Abstract
Background:
Physical impairment and dependency on others may be a threat to dignity.
Research questions:
The purpose of this study was to explore dignity as a core concept in caring, and how healthcare personnel focus on and foster dignity in nursing home residents.
Research design:
This study has a hermeneutic design.
Participants and research context:
In all, 40 healthcare personnel from six nursing homes in Scandinavia participated in focus group interviews in this study.
Ethical considerations:
This study has been evaluated and approved by the Regional Ethical Committees and the Social Science Data Services in the respective Scandinavian countries.
Findings:
Two main themes emerged: dignity as distinction (I), and dignity as influence and participation (II).
Discussion:
A common understanding was that stress and business was a daily challenge.
Conclusion:
Therefore, and according to the health personnel, maintaining human dignity requires slow caring in nursing homes, as an essential approach.
Introduction
Dignity is a complex and contested concept and one that is difficult to define. 1 The complexity of the concept is reflected in the wide range of theoretical, personal, and professional perspectives on dignity. Professional perspectives on dignity often identify broader issues related to policy statements, education, the context of nursing care and activities that promote or threaten dignity. 2 However, despite this knowledge, the understanding of healthcare as a caring practice fostering dignity is sparse. Since care is a moral attitude in nursing, according to Gastmans, 3 the concept of dignity may therefore be considered as a foundational normative concept in the ethics of nursing.
Background
Dignity comes from Latin (decus), meaning ornament, distinction, honor, and glory. The expression of human dignity, meaning the highest value, affects us deeply and personally. The principle of human dignity is a universal affirmation, and often used in appreciation of the importance of human individuals. 4 Preserving residents’ dignity is considered a major aim of health sciences. 5,6 Caring as a moral attitude in healthcare may be considered as sensitive and supportive in situations and circumstances with vulnerable residents who need help. 3 No one can consciously simulate caring attitudes. A caring attitude in this sense may arise spontaneously through daily encounters with suffering individuals. A caring attitude is an expression of respect for human dignity, based on a personal relationship, through the “act” of being directly receptive to the ethical appeal coming from the patient 3 although even before this fulfillment will happen. 7 Relationships arise when healthcare personal consider the patient to be important as a person. According to Edlund, 8 all human beings possess dignity as an inner and inviolable property, which Edlund denominates as absolute. Therefore, this absolute quality of dignity can never be injured or destroyed by others or by ourselves. Additionally, the phenomenon of dignity has a relational aspect, belonging to the social context as well as to human physical and psychological dimension of beings. In this study, the concept of dignity was understood as both absolute and relative as well as relational, related to the interaction between the healthcare personnel and the residents. As such, residents’ experiences of dignity may be violable. Physical impairment and dependency on others may be a threat to dignity. 9 Relative dignity is related to the Golden rule: “To do unto others as you would be done unto” (Luke, 6.31). 10 From this concept of equality, the Golden rule is understood as something that we all have in common. However, since we as human beings at the same time are born unique, the Golden rule may lead to indignity if we are not aware of this important aspect of uniqueness, as our actions then may be based on thoughtless generalizations. Additionally, dignity is two-fold, indicating both directed toward one self and toward the other. From this angle, everyone knows how to show dignity due to our own inner experiences. 7 Lohne et al. 11 also found that the family caregivers in nursing homes experienced violation and uneasiness on behalf of the residents, as if it were happening to them. When residents were treated with dignity, they felt respected and valued.
Jacobsen and Sørlie 12 found that care providers experienced ethical challenges every day in nursing homes. Due to this, the care providers expressed frustrations and feelings of powerlessness. Their main concern was that the caring culture in the nursing home was not being supported due to disagreements about basic values in the organization, as well as daily challenges concerning the balance between autonomy and dignity (Jacobsen and Sørlie 12 ). However, we still have little empirical knowledge about how dignity may be fostered and supported in healthcare practice in nursing homes. This article focuses on how healthcare personnel perceive and express the relational dimension of dignity in their daily activities at the nursing home.
Aims of the study
The purpose of this article is to present results about how healthcare personnel focus on and foster experiences of dignity in nursing home residents.
Research questions
How do health personnel describe and explain experiences of dignity in the context of the nursing home?
How do health personnel narrate their understanding of preservation and protection of dignity in the lives of residents in nursing homes?
Ethical approval
This study is a part of a larger study on nursing homes in Scandinavia that has been evaluated and approved by the Regional Ethical Committees and the Social Science Data Services in the respective Scandinavian countries. Participation in this study was voluntary.
Design
This hermeneutical study has a descriptive and explorative design with an element for application, based on focus group interviews with healthcare personnel. 13 Clinical application research strives to translate caring science theory into significance for caring praxis. 14 Application research is supposed to increase a common understanding, both between the researchers and the participants—as well as between the participants (healthcare personnel), which may over time result in better care, according to Lindwall et al. 15
Participants
In all, 40 health personnel participated in this study. Most participants worked as nurses but also as physiotherapists, ergo therapists, activity managers, leaders, canteen-staff, and unskilled workers.
Methods
Context of data collection
This research project took place at six nursing homes: three nursing homes in Norway, two in Sweden, and one in Denmark participated in the study. Data collection was performed by interviews of six focus groups of health personal. 16 Semi-structured guides were developed guiding the interviews, which were performed three to five times with each group at each nursing home (about seven participants in each group). Each focus group interview had a substantially progression: at the first meeting, we focused on what the health personal experienced as most important concerning working with older residents, and how they understood the concept of dignity. We also asked the participant to write down at least two experienced narratives before our next meeting: one narrative with a focus on dignity and another with a focus on indignity. At the second interview, we discussed these narratives in the whole group. The last three to five focus group interviews we focused on challenges according to fostering dignity in the care of the older residents, as well as the participants’ experiences and understanding about these challenges and their potential solutions.
Data analysis and interpretation
The analysis and interpretation of data were performed collectively by all the researchers. Data were analyzed through a content analysis, based on Krueger and Casey. 16 The analysis was used to interpret meaning from the content of the text and the coding categories were derived directly from the text data. According to Krueger and Casey, 16 the analysis ought to be conducted by the persons who had been physically participating during the interviews. Therefore, the six different groups of researchers conducted the interpretation developed from the data of the transcribed text before sending it to the rest of the research group. From this interpretation, the researchers gathered the collective interpretations into a common document, which again was given a plenary judgment before it was transferred to an article, by the first author.
Findings
Findings are based on narratives, spoken by health personal. Two main themes emerged from the data analysis concerning fostering relational dignity in the care of nursing home residents: dignity as distinction (I), and dignity as influence and participation (II).
Theme I: dignity as distinction
According to healthcare personnel, a main concern related to relative dignity is distinction, meaning different or separate like individuality. Dignity is usually communicated through individuality implying respect (like re-spect, meaning re-looking or looking again), listening, eye contact, vocal pitch, posture (body posture), calmness, and friendliness. Respect was understood as the most significant dimension from the perspective of health personnel. Additionally, respect calls for re-flect (reflection). According to the participants, dignity was perceived when the residents felt accepted as unique and complete persons and when they experienced protection and safety: “Human beings grow when they are met with dignity,” according to one participant, and continued: “… some years ago a woman with dementia was admitted, and (she was) very shy and afraid, right, sitting with her bag and looking down … her hair was covering her eyes. We had no contact with her; that was really impossible. I think we tried for two hours … and then I thought … we have to try, so I did what no one else has done before, I guess: I laid down on the floor, crawling under the table.” Then I looked up in her face and smiled at her and I said: “Hey there,” and then I received this beautiful smile, and every time (since then) she recognized me and gave me this beautiful smile and said to me: “Hey there” … … if one does not feel equal to see the other person, when accomplishing nursing care—then the dignity is lost. You might as a staff (member) perform dignity, but if it is not an equal relation to the other (the resident), then the care is really not particularly positive. So if the care is mechanical … like if I practice care without seeing the person that is in need of being cared for and if I do not respond to how the resident is today … you have to accommodate the caring activities to whether the resident is tired or confused … or whatever is happening. So if you as a health care personal continually try to read the residents wishes and needs, then the relation might develop towards more equality. And this is exactly where the attention should be directed all the time … One of our residents is very demented and has no family caregivers, and he loves to watch football, he is from Vålerenga. Then I thought, I love football but I hate Vålerenga (football club), however I can still watch one Vålerenga match (I thought) … So I sent an email to the club and told about our demented resident of 82 years … And there we went, he was dressed in a dark suit and we were seated on the VIP tribune and we were treated with this and that …, but all this joy that we shared … I was … this was actually on my day off … but we were there together, both enthusiastic, and all the glances, and all the pleasant (things we shared)—this is what I hope that my mother and father will experience in a nursing home, that what they like … this is my passion … We have to interpret a little. One tries to be sensitive and look at expressions of the face whether there is something; to interpret and sense the residents’ wishes and needs. If one does not see the other human being, then dignity is at risk. It (dignity) has to do with care, that one really cares and imagines how the other person experiences things. The residents should feel that they are at home. They should not feel that they are at a nursing home. It is their home. We are there to help them. This is an art. Respecting the residents’ choices and wishes, also what they do not want, so that we do not offend the personal integrity is crucial, according to the staff.
Theme II: dignity as influence and participation
Influence and participation was another important aspect of the relational dignity in healthcare practice. According to one participant, the residents are a sort of immigrants: How can the citizen feel at home? Moving to a nursing home is like immigrating to a foreign country. It makes residents feeling threatened, existing without autonomy, personal influence or will. One female resident was forced to move due to her illness. So we were trying to protect some of her self-control. It is very important that the residents can influence when to go to bed or when to go for a walk. It is also about the small things, during meals and other experiences … about having influence. So, influence is a crucial part of their dignity … so is autonomy. The residents should take part in decisions. This is also about dignity. They need to be more involved in decisions and self-management, which also belongs to their dignity and to their identity.
The “little things” were frequently mentioned by the staff, meaning how and why things had to be done. In the nursing homes, such activities were decisive daily tasks like knocking at the door before entering the resident’s room, sensory stimulation (recognizing the smell of fresh bread, hearing music, or taste stimulation during meals), and negotiations between routines and individual wishes and wants. The little things were understood as important to the residents and increased the fellowship and participation among the residents. An important issue was to create a dignified social gathering between or toward the residents. In this perspective, the understanding of dignity was not only a question of actions or activities as such, but rather an issue of how these activities should be performed in the daily life at the nursing homes.
“Dignity should be put out as an agenda,” was suggested by one participant: “We should give the power to the people and let the citizens free!” This parole may also increase influence and participation among the residents. “One should live ones attitudes!,” according to another participant, meaning that you should practice what you preach. Developing the possibility for the residents to decide for themselves would help protect their dignity and thereby minimize their vulnerability, according to the staff. In addition, when preserving dignity, experiences of respect were increased in both the residents and in the health caregiver, according to the participants. This was another crucial point based on the experiences narrated by the staff. Relational dignity was thus experienced as two-sided and mutually relieving.
The participants were genuinely engaged in having a continuous focus on the residents’ experiences and vulnerability. Loyalty was understood as extremely important, primarily loyalty to the integrity of the residents. Among the participants, “listening before talking” was often mentioned as an essential approach toward the residents. “Reading the residents wishes and needs is the core in caring,” according to the participants. Also regular social and meaningful activities like singing groups, question-and-answer-groups, and sharing personal narratives for training memory and language in groups together with the residents was understood as most helpful in preventing loneliness and cognitive impairments in the residents. In this way, indignity was prevented. At the same time, the health personnel that participated in this study were fully aware of their own power in the relations with the residents: We should never forget that this job is one of the jobs with most power because we are really assisting vulnerable and frail persons … so we have so much power which really should be treated in the best way.
To sum up, relative human dignity was understood as the ability of the healthcare personnel to acknowledge the every residents’ unique individuality despite the large group of residents at the nursing home. Dignity in nursing homes depended to an extended degree on health personnel’s creativity in increasing the residents’ power through autonomy, responsibility, and voluntarily participation in daily life at the nursing home. Additionally and according to one participant; “effectivity (at the nursing home) leads to the sacrifice of quality. When you are tired, then you have no capacity to behave ethically.” Business was therefore a problem, as well as time, according to the staff and the combination between rushing and awareness was a great challenge every day. Our study also indicates that indignity increases suffering. Dignity is therefore important to develop and defend in nursing homes.
Discussion
Methodologically, this study was based on longitudinal focus group interviews with Scandinavian healthcare personnel in six nursing homes. Nine researchers were involved in both data collection and interpretation of findings, which may have challenged the research focus. On the other hand, all researchers shared a semi-structured interview guide and two researchers, one as moderator and the other as the referent, led each focus group interview. In this respect, the organizations of themes and questions throughout the conversations were congruent and the group processes were organized in a similar way in the nursing homes. Concerning the interpretation of data, our research group consists of experienced researchers with years of practicing in reading, understanding, synthesizing, and interpreting interview texts. This may also have contributed to increase the comprehensive understanding as well as the profundity in this study, both during the data collections and during the interpretation of the findings. Additionally, this longitudinal design, involving six nursing homes and 12 researchers, may have increased the validity through triangulation, in this Scandinavian study on nursing homes.
The evaluation carried out at the last focus group interview pointed out that these conversations had been experienced as inspiring, significant, and educational among the caregivers. The staff experienced sharing such personal experiences early in the interview process as both frightening and beneficial since they gained new knowledge through sharing challenges and problems with their colleagues. At the same time, business and stress was a daily problem, according to the participants.
Findings in this study were based on narratives from health personnel in Scandinavian nursing homes. Two main themes emerged from the data analysis: dignity as distinction (I), and dignity as influence and participation (II). According to this study, Scandinavian healthcare personnel during these conversations seemed to be fully aware of the importance of dignified care. Substantially, and in accordance with research, dignity was understood as one core value of caring. At the same time, dignity was experienced as the most challenging issue at the nursing homes, often due to effectivity, daily stress, and overload. While the residents had too much time for themselves, the health personnel had far too little. Busyness was therefore a problem as well as time, according to the staff. Therefore, balancing rushing and awareness was a huge challenge for every participant. Nevertheless, re-spect cannot take place in business and lack of time. Respect as re-looking and re-flection through listening takes time. Awareness and individual focus, however, require both time and presence. Flexibility, individuality, and autonomy can only occur in a context of calmness, slowness, and humanity. Dignity takes time.
Dignity as slow caring
Lillekroken 17 discovered the concept of slow nursing in the context of dementia, meaning taking time and being present together with the patients. From this perspective, slow caring might protect the vulnerable and suffering residents’ against paternalism or acts of omission. 18 Slow caring focuses on respect for the patient and emphasizes quality and depth by paying attention to the patients’ needs and resources in its broadest sense: slow caring opens up for time and space, promoting a way of living that emphasizes quality rather than quantity. This important and challenging perspective seems to be a useful perspective in the context of nursing home. Moving “slowly” is a way of living, implying that the product is secondary to the process. Slow caring is therefore to slow down instead of moving faster: the secret balance in slow caring is doing everything in the proper speed—sometimes fast and sometimes slow—and sometimes in between. Being slow means never trying to save time just for the sake of it, even if circumstances force us to speed up. 17 The slow movement as an antidote to our obsession with “fast” (food, travel, life), according to Gallagher, emphasizes virtues as integrity, patience, courage, and respectfulness. Slow ethics values heterogeneity over homogeneity and sensitivity over insensitivity. 19 Slow healthcare practice embraces the reality of healthcare complexity and uncertainty. 20
The participants agreed that dignity is humanity, meaning individuality, autonomy, sensitive listening, respect, protection, and safety. This is in accordance with a concept analysis of dignity, 20 and also in line with Oosterveld-Vlug et al., 9 Haddock, 21 Nåden and Eriksson, 22 and Eriksson. 23 Sensitive listening has been understood as listening carefully, according to Walsh and Kowanko 24 and respect implies giving older people a space of their own, which serves as a symbol of the residents’ individuality. 1,9
Based on individual interviews with care providers in nursing homes, Jacobsen and Sørlie 12 found challenges related to the balance between autonomy and dignity. The caregivers had experienced some degree of weak restraint toward the residents, due to some of the residents’ decision-making capabilities. They also reported that the residents’ loss of freedom was frustrating and ethical challenging to the care providers. With reference to Vetlesen, 25 the need for care within the context of frailty and dependency is two-fold: too little care indicated sins of omission, while too much care indicates curatorship and paternalism. These two aspects should therefore stay in balance. This challenge was also reported by Oosterveld-Vlug et al. 9 Several of the participants’ experiences in our study were related to frustrations toward the lack of balance between residents’ autonomy and the personal influence and wishes. This balance, however, is often hidden in the little things; important but minor, daily issues. 26 The most complicated challenges were related to the vulnerable residents experiences due to suffering from mental confusion and dementia. These findings are also in accordance with Jacobsen and Sørlie 12 and Rehnsfeldt et al. 27
The focus of care is often directed on residents’ strong dependency on help from others. Since mental confusion often fluctuates and might be hidden in the context, meaning the importance of focus on the here and now as a slow caring attitude. Paternalism as a contextual phenomenon is usually understood when authority and force are used, often related to business and stress. Power as a use of force, according to Foucault, 28 is usually silent and may even occur without the participants’ realizing it. Within the context of dependency and vulnerability, this kind of power may occur too often, as hidden, often daily and unlimited between people. This study exposed power narratives in the experiences of the health personnel. These narratives also reveal the respondents’ awareness about power structures, as well as their understanding of how suffering, daily stress, and effectivity create negativity. A caring perspective in the resident’s world can only be understood from a perspective of suffering, according to Eriksson. 29
Dignity as distinction was experienced when the healthcare personnel listened to the residents’ life-stories about their habits, earlier experiences, and their likes and dislikes. Listening takes time and may only occur in a context of slow caring. Through these stories, healthcare personnel were much more able to experience their own sensitivity and awareness together with the residents, which also contributed positively to the health worker. Individualized care implies encouraging the residents to be active and to make decisions, meaning having influence and participation based on personal needs, which again may contribute to the experience of being useful and not being a burden, 8,9,30,31 which simultaneously may strengthen the experiences of feeling dignity and respect.
According to Løgstrup, 7 one can never encounter another person without holding some aspect of the others person’s life in one’s hands, even if this might be next to nothing, like only a temporary sense of atmosphere or an innocent harm. However, this aspect may also be so vital that it simply may determine, ethically spoken, whether the other will succeed in his or hers life (p. 25). This reflection is important since it reveals dignity, both as a fundamental and decisive value in nursing and as a preventing aspect in vulnerability and suffering.
Most of the Scandinavian healthcare participants stressed the importance of making a homelike atmosphere in the nursing home. Considering that a home is a place where people live, a nursing home is obviously a home. On the other hand, a nursing home is also an official work place, with its own staff, rules, and routines. Additionally, a nursing home is a collective home, with only some possibilities for privacy. Therefore, one of the largest challenges in nursing homes is the encounter between the system and individual influence and participation, aiming to balance the individuality with autonomy, integrity, and respect, in spite of vulnerability and dependency of the system and the staff. 9 Healthcare personnel in each country pointed out that protection of the citizen was an important issue. By this they meant both protecting the residents’ from a rigid system and from their fellow confused residents.
According to Nåden and Eriksson, 22 Rehnsfeldt et al., 27 and Lohne et al., 11 residents and their relatives have experienced both dignity and indignity in Scandinavian nursing homes. At the same time, and according to this study, healthcare personnel in Scandinavia are fully aware of the importance and meaning of preserving dignity in this clinical context. One should live one’s attitudes, as one participant suggested. According to our findings, stress and busyness may be a challenge in fostering dignity in the care of nursing home residents in Scandinavia. At the same time, slow caring seems be a contrast to stress and busyness, which again is causing indignity.
Conclusive understanding
Dignity is the core in caring. The essence of preservation and protection of dignity in the context of frailty and vulnerability is, according to this study, acknowledging each resident’s unique individuality through distinction, from the perspective of healthcare personnel. Additionally, increased personal influence and voluntarily participation, among the residents in nursing homes, seems to be essential to preserve and protect their dignity. Both aspects presupposes sensitivity and creativity among the caregivers, understood as increased awareness in combination with respect, protection, and safety related to daily activities, according to the staff. A common understanding among the health personnel in fostering dignity in Scandinavia was that stress and busyness were a daily challenge. Therefore, and according to the comprehensive understanding from Scandinavian health personnel, maintaining human dignity requires slow caring in nursing homes, as an essential approach to achieve quality and depth.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supporeted by the Norwegian Research Council (grant number: 19088999.