1. Background
International nursing organizations and societies have always highlighted issues such as taking care of patients, showing respectful behavior, and preserving human dignity as nursing priorities. Moreover, the inseparable part of nursing is to respect human rights, including cultural rights; right to live and choose; human dignity; and respectful behavior. These rights are not influenced by nationality, race, religion, culture, skin color, age, gender, disease, disability, or political, social, and economic situations (Nursing & Midwifery Council 2008). In this regard, in nursing ethics of some countries, it is stipulated that “All human beings deserve human dignity and it is necessary to respect them in any condition.” Some scholars believe that the most specialized part of nursing function is to deliver care service in a way that the patient does it for himself or herself in the same way, if the patient had the ability, willing, and knowledge (Baillie & Gallagher 2011). According to them, care is a nursing ethical ideal and obligation because the essence of nursing is to preserve human dignity (Williams 2011).
According to some scholars, nurses should value human dignity to preserve the artistic nature of nursing (Olshansky 2007; Kalb & O'Conner-Von 2007). Many relevant studies report that the most important components of preserving human dignity (according to the participants’ view) are receiving respectful treatment, establishing effective communication, maintaining privacy, keeping confidentiality, and giving patients the right to choose (Matiti & Trorey 2008).
In this regard, mothers should receive special attention because while being hospitalized, they enter an unfamiliar environment, are surrounded by strange individuals, force to leave their motherly or marital duties, and take up new activities that are determined by the medical team. Moreover, after delivery, they face with a series of new needs, fears, and expectations.
According to some scholars, in unfamiliar and anxiety-provoking environment such as maternity unit, mothers feel unsafe and scare as their personal information is known to others or their bodies are examined and showed for the childbirth (Baillie, Gallagher & Wainwright 2008). For instance, reported by participants in a study, the human dignity means refusal of nakedness of the patient’s body and receiving appropriate and enough care from the nurses (Lin, Tsai, & Chen 2011). In such conditions, response to mother’s needs and respect her human personality are considered as a step to reduce her anxiety and increase her satisfaction with the care delivered to her during or after childbirth.
Moreover, patients are among the most vulnerable social groups, because they have not only lost their normal physical abilities but also suffer from certain psychological, social, and economic pressures related to their illnesses (Joolaee, Nikbakht-Nasrabadi & Parsa-Yekta, 2009). Since human dignity, especially among mothers, has not received proper attention by nursing pioneers and researchers, there are few provisions and instructions on this issue in countries like Iraq and the Kurdistan Region. Therefore, thanks to the researcher’s activities in instructing nursing and midwifery students in different gynecology and obstetrics wards and encountering with situations where the mothers’ human dignity was ignored, I aimed to conduct the present qualitative study to explore the concept of mothers’ human dignity from the perspective of gynecological nurses.
The nurses’ lived experience of preserving human dignity among mothers refers to discovering the meaning and concept of human dignity according to the maternity nurses’ views and experiences. We hoped that providing clinical care be lined up with their discovered experiences, views, and beliefs about respecting patients, the mothers’ satisfaction be met, and their human values be preserved by making use of their opinions.
Purpose of the study
The aim is to explore and describe nurses’ views and perceptions about human dignity according to their lived experiences of working in maternity care unit in Kurdistan, Iraq.
Research question
What are the views and ideas of maternity nurses regarding human dignity?
2. Materials and Methods
This study adopted an inductive content analysis approach to explore the participants’ views regarding the human dignity of mothers according to their experiences. Content analysis is a systematic coding and categorizing approach, which can be used to explore a large amount of textual data to identify the patterns of communication (Gbrich 2007).
Data collection and participants’ characteristics
The study participants were 10 Kurdish nurses who worked in delivery room of maternity hospital with a variety of work experiences from 1 to 37 years. Data were collected by semi-structure interviews. The sample included female nurses who met the inclusion criteria of the study. The participants were Kurdish registered nurses currently working in the delivery room. All of them had maternity nursing experience and were willing to participate in the study. Interviews lasted 30 to 80 minutes and conducted in Kurdish and then translated into English. 
They were tape recorded and transcribed verbatim. The interviews’ questions focused on the nurse’s experiences of human dignity and the meaning of human dignity from their perspective. These questions were open ended such as “what do you think about aspects of human dignity according to your experience of working here.” Interviews continued with exploratory questions such as how and what questions. Different themes and subthemes were identified through content analysis. 
Data analysis
Drawing on work by Graneheim & Lundman (2004), the following steps were taken to analyze the collected data:
Transcribing the interviews verbatim and reading them several times to obtain a sense of the whole,
Dividing the text into meaning units that were condensed,
Abstracting the condensed meaning units and labeling them with codes,
Sorting codes into subthemes and themes based on their similarities and differences, 
Formulating themes as the expression of the latent content of the text.
Finally, 11 subthemes and 3 main themes were explored. According to the method described by Graneheim and Lundman, on the day of each interview, the recorded voices were transcribed in Kurdish language (Dyer 2005). The transcriptions were then meticulously translated into English. The texts were then read several times and divided into condensed meaning units related to women’s human dignity which were further abstracted and labeled with primary codes such as “insufficient facility for patient care,” “crowdedness of the wards,” “poor husband support,” and so on. Following these steps, the comments of the researcher were applied to modify the subsequent interviews to obtain codes. The codes were sorted as several subthemes (e.g. insufficient health services, poor man power, and war situation) and themes (e.g. providing sympathetic care for women as a human need) based on their similarities and differences with respect to nurses’ opinions about human dignity. Finally, a thematic structure of the latent content of the text was developed (Dyer 2005) and (Gbrich 2007) based on the above-mentioned analysis, 9 subthemes and 3 main themes emerged.
Trustworthiness and study limitation
Trustworthiness was established through member checking, peer checking, and prolonged engagement. Member checking was done by asking the respondents to verify the preliminary findings from the earlier interviews (Graneheim & Lundman 2004). Prolonged engagement was done by the author in the research field to attract the participants’ trust and gather in-depth data.
No particular limitations were faced during the research. However, since the participating nurses did not want hospital managers to be informed of their ideas, the researcher tried to win their trust and ensure them about the confidentiality and anonymity of data both before and during the interviews.
Ethical considerations
The research protocol was approved by Ethics Committee of Hawler Medical University/College of Nursing. A detailed description of the study, the risks and benefits, data confidentiality, and informed consent procedure were given during the initial contact with prospective participants and before their participation. Upon their recruitment, the participants were explained about their rights to withdraw from the study at any time and asked to sign informed consent forms. After receiving the subjects’ permission for recording the interviews, the interviews were audiotaped. The digitally recorded interviews and transcripts were stored on the researcher’s password-protected laptop and were deleted as the study finished.
Since the participants’ distrust would make impossible further interviews in a small environment like Hawler Hospital, the researcher made every effort to conduct the interviews in comfortable conditions, establish close relationships with the subjects, and win their trust to encourage them to share their experiences.
3. Results
Based on nurses’ responses to the interview questions, the study findings identified 3 main themes of “mothers’ deprivation of basic health care services,” “women’s right to have sympathetic care,” and “negligence of the mothers’ human rights from different aspects.”
Mothers’ deprivation of basic health care services 
According to the participants’ statements, “mothers’ deprivation of basic health care services and facilities” was an important theme. The participants’ lived experiences, in regard to the meaning of this theme, frequently referred to the subtheme of taking care with insufficient facility and services. They also stated that these problems could be tackled by commitment acquired during their work and having a maternal sense which made them life-saving people. To explain this theme more clearly, in study nurses’ views, human dignity refers to the ability to take care of mothers and provide health facility for them. The participants’ talks implied crowdedness of the wards, lack of human resources, ineffective control of infectious diseases, and war zone situation. In this regard, participant No.1 said:
“In the hospital, we do not have facilities (clothes and bed sheet) and the patients need to bring them with themselves. Well, this weakness that we do not have anything for the patients is related to the internal system of the hospital. We do not have clothes or bed sheets for the patients and infants, and this is a weakness of our health care system that we cannot fulfill our patients’ needs.” 
One of the issues that the participants had mentioned several times was lack of facilities to control infectious diseases in maternity ward, as referred to it in the following statements.
“Most mothers refer to here while they suffer from hepatitis, and they are unaware of it. I don’t know the reason, but most of them have this disease. We have an isolation room, and we send hepatitis patients there, but most of the time the results of their examinations are not ready until two days. Previously, there was a method through which the examination results would be prepared within 20 minutes, but now they are not announced until two days and we don’t know if the results are positive or negative. The quick method of hepatitis examination is only carried out for elective cesarean sections but not for emergency situation. It is not done for everyone. That is, those who need an emergent cesarean section or childbirth are not examined. We even required that this examination should be carried out for Syrians, and it’s ok if it is not done for our patients, but they didn’t accept, and now we don’t know who has this disease and who doesn’t.”
Another participant mentioned:
“If one of my family members asks me to accompany her to the maternity ward and help them with the delivery, for example, if my sister or my brother’s wife asks me to accompany her, I’ll tell her to bring things like bed sheet and 10 meter clean white cloth, then I’ll go with her. I told them that these things would be used to clean you and then discarded. Because there are no such clean facilities, and there are unclean and inappropriate cloth to do the cleaning with. We don’t have a well-cultured society or a well-organized system. We don’t have the rights of a nurse, that is neither nurse rights nor patient rights are observed.”
Lack of enough time to communicate with the patient is another issue that one of the nurses referred to as a factor to neglect human dignity of patients.
“We really have so much to do that we cannot talk to the patients even some few words. I’m a friendly person but I don’t have time to spend greeting with the patients, support them, and this gives me a bad feeling. In this crowded situation, what should I do first…”.
In this regard, the participants stated
“We just have one women’s hospital, so if a nurse does not have time to provide the patients with health care and take care of them mentally and emotionally, you need to give her the due because there’s a heavy burden on the nurses’ shoulders and the patients are outnumbered. Half of the Iraqi mothers have their childbirth in this hospital. I dare to say half of Iraq refer to this hospital, because other places are either at war or occupied by ISIS or the people are displaced, so the circumstances are really terrible here.” 
At the same time, another participant referred to the failure of administration of such trainings by the members of other health care team. 
“Here we just have a name list and nothing else, so just out of my own interest I teach mothers about how to wash their vaginal area with tepid salty water and adhere to health and nutrition hints. I also teach them about appropriate methods of birth control; however, others do not do these and ignore them. We do not even have posters to teach mothers properly.”
All of these statements imply poor women’s care and inappropriate facilities while having shortages and problems. These situations are quite influential. According to the nurses’ comments, these circumstances impede provision of health care to patients as human right and it is necessary to save their human dignity. 
Women’s right to have sympathetic care 
Another theme deduced from the meaning of human dignity was the “right of sympathetic care for women.” This theme consists of some subthemes and refers to helping mothers by nurses with remarkable eager because of having a maternal feeling toward them and their infants, making friendly communication with them, and taking advantage of their own maternal experiences. Here, mothers take advantage of another human’s utmost help to give birth to another human. In their experiences, nurses frequently referred to subthemes of sympathy and comfort with mother, providing the possibility of communication between mother and infant, recognizing the patient’s needs as a human, reducing pain and suffering, and supporting mothers mentally and emotionally. Then the researcher used their ideas and experiences to extract the theme of “sympathetic care of mother.” 
One participant considered being a woman and having maternal or humanistic feeling and experience as sympathy and main human factor regarding the women. In other words, this feeling revealed her understanding with regard to emotional needs of mother.
“As a nurse, I’m both a woman and a mother, and I sympathize with infants, I take care of infants and I don’t get satisfied even if I become unaware of my infant for some minutes, I think if something goes wrong.”
In this regard, one of the nurses considered such emotional supports as the cause of the mother’s comfort and survival who was crying for losing her infant. She described it as follows.
“I started talking to that sorrowful mother and told her God would give you a great reward if you tolerate. I told her you were young and had enough time to have children again, you need to be tolerant; this infant would go to the Heaven and open one of the Heaven’s gates for you. So I condoled her a lot, I told her God had taken this infant for Himself and you need to accept that it would be in a great place. When she heard what I had told her, she accepted to take her infant out, so we handed it to its dad to see to the procedure. What I did was physically and mentally useful for the patient because if you leave a mother alone in such a situation, her deep sorrow causes severe bleeding, which is highly hazardous, so what I did set her free from these problems.”
The nurses’ mental support of mothers and maternal feeling toward them and also spotting the women’s needs as humans are clearly referred to in the following statements. 
“Looking at patients, I can see if they have mental problems, and I help them because I feel they need emotional help, they’re more in need of emotional help. When I look at them, I can easily read their states in their face and see if they have mental problems. These states occur a lot here. When I see this state, and as for sympathy, I go and talk to and condole the patient.” 
The nurses’ attempt to mother’s human dignity without any expectations in order to reduce mother’s pain and suffering are presented in the following statements.
“I need to help mothers get rid of their pain and problems because to me my work means to set mothers free from their agony and disease and reach the safe state or peace. This is my responsibility because I’ve studied and know that I need to get the patient out of pain, like a human who has referred to for abortion or one who has undergone surgery and is bleeding and the place of her surgery is infected and painful, I teach her how to use the medicine and how to take care of her ulcer so it can heal sooner.”
In other words, the nurse’s focus on mental support of mother and her attempts to establish an emotional relationship with the mother and her infant is defined by the researcher as “right of sympathetic care,” which is another deduced theme that can reflect the nurse’s endeavor to maintain human dignity. 
Negligence of the mothers’ human rights from different aspects
This theme includes subthemes like irresponsibility of hospital personnel with regard to the mothers, getting money for service delivery, and lack of supporting mothers by their family. Based on the study participant’s comments, the researcher extracted such subthemes with regard to the mother’s human dignity. Regarding the first subtheme, for instance, one of the nurses stated:
 “They (nurses and physicians) don’t clean the patient before delivery. They use gloves for deliveries, but don’t change them. They don’t use sterile cloth and set when a child is delivered, and put the baby on mother’s tummy and on her clothes, which is bad for infection.”
Another participant talked about her experience about human dignity as follows: 
“Rapture of membrane should be carried out by doctors. But when I tell the doctor that a patient has meconium and you need to conduct the procedure, she tells me to do it because she may get dirty. This is not so good. There’s even guideline that stipulates that rapture of membrane  is the doctors’ duty not the nurses, but they don’t follow, so we have to do it. After all, we need to help the patients, and it is blessing.”
On another occasion, another participant mentioned nurses’ taking bribes to perform necessary care of mothers.
 “After performing a delivery, nurses take money off the patient, and patients are happy to pay. This meant that nurses focused all attention on those patients and ignored others.”
 In such an atmosphere, taking bribes to look after certain patients and neglect others was mentioned as another issue associated with patient’s safety. The experiences told by some of the participants helped with extraction of the women’s limited family support. For example, one of the nurses said:
“There were cases that the husband had not let his wife to rest sufficiently, so her baby had been aborted. In such cases, we meddle, we need to do so, and we should guide the woman. If necessary, we talk to her husband. However, not everyone does such things, but I think it’s a part of our humanity”.
The meaning unit of limited support of mothers by Kurdish men is also the interpretation and essence of the following statements which refer to women’s deprivation of human rights.
“Women used to have childbirth at home because their husbands did not let them go to hospitals. They would think that there would be male doctors or nurses in the hospitals also they like to have childbirth at home because they’re scared. They think no one takes care of them in hospitals.” 
Based on participants’ words, the nurse’s views and experiences toward women’s human dignity and even patient’s right identified many facts regarding poor human dignity and rights in nursing care. In fact, it is likely that understanding the expectations of people and knowledge about human dignity may be nursing is a task that is full of goodness and a sign for the nurses kind behavior to provide dignity and respect for women.
4. Discussion 
According to the results of the present study, i.e. the main themes of the “mother’s deprivation from basic health services,” “women’s right to have sympathetic care,” and “negligence of the mothers’ human rights in different ways,” the researcher concluded that from the participants’ opinion, respecting mothers’ human dignity means establishing a sympathetic relationship with mothers. Because nurses referred to the mothers’ deprivation from human rights by their family and companions, creating grounds for mothers as important members of the society (who play an important role in educating and maintaining the family) to have such rights can pave the way to value human dignity of the mothers as human beings. 
In this regard, a team of Taiwanese researchers carried out an investigation on Taiwanese patients’ opinion about preserving patient’s human dignity. Based on the results, they reported that paying attention and respect to humanity of a patient is among significant semantic aspects of patients’ respect. Moreover, according to the results of a study carried out in Sweden regarding the nurses’ view about preserving patient’s human dignity, it was concluded that “considering the patient as a sibling” is similar to her need to be provided with compassionate care service (Lin, Tsai, & Chen 2011; Heijkenskjöld, Ekstedt & Lindwall 2010). 
Furthermore, one of the study results was the mothers’ deprivation from human rights and in the participants’ view, the nurses’ respect for patient’s human rights was regarded as a spiritual value. Unconditioned respect for individuals is not only a religious responsibility but also the foundation for concepts in nursing profession. Nursing pioneers like Florence Nightingale and Mother Teresa have focused on the lack of respect for patients with respect to their age, materials, education, and disease state. The basis for their mental belief is that all patients have equal essence in the presence of the divine absolute perfection (Williams 2011).
On the other hand, in their qualitative study, Gustafsson, Wigerbland, and Lindwall (2012) explored human dignity from the perspective of the nurses who were taking care of patients with criminal records. They found that paying attention to the patient and trying to preserve her human value are among moral obligations to fulfill human responsibility based on respect for equality, brotherhood, and similarities. The nurses who took care of the patients with criminal records tried to instill them a sense of value as a human, in other words, protect their internal and absolute dignity. 
Therefore, according to the results of the present study and their study, an aspect of relative human dignity, which depends on human moral virtues according to Nordenfelt’s views, is in agreement with values of the nursing profession. Also, providing the patients with unconditioned care services is a manifestation of patient’s respect. Nordenfelt described human internal dignity as the man’s unique and imperishable feature and stated that all individuals equally possess these features due to their human nature. Among human capacities and features, he also highlighted common sense, reasoning ability, and self-planning capacity. Some of our study participants, according to their experience-based understanding, mentioned that preserving patient’s human dignity is fulfilled through delivery of basic medical care by the qualified and responsible human resources. One of the semantic aspects related to this issue, which was more emphasized, was “irresponsibility among the staff of the wards.”
Moreover, it was revealed that medical and nursing mistakes might occur due to lack of patient’s valuation. In other words, patient’s safety is a concept intermingled with human dignity, and all measures to maintain the patient’s safety are actually taken to preserve and promote the patient’s dignity (Eriksen et al. 2012). To put it in a nutshell, observing patient’s safety is a moral value which is based on high human values and protecting them. A group of researchers believe that a professional nurse is not permitted to blame others for her negligence and mistakes, but she is responsible for her own actions (Slettebø et al. 2009; Sensen 2011; Lundqvist & Nilstun 2007). 
Moreover, lack of sufficient opportunity to communicate with patients was another concept found in the study out of the participants’ opinions and beliefs about respect for patients, which was frequently heard in their talks. According to other studies, spending enough time with patients and listening to them are among the basic components of care in nursing profession, which will bring about positive medical outcomes for the patient (Tirgari et al. 2013). Furthermore, poor interpersonal communication skills among the medical personnel is one of the most important cause of dissatisfaction of the patients with medical services delivered by the hospitals.
In general, the findings of the present study indicate that institutionalization of human dignity and values in the nature of all humans is among medical care components. Respect for patients means fulfilling medical responsibilities and providing and delivering care services and facilities.

Acknowledgments
This study was financially supported by Hawler Medical University/College of Nursing. The author expresses her gratitude and thanks to the study nurses and other people whose help make this study possible.
Conflict of Interest
The author declared no competing interest.


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