), with an additional choice of ‘‘Does not apply to me’’ (0) offered. Scale scores can range from 52 to 208, with lower numbers indicating a more positive perception of the nurse’s work environment. An overall Cronbach’s alpha reliability of .96 has been previously reported.30 The NWI-R had a Cronbach’s alpha of .97 for the total scale score in this study. Inner spiritual commitment. This was measured using a single item in the demographic question set, for which respondents rated themselves on degrees of spiritual commitment from ‘‘Very Strong’’ (1) to ‘‘Not an important part of my life at all’’ (5). Ability to advocate. This was measured using a single item in the demographic question set, for which respondents rated themselves on how often they advocated for another person’s needs in their area of nursing practice, ranging from ‘‘never’’ (1) to ‘‘much of the time’’ (4). Health status. This was measured using a single item in the demographic question set, for which respondents rated themselves ranging from ‘‘Feel poorly, need assistance’’ (1) to ‘‘Feel very well, function independently’’ (5).
Results Sample description The final sample of 133 nurses was 98% female (not unexpected in a sample of nurses for this time period), and the median age group of the sample was 46–55 years, with 34% of the sample falling into this category. Another 39% of the sample was over 56 years of age. This is consistent with the reported median age of registered nurses practicing in the United States in 2008.48 Time in nursing ranged from 1 to 30þ years, with slightly over half the respondents (54.2%) having 10 years or less in their current position and 40% employed in their current nursing position between 10 and 30 years; 46% held a Bachelor of Science in Nursing as their highest educational attainment, while 3.8% reported having a doctoral degree in nursing; and 24% of the sample reported their highest educational degree in another discipline. Table 1 shows the distribution of highest level of nursing education reported by the respondents. The sample reflected a broad range of familiarity with the demands of nursing care. While the final sample of 133 was smaller than the planned sample of 180, the data analysis revealed moderate to moderately strong associations between variables with the resulting power greater than .90 and removing concerns regarding the final sample size.49 This sample of professional nurses reported a high level of personal dignity, with a mean score of 31.26 (standard deviation (SD): 10.17) with the scores positively skewed (3.67). Therefore, a one-sample t-test was done to determine the probability of obtaining a similar mean dignity score in the general population. The statistically significant results (t ¼ 35.44, p ¼ .000) indicated that the mean dignity score for this sample 8
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Table 1. Highest educational preparation (N ¼ 133). Associates
Bachelor
Master
Doctoral
Total
Degree
n
%
n
%
n
%
n
%
n
%
Nursing Non-nursing
0 3
0 2.3
61 8
45.9 6.0
54 19
40.6 14.3
5 2
3.8 1.5
120 32
90.2 24.0
Total responses ¼ 149 due to some respondents having both nursing and non-nursing degrees.
of nurses was different from the general population (as a statistical probability). Since the distribution of scores on the DI were skewed, non-parametric statistics were used for further analysis.
Dignity and self-esteem of nurses It has been suggested theoretically that dignity and self-esteem share certain components.18 To explore this in a sample of professional nurses, a correlation matrix of dignity and self-esteem items was constructed. Spearman Rho Correlation was computed due to the skewness of the sample and was rx ¼ .62 (p ¼ .000), indicating a positive and moderately strong association between the two variables. Eight items on the DI were found to have very low correlation with items on the SES, suggesting that they are unique to dignity rather than to self-esteem. These items dealt with having personal beliefs, independence of thought and of action, self-care ability, and expectation of worthiness. There were also three SES items which had very weak correlation with dignity, and these addressed thinking well of oneself and what one does, feelings of uselessness, and feeling proud. While there is clearly a relationship between dignity and self-esteem in this sample of nurses, there are also distinctions to be made between the two self-characterizations (see Tables 2 and 3).
Dignity and work satisfaction of nurses It is suggested that professional nurses’ satisfaction with their practice environment influences the quality of patient care and outcomes.30 In the practice environment, respecting patient dignity is expected. In this sample of professional nurses, there was a significantly positive but moderate association between nurses’ personal dignity and nurses’ work satisfaction (rx ¼ .37, p ¼ .000). Certain DI items had a consistently positive and significant relationship across most of the NWI-R items, for example, ‘‘I have a sense of freedom’’ and ‘‘I have a good sense of self-esteem’’. Since the SES score had a similar positive association with NWI-R score (rs ¼ .29, p ¼ .001) as the DI score, it is not surprising that an item reflecting dignity and an item reflecting self-esteem would have consistent association with NWI-R items.
Dignity and personal demographic traits Dignity and inner spiritual commitment. The relationship between nurses’ personal sense of dignity and the trait titled inner spiritual commitment (as a marker for ethical values) was examined. Respondents rated themselves on degrees of spiritual commitment from ‘‘Very Strong’’ (1) to ‘‘Not an important part of my life at all’’ (5), and analysis of variance was done to look for differences in dignity among the spiritual commitment categories. A statistically significant positive difference was found (F ¼ 3.49 (df ¼ 4), p ¼ .01), with greater dignity in all other degrees of spiritual commitment when compared to ‘‘Not important at all.’’ 9
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Table 2. DI and SES items that are not significantly correlated (N ¼ 133). SES items At times I think I am I feel I do not have no good at all. much to be proud of.
DI items I am allowed to have personal beliefs. I have independent thoughts. I can do physical activities that I want to do. I am able to care for myself. I respect my friends and family. I treat others with a sense of respect. Others know that I respect them. Others should treat me as being worthy.
r p r p r p r p r p r p r p r p
.113 .198 .118 .178 .135 .131 .070 .426 .069 .432 .019 .827 .082 .354 .152 .082
.107 .222 .032 .714 .044 .616 .004 .962 .163 .060 .068 .436 .141 .106 .158 .069
I certainly feel useless at times. .097 .270 .049 .576 .066 .451 .122 .164 .115 .192 .118 .178 .125 .158 .006 .946
DI: Dignity Instrument; SES: Rosenberg Global Self-Esteem Scale. Negatively worded SES items were reverse scored for analysis.
Table 3. DI and SES items that are significantly correlated (N ¼ 133). SES items Satisfied Have good Am a person Feel that I’m with myself qualities of worth a failure
DI items I am allowed to have personal beliefs. I have independent thoughts. I can do physical activities that I want to do. I am able to care for myself. Others know that I respect them. Others should treat me as being worthy.
.321** .206* .231** .323** .244*
.209*
.312** .211* .226**
.332** .359**
.283* .292*
Positive attitude toward myself .236**
.228**
.204*
.235*
.190* .283*
DI: Dignity Instrument; SES: Rosenberg Global Self-Esteem Scale. Negatively worded SES items were reverse scored for analysis. *p ¼
Exploring nurses’ personal dignity, global self-esteem and work satisfaction
Nursing Ethics 1–17 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014567024 nej.sagepub.com
Bonnie A Sturm and Jane C Dellert Seton Hall University, USA
Abstract Background: This study examines nurses’ perceptions of dignity in themselves and their work. Nurses commonly assert concern for human dignity as a component of the patients’ experience rather than as necessary in the nurses’ own lives or in the lives of others in the workplace. This study is exploratory and generates potential relationships for further study and theory generation in nursing. Research questions: What is the relationship between the construct nurses’ sense of dignity and global self-esteem, work satisfaction, and identified personal traits? Participants and research context: This cross-sectional correlation study used a stratified random sample of nurses which was obtained from a US University alumni list from 1965 to 2009 (N ¼ 133). Ethical considerations: University Institutional Review Board approval was achieved prior to mailing research questionnaire packets to participants. Participation was optional and numerical codes preserved confidentiality. Findings: Statistical results indicated a moderately strong association between the nurse’s sense of personal dignity and self-esteem (rx ¼ .62, p ¼ .000) with areas of difference clarified and discussed. A positive but moderate association between nurses’ personal dignity and nurses’ work satisfaction (rx ¼ .37, p ¼ .000) and a similar association between self-esteem and nurses’ work satisfaction (rs ¼ .29, p ¼ .001) were found. A statistically significant difference was found (F ¼ 3.49 (df ¼ 4), p ¼ .01) for dignity and categories of spiritual commitment and for nurses’ personal dignity when ratings of health status were compared (F ¼ 21.24 (df ¼ 4), p ¼ .000). Discussion: Personal sense of dignity is discussed in relation to conceptual understandings of dignity (such as professional dignity) and suggests continued research in multiple cultural contexts. Conclusion: The relationships measured show that nurses’ sense of dignity has commonalities with selfesteem, workplace satisfaction, spiritual commitment, and health status; the meaning of the findings has ramifications for the welfare of nurses internationally. Keywords Nurses’ dignity, professional dignity, self-esteem, spirituality, work satisfaction
Corresponding author: Bonnie A Sturm, College of Nursing, Seton Hall University, 400 South Orange Ave, South Orange, NJ 07079, USA. Email: [email protected]
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Introduction Dignity is a concept that is relevant to nursing practice and research and is most often considered in light of preserving the patient’s dignity in practice situations. While there is a growing body of research that examines influences upon patient dignity,1–3 and recent publications examining the concept of professional dignity,4,5 an understanding of the nurse’s own sense of dignity and the potential meaning of this influence is largely unexplored. This implies that there are nurse actions or ways of being/interacting within the interpersonal nurse–patient relationship as well as other workplace relationships, which have the potential to diminish or to preserve the other’s dignity. The dynamic interrelatedness of relationship between the nurse and others is a process with transformative and influential potential. This is consistent with the work of several nurse theorists: Newman’s6 theory of nursing as expanding consciousness, Watson’s7 theory of care, and Eriksson’s8 theory of caring science, which provide a theoretical premise for this exploratory research. This study focuses on the nurse’s sense of personal dignity and supposes that how a nurse views dignity in self will be associated with other attributes of self.
Dignity and nurse perceptions of self It is theoretically posed that nursing behaviors, such as actions supporting or diminishing dignity, are a part of a reciprocal relationship with patients or with colleagues and are moderated by the nurse’s sense of self. From a psychological perspective, Peplau,9 noted seminal psychiatric nurse theorist, consistently emphasized the necessity that the nurse become increasingly aware of the influence of personal motivations and values as these influence the quality and equanimity of the nurse–patient relationship. It is important to examine the nurse’s personal sense of dignity because the nurse’s work with patients, colleagues and the community can be influenced by this perception.10,11 Additionally, the nurse’s attitude and degree of self-awareness has the potential to influence whether the nursing care provided will support patient dignity.12
Dignity in the workplace Professional Nursing Organization codes emphasize the necessity that nurses advocate for and deliver patient care that protects the dignity of patients and also recognize the need for respectful collaborative relationships among colleagues.13,14 The American Nurses Association (ANA) Code of Ethics places respect for human dignity as the first item in the first provision, and while it is common for nurses to assert concern for human dignity, it is generally viewed as a component of the patients’ experience rather than as something necessary in the nurses’ own lives or in the lives of others in the workplace. In recent years, the construct professional dignity has specifically been examined in nursing,5,15,16 uncovering new conceptual understandings of this similar, but not identical, construct; however, this has brought new and important attention to how the dignity of the nurse may be challenged in workplace environments. This is particularly important from a global perspective of dignity in the work-life of nurses, which is heavily influenced by cultural norms, the rights of women, class and segregation, economic power, and poverty. Considering this, however, it is interesting that the dignity of nurses is and remains of current concern in more affluent countries such as the United Kingdom or the United States, as evidenced by ongoing research efforts.
Relevance to nursing ethics Studying the nurse’s sense of dignity has relevance to the study of nursing ethics because the doing of ethical nursing requires the development of self-awareness, a growth in human understanding, and the feeling for an 2
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ethic of care. Gallagher17 reminds us that ‘‘Doing respect in everyday practice is not, however, always a straightforward matter’’ (p. 366). How will a nurse find an effective way to advocate for improved collegial relations or to constructively address a demeaning comment made in the workplace, without observing and respecting personal interior experiences and reactions? How can a nurse uphold the patient’s autonomy or provide acceptance of a family’s choice to allow death, in a way that also provides a loving presence, if unaware of interior values and the unconscious coloring caused by personal motivations and past experiences? In viewing nursing as a caring science and a relational practice,18 and perhaps in its finest moments a sacred practice, a greater understanding of the nurse’s self-perceptions is relevant. This study is a preliminary step which should encourage continued research, which could focus upon understanding ways to develop ethical competencies in nurses, including moral agency and the nurse’s ability to interact in ethical and effective ways within practice environments that may include patients, colleagues, and others involved in healthcare systems.
Study purpose and plan This study was designed to explore the relationship between the construct nurse’s sense of dignity with the key variables of self-esteem and work satisfaction, as well as with the following personal traits: nurse’s age, years in nursing practice, years in current work setting, level of education, sense of spiritual commitment, perceived ability to advocate, and health status. For purposes of this study, dignity was defined as ‘‘A dynamic, subjective, human sensation in which autonomy, respect, and worthiness occur together and are felt internally as a component of self-esteem’’ (p. 52).19 The purpose of this descriptive study was an attempt to learn more about how nurses perceive dignity in themselves and what factors might be associated with their perceptions. Additional theoretical underpinnings are described in relation to each variable. At the time of this study, no other studies were found to demonstrate any specific statistical associations between the identified variables, although the academic and clinical experiences of the researchers, as well as the publication of some related theoretical literature, did support a reasonable potential for several of the proposed associations. Whether a nurse’s sense of personal dignity is related to self-esteem, work satisfaction, or other personal traits of the nurse is largely unknown. Since ‘‘dignity is also understood as the outcome of relationships of care and a concern for the wholeness and integrity of the person or personhood’’ (p. 138),20 it follows logically that there is merit in exploring the nurse’s personal perceptions of dignity. This first study is exploratory and multiple regressions were not planned for initial data analysis. This article provides a report of the planned bivariate correlations and includes a discussion of these findings in relation to the concept of dignity in nurses.
Background At the time of this study, a preliminary search of the literature published in English utilizing several databases, including CINAHL with Full Text, Academic Search Premier, ERIC, PsycARTICLES, PsycINFO, Health Source: Nursing/Academic Edition, CINAHL, and ScienceDirect from the years 1997 to 2009, produced a variety of studies that focused on the threatened dignity of patients in hospital and nursing home settings and several that suggested nurses could make improved efforts to provide care that preserved patient dignity. When this study was designed, no research studies were found that specifically examined the nurse’s sense of personal dignity. The subject terms (STs) dignity and self-esteem and nursing yielded 6 publications, but none focusing on the nurse. Using the STs nursing and job and/or work satisfaction, and dignity when entered together, rendered 12 scholarly publications. The STs Nursing and work satisfaction yielded 35 publications most of which did not mention the term dignity. A term that has received increasing current interest, professional dignity, was not searched prior to commencing this study; however, additional publications between 2010 and 2014 provide further understandings of professional dignity, a related 3
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Nursing Ethics
concept. Literature published after completion of data collection for this study was reviewed, and those with relevance to the findings are cited in the ‘‘Introduction’’ and ‘‘Discussion’’ sections of this report. A large-scale study examining the concept of dignity in patient care was published in Great Britain by the Royal College of Nursing,21 but there exists no comparative body of research examining the concept in practice environments in the United States. No studies were found that specifically examined the nurse’s sense of personal dignity in relation to the proposed variables.
Theoretical perspectives on nurse’s sense of dignity The nature of reciprocity in the psychodynamic relationship between nurses and others means that the nurse’s self-perceptions of dignity will likely play a part in the nurse’s work with patients or colleagues. Because of this, it is important to consider the influence of reciprocity in situations in which the nurse cares for the welfare of another and to clarify that the reason for considering the nurse’s sense of dignity is not only to justly preserve the nurse’s humanity but because the nurse’s actions carry the potential to influence patient well-being and work culture. Being able to be aware of how one functions while in the midst of working with a patient is evidence of the positive development of the nurse.9 While this care is directed toward the other, it requires an awareness of oneself in action which includes one’s feelings toward self. In short, the nurse’s sense of dignity is linked with what virtue or feeling of care might arise from within and does then include the other. The caring relationship involves responsiveness and reciprocity,22,23 constituting a form of mutual exchange that requires the nurse to experience sensitivity for the other’s position and to reciprocate with respect for the other’s views, needs, and wishes. Mutual exchange would also require simultaneous awareness of self, which would include consciousness of the needs and values of the nurse. It has been suggested that a singular focus upon the patient’s experience in the exchange may be partly responsible for the lack of attention given to the nurse’s experience of self.24 Therefore, the active cultivation of respect for human dignity (within the nurse) is central to actions identifiable as ethical behavior in nursing;13,24 however, what are the traits and qualities of a nurse who can provide this type of relationship? While it is beyond the scope of this study, the question of how these qualities may be supported and refined naturally arises. The nurse has the potential to foster the dignity of the patient and of one’s colleagues, but the awareness of the need to do so may, in fact, only be recognized by a nurse who personally values similar experiences in self.
Theoretical background: key study variables This study was designed to explore whether a relationship exists between nurses’ sense of dignity (in self), and several other key variables and personal demographic traits. These potential associations with the primary variable, nurse’s sense of dignity, have not been previously researched in this way. Theoretical definitions, rationales of linkages, and operational definitions of the three key variables follow. Dignity. There exist theoretical definitions of dignity in the literature which provide an introductory understanding of the concept. A selection (far from exhaustive) is included here. Wiegman’s19 research posits that ‘‘dignity is a dynamic, subjective, human sensation in which autonomy, respect, and worthiness occur together and are felt internally as a component of self-esteem. It is highly valued among people and has a universally shared meaning’’ (p. 52). Conceptual research from Jacelon et al.25 led to defining dignity as ‘‘an inherent characteristic of being human; it can be subjectively felt as an attribute of the self, and is made manifest through behaviors that demonstrate respect for the self and others’’ (p. 82). Nordenfelt26 notes that dignity includes both objective and subjective components. Edlund et al.27 state, ‘‘Dignity is a 4
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concept that is only applicable to human beings and implies being whole as a human being, as an entity of body, soul, and spirit’’ (p. 858). This study examines the nurse’s perceptions of dignity in self. The concept dignity was operationalized with a modified version of The Dignity Instrument (DI), developed by Wiegman19 and is based on her definition of dignity. Self-esteem. The concept of ‘‘global self-esteem’’ is theoretically defined as The way in which one perceives one’s self; holding a positive or negative viewpoint towards oneself; constituting an overall sense of one’s worth or value. People desire high self-esteem and this signifies a positive self-regard, which is not explained as egotism. Self-esteem is considered to be one component of the self-concept.28
The concept global self-esteem is measured utilizing the Rosenberg Global Self-Esteem Scale (SES).29 Dignity and self-esteem (rationales for association). One aim of this study was to discover the degree to which dignity and self-esteem are related for professional nurses. Wiegman19 documents that the concepts measured as dignity and self-esteem are not equivalent. The concepts of dignity and self-esteem appear to share certain components, but this conceptual relationship requires further investigation and description. How nurses behave toward and with other nurses is likely to impact the nurse’s sense of self (which may be an aspect of dignity or of self-esteem or of both), supporting the need for further exploration. Work satisfaction. The Revised Nursing Work Index (NWI-R), developed by Aiken and Patrician,30 has been used to measure characteristics of professional nurse practice environments thought to affect patient care outcomes and nurse–physician relationships. Aiken and Patrician report that this instrument has been sufficiently tested to allow its use with survey research techniques to study samples of nurses working in varied healthcare environments. The NWI-R was used to operationalize the concept nurse work satisfaction in this study.30 Dignity and work satisfaction (rationales for association). The dignity of the nurse may be compromised by human interactions in the workplace, financial restrictions, or cultural climate. Workplace environments are influenced by the presence or absence of respectful collegial interactions.31 The dignity of the nurse as experienced in the workplace has been referred to as professional dignity, and the importance of valuing it, as well as its potential impact in the workplace environment has been noted.16 It is not uncommon for nurses in the workplace to experience criticism delivered with disrespectful and pejorative tenors, particularly in situations where nurses may challenge the actions of a physician or supervisor. This may include prolonged and targeted bullying behaviors or may be limited to simple untargeted negative criticism by an inconsiderate colleague or superior. Bullying and negativity in nursing workplace settings are not uncommon and impact negatively on the workplace climate.32–34 It is proposed that workplace satisfaction may be associated with nurses’ sense of dignity because the quality of workplace relationships has the power to compromise the dignity of the nurse, particularly if the nurse is belittled or embarrassed in front of others. When these types of feelings are internalized, negative projections (such as anger or resentment) can be displaced into the work environment and create a cultural climate wherein the dignity of the nurse is overlooked and the nurse becomes unaware of the impact of his or her behaviors on the culture of the work environment and on the quality of patient care. Additionally, a financially restrictive healthcare environment can present nurses with ethical dilemmas in which they can feel their professional dignity is compromised, leading to a loss of work satisfaction, where some may seek transfers, new employment, or even leave nursing.35 5
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Nursing Ethics
Theoretical background: dignity and personal traits of nurses In this study, certain personal traits were measured under demographics, and correlations between these and nurse’s sense of dignity were proposed as worthy of exploration, but which lacked published supporting findings as to these relationships. The rationales for proposing these relationships follow. Inner spiritual commitment. This term was meant to capture whether a nurse felt committed inwardly to a belief and responsibility to something larger than oneself or to some nature of higher spiritual being. It was purposely non-religious and was an attempt to capture a sense of accountability beyond one’s own personal desires, which is why it can be viewed as a marker for ethical values. Since the concept of dignity has been noted to include spiritual dimensions such as holiness, caring, respect, wholeness, and service for the greater good,8 it was reasonable to explore the potential relationship between spiritual commitment and sense of dignity. Ability to advocate. This personal trait was chosen because it is reasonable to propose that nurses with a higher sense of personal dignity might perceive themselves to be workplace advocates. Most nurses value advocacy and believe they will advocate for patients,36 but there are also studies that show that nurses may choose to advocate in accordance with organizational objectives over patient needs.37,38 Therefore, wanting to advocate for others can be different from the actual doing of advocacy and worth examining further. The item measuring advocacy was constructed to try to ascertain the nurse’s advocacy actions, rather than their beliefs. Health status. No published research was found to support a relationship between sense of personal dignity and health status, but dignity is an expression of worthiness, and this sense of worthiness can be inherent or influenced by the way one is treated or by what one can engage with. A loss of physical capacity or function can diminish autonomy, decreasing what Nordenfelt26 terms dignity of identity, negatively impacting the nurses’ sense of self-worth. Therefore, it is reasonable to examine a possible association between sense of dignity and health status. The item measuring health status was constructed to capture the nurses’ perception of their general health and function.
Aim The aim of this study was to explore potential relationships between the nurse’s sense of dignity and selfesteem, the nurse’s sense of dignity and work satisfaction, and the nurse’s sense of dignity with several personal traits. The rationale is that through knowing more about the nurse’s personal sense of dignity, it may become possible to recognize and develop the characteristics needed to provide sensitive, individualized, ethical, and respectful patient care and to develop the skills required to ethically and effectively navigate workplace settings. This exploratory descriptive study is an attempt to learn more about how nurses perceive dignity in themselves and what factors might be associated with their perceptions.
Research questions A number of questions were posed to examine the concept of dignity in professional nurses: 1. To what extent are the nurse’s sense of dignity and self-esteem related? 2. Is there a relationship between the nurse’s sense of dignity and work satisfaction? 3. Is there a relationship between the nurse’s sense of dignity and the following personal traits: nurse’s age, total number of years in nursing practice, number of years spent in the same current work 6
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setting, level of education, spiritual commitment, perceived ability to advocate (for another person’s needs in area of practice)?
Method Following receipt of University Institutional Review Board approval, this cross-sectional correlation study utilized research questionnaire packets that were mailed in June 2009 to a sample of registered professional nurses; 566 packets were prepared and mailed to obtain an adequate study sample. A postcard was sent to all 566 names 2 weeks after the initial mailing in an effort to improve the response rate. The postcard reminded the recipients of the packet previously sent, thanked them for their assistance, and requested them to complete and return the questionnaires if not already done.
Sampling procedure A sample was randomly selected from the alumni list of a well-established College of Nursing in a major mid-Atlantic US Catholic University. It was determined that a sample of 180 respondents would provide power of .80 with medium effect for a study with nine variables.39 The alumni list contained 4554 names of graduates between 1965 and 2009 in alphabetical order according to zip code. A stratified random sampling technique was used to assure that the subject pool would be representative of the graduates of the college living throughout the United States.39 Of 566 mailed packets, 11 were returned undelivered, and 133 usable questionnaires were returned and analyzed for a respectable response rate of 24%.
Instruments Participants in the study responded to three questionnaires: (a) the DI developed by Wiegman and modified with permission for a sample of professional nurses, (b) the SES, and (c) the NWI-R, as well as a set of demographic items (including one Likert-type question each for the following items: spiritual commitment, ability to advocate, and health status). Two open-ended questions were included which asked for descriptions of situations that impacted the nurse’s sense of personal dignity; content analysis of these responses will be discussed in a future publication. DI. The DI was developed, tested, and revised by Wiegman19 to measure dignity in adults. The DI was developed using samples of English-speaking, community-living, working, or retired male and female adults 18 years and older recruited from colleges, church groups, and military veterans organizations, making it appropriate for use with an adult population living in the community. Face, content, and construct validity were established by Weigman19 for the current 24-item scale, which has been previously shown to have a reliability of .91. The DI measures factors of Autonomy, Self-Respect/Self-Worthiness, OtherRespect, and Other-Worthiness and produces a single-scale score. The five response options for each item range from ‘‘almost always’’ to ‘‘almost never,’’ with the range of scale scores from 24 to 120 and lower scores indicating higher level of dignity. In the current sample, the DI modified for a nurse sample demonstrated a Cronbach’s alpha of .88. Although the DI has not been widely used, it was developed using robust psychometric approaches with community-dwelling adults 18–79þ years of age. Other instruments have been developed to study dignity in long-term care patients,40 palliative care patients,41–46 or the elderly.47 Since this study explored the concept of dignity in a sample of nurses rather than patients, it was more appropriate to use the DI. 7
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SES. The SES is a 10-item instrument that produces a single measure of global self-esteem and has been validated in adolescent, adult, and geriatric populations. Half of the items are worded negatively and are reverse scored for analysis. Item response options range from ‘‘Strongly Agree’’ (1) to ‘‘Strongly Disagree’’ (4). Scale scores can range from 10 to 40, with lower scores indicating higher self-esteem. Reliability indexes ranging from .77 to .88 have been reported.29 In this study, the SES had a Cronbach’s alpha of .82. NWI-R. The NWI-R was developed and tested by and Patrician, and content and criterion validity of the instrument were established.30 The instrument produces a single total score and has sub-scales for autonomy, control, and relationships with physicians. There are 52 items in the total scale. Response options range from ‘‘Strongly Agree’’ (1) to ‘‘Strongly Disagree’’ (4), with an additional choice of ‘‘Does not apply to me’’ (0) offered. Scale scores can range from 52 to 208, with lower numbers indicating a more positive perception of the nurse’s work environment. An overall Cronbach’s alpha reliability of .96 has been previously reported.30 The NWI-R had a Cronbach’s alpha of .97 for the total scale score in this study. Inner spiritual commitment. This was measured using a single item in the demographic question set, for which respondents rated themselves on degrees of spiritual commitment from ‘‘Very Strong’’ (1) to ‘‘Not an important part of my life at all’’ (5). Ability to advocate. This was measured using a single item in the demographic question set, for which respondents rated themselves on how often they advocated for another person’s needs in their area of nursing practice, ranging from ‘‘never’’ (1) to ‘‘much of the time’’ (4). Health status. This was measured using a single item in the demographic question set, for which respondents rated themselves ranging from ‘‘Feel poorly, need assistance’’ (1) to ‘‘Feel very well, function independently’’ (5).
Results Sample description The final sample of 133 nurses was 98% female (not unexpected in a sample of nurses for this time period), and the median age group of the sample was 46–55 years, with 34% of the sample falling into this category. Another 39% of the sample was over 56 years of age. This is consistent with the reported median age of registered nurses practicing in the United States in 2008.48 Time in nursing ranged from 1 to 30þ years, with slightly over half the respondents (54.2%) having 10 years or less in their current position and 40% employed in their current nursing position between 10 and 30 years; 46% held a Bachelor of Science in Nursing as their highest educational attainment, while 3.8% reported having a doctoral degree in nursing; and 24% of the sample reported their highest educational degree in another discipline. Table 1 shows the distribution of highest level of nursing education reported by the respondents. The sample reflected a broad range of familiarity with the demands of nursing care. While the final sample of 133 was smaller than the planned sample of 180, the data analysis revealed moderate to moderately strong associations between variables with the resulting power greater than .90 and removing concerns regarding the final sample size.49 This sample of professional nurses reported a high level of personal dignity, with a mean score of 31.26 (standard deviation (SD): 10.17) with the scores positively skewed (3.67). Therefore, a one-sample t-test was done to determine the probability of obtaining a similar mean dignity score in the general population. The statistically significant results (t ¼ 35.44, p ¼ .000) indicated that the mean dignity score for this sample 8
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Table 1. Highest educational preparation (N ¼ 133). Associates
Bachelor
Master
Doctoral
Total
Degree
n
%
n
%
n
%
n
%
n
%
Nursing Non-nursing
0 3
0 2.3
61 8
45.9 6.0
54 19
40.6 14.3
5 2
3.8 1.5
120 32
90.2 24.0
Total responses ¼ 149 due to some respondents having both nursing and non-nursing degrees.
of nurses was different from the general population (as a statistical probability). Since the distribution of scores on the DI were skewed, non-parametric statistics were used for further analysis.
Dignity and self-esteem of nurses It has been suggested theoretically that dignity and self-esteem share certain components.18 To explore this in a sample of professional nurses, a correlation matrix of dignity and self-esteem items was constructed. Spearman Rho Correlation was computed due to the skewness of the sample and was rx ¼ .62 (p ¼ .000), indicating a positive and moderately strong association between the two variables. Eight items on the DI were found to have very low correlation with items on the SES, suggesting that they are unique to dignity rather than to self-esteem. These items dealt with having personal beliefs, independence of thought and of action, self-care ability, and expectation of worthiness. There were also three SES items which had very weak correlation with dignity, and these addressed thinking well of oneself and what one does, feelings of uselessness, and feeling proud. While there is clearly a relationship between dignity and self-esteem in this sample of nurses, there are also distinctions to be made between the two self-characterizations (see Tables 2 and 3).
Dignity and work satisfaction of nurses It is suggested that professional nurses’ satisfaction with their practice environment influences the quality of patient care and outcomes.30 In the practice environment, respecting patient dignity is expected. In this sample of professional nurses, there was a significantly positive but moderate association between nurses’ personal dignity and nurses’ work satisfaction (rx ¼ .37, p ¼ .000). Certain DI items had a consistently positive and significant relationship across most of the NWI-R items, for example, ‘‘I have a sense of freedom’’ and ‘‘I have a good sense of self-esteem’’. Since the SES score had a similar positive association with NWI-R score (rs ¼ .29, p ¼ .001) as the DI score, it is not surprising that an item reflecting dignity and an item reflecting self-esteem would have consistent association with NWI-R items.
Dignity and personal demographic traits Dignity and inner spiritual commitment. The relationship between nurses’ personal sense of dignity and the trait titled inner spiritual commitment (as a marker for ethical values) was examined. Respondents rated themselves on degrees of spiritual commitment from ‘‘Very Strong’’ (1) to ‘‘Not an important part of my life at all’’ (5), and analysis of variance was done to look for differences in dignity among the spiritual commitment categories. A statistically significant positive difference was found (F ¼ 3.49 (df ¼ 4), p ¼ .01), with greater dignity in all other degrees of spiritual commitment when compared to ‘‘Not important at all.’’ 9
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Table 2. DI and SES items that are not significantly correlated (N ¼ 133). SES items At times I think I am I feel I do not have no good at all. much to be proud of.
DI items I am allowed to have personal beliefs. I have independent thoughts. I can do physical activities that I want to do. I am able to care for myself. I respect my friends and family. I treat others with a sense of respect. Others know that I respect them. Others should treat me as being worthy.
r p r p r p r p r p r p r p r p
.113 .198 .118 .178 .135 .131 .070 .426 .069 .432 .019 .827 .082 .354 .152 .082
.107 .222 .032 .714 .044 .616 .004 .962 .163 .060 .068 .436 .141 .106 .158 .069
I certainly feel useless at times. .097 .270 .049 .576 .066 .451 .122 .164 .115 .192 .118 .178 .125 .158 .006 .946
DI: Dignity Instrument; SES: Rosenberg Global Self-Esteem Scale. Negatively worded SES items were reverse scored for analysis.
Table 3. DI and SES items that are significantly correlated (N ¼ 133). SES items Satisfied Have good Am a person Feel that I’m with myself qualities of worth a failure
DI items I am allowed to have personal beliefs. I have independent thoughts. I can do physical activities that I want to do. I am able to care for myself. Others know that I respect them. Others should treat me as being worthy.
.321** .206* .231** .323** .244*
.209*
.312** .211* .226**
.332** .359**
.283* .292*
Positive attitude toward myself .236**
.228**
.204*
.235*
.190* .283*
DI: Dignity Instrument; SES: Rosenberg Global Self-Esteem Scale. Negatively worded SES items were reverse scored for analysis. *p ¼
