Dignity in the care of older people – a review of the theoretical and empirical literature
Ann Gallagher*
1, Sarah Li1, Paul Wainwright1, Ian Rees Jones2 and3
Address:
103, First Floor, Neuadd Ogwen, School of Social Sciences, Bangor University, Bangor, Gwynedd, LL57 2DG, UK and
University of Hong Kong, Shatin, N.T., Hong Kong
Email: Ann Gallagher* - a.gallagher@hscs.sgul.ac.uk; Sarah Li - sli@hscs.sgul.ac.uk; Paul Wainwright - p.wainwright@hscs.sgul.ac.uk;
Ian Rees Jones - i.r.jones@bangor.ac.uk; Diana Lee - tzefanlee@cuhk.ed.hk
* Corresponding author1Faculty of Health and Social Care Sciences, Kingston University & St George's University of London, Kingston Hill, KT2 7LB, UK, 2Room3Faculty of Medicine, Chinese
Abstract
Background:
vulnerable people. The empirical and theoretical literature relating to dignity is extensive and as
likely to confound and confuse as to clarify the meaning of dignity for nurses in practice. The aim
of this paper is critically to examine the literature and to address the following questions: What
does dignity mean? What promotes and diminishes dignity? And how might dignity be
operationalised in the care of older people?
This paper critically reviews the theoretical and empirical literature relating to dignity and clarifies
the meaning and implications of dignity in relation to the care of older people. If nurses are to
provide dignified care clarification is an essential first step.Dignity has become a central concern in UK health policy in relation to older and
Methods:
and empirical studies relating to dignity. The following databases were searched: Assia, BHI,
CINAHL, Social Services Abstracts, IBSS, Web of Knowledge Social Sciences Citation Index and
Arts & Humanities Citation Index and location of books a chapters in philosophy literature. An
analytical approach was adopted to the publications reviewed, focusing on the objectives of the
review.This is a review article, critically examining papers reporting theoretical perspectives
Results and discussion:
identify key dignity promoting factors evident in the literature, including staff attitudes and
behaviour; environment; culture of care; and the performance of specific care activities. Although
there is scope to learn more about cultural aspects of dignity we know a good deal about dignity
in care in general terms.We review a range of theoretical and empirical accounts of dignity and
Conclusion:
nurses understand dignity and adequate resources to operationalise dignity in their everyday
practice. Using the themes identified from our review we offer proposals for the direction of future
research.We argue that what is required is to provide sufficient support and education to help
Published: 11 July 2008
BMC Nursing
Received: 30 July 2007
Accepted: 11 July 2008
This article is available from: http://www.biomedcentral.com/1472-6955/7/11
© 2008 Gallagher et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.2008, 7:11 doi:10.1186/1472-6955-7-11
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1. Background
In United Kingdom health policy there is much rhetoric
about dignity. Reports have highlighted ageism, care deficits
and indignity in health and social care services [1-4].
Government responses have included, according to press
reports, that every NHS hospital should have a 'dignity
nurse' [5]. Reactions in the media were less than supportive
of the initiative and it was described as "an insulting
and cheap gimmick" [5]. The 'dignity nurse' proposal was
abandoned in response to advice from senior nurses [6].
The policy documents and reports did not define dignity
and the idea was used, for the most part, in a rhetorical
manner and for dramatic effect. Nevertheless, the emphasis
placed on dignity means that it cannot be ignored as an
issue for health care professionals. Dignity in care is for
example one of three themes in the report "A New Ambition
for Old Age" [7], which outlines the next steps in
implementing the National Service Framework for Older
People and which should therefore be an influential document
in the future planning and management of service
for older people.
Dignity is not, of course, a new idea. Philosophically it can
be traced at least as far back as the writings of Aristotle. It
has an established place in human rights discourse and
within, for example, the philosophy of the hospice movement.
The first statement in the preamble to the 1948 Universal
Declaration of Human Rights refers to "recognition
of the inherent dignity and of the equal and inalienable
rights of all members of the human family" http://
www.udhr.org/UDHR/default.htm.
In addition to increasing attention to indignity and policy
responses, particularly in relation to the care of older people,
there is a growing body of empirical and theoretical
literature relating to dignity [8-16].
However, in spite of the wide-ranging body of literature
relating to dignity, the common usage of the term seems
more likely to confuse and confound than to clarify the
meaning of dignity. If nurses are to be "personally
accountable for actions and omissions", respecting the
dignity of patients [17], clarification is an essential first
step. To this end we critically examine three key questions
relating to dignity: What does it mean? What promotes
and diminishes dignity? How should it be operationalised
in relation to the care of older people?
2. Methods
2.1 Dignity – Sources of Meaning
There are different approaches to understanding ideas or
concepts such as dignity: we can think critically and philosophically
about them; we can ask or observe people to
find out what they understand by dignity, taking into
account their experience and world view; or we can look
to the humanities and consider accounts in novels,
poetry, theatre or the visual arts. In this paper, we focus on
the first two perspectives. Philosophers engage in critical
reflection and offer typologies and accounts of dignity
generally without reference to empirical data (other than
from hypothetical examples, anecdote and personal experience).
Social scientists collect, reflect on and derive
themes, meanings and theories from empirical data from,
for example, interviews and observation. These accounts
are likely to be rich with emotion, experience and lived
values.
The relationship between these disciplines and between
theoretical and empirical perspectives on dignity is not
straightforward and may most helpfully be viewed as a
dialectical process, a conversation in which theory
informs and generates empirical work and empirical work
informs and challenges theory. In relation to dignity, a
concept discussed and applied in relation to the everyday
complexities of nursing practice, such a dialectic is necessary.
Theory without empirical data is likely to be esoteric
and disconnected from the reality of practice. Empirical
data without theory enlightens neither the particular nor
general aspects of practice and has the potential to lull the
practitioner into unreflective positions of hopelessness or
complacency.
2.2 Search strategy
We have not attempted to produce a systematic review, in
the sense generally understood by this term. We have
however attempted to be thorough and rigorous in our
search for relevant publications and we therefore give a
brief description of our search strategies. We adopted two
approaches to locating relevant literature in relation to
dignity: a conventional search strategy to locate empirical
literature; and a broader approach enabling us to locate
papers and book chapters in applied ethics and philosophy,
enabling us to engage with a broad and historically
wide-ranging body of literature.
Our search strategies for the empirical literature included
a) a search of abstracts in Assia (Applied Social Sciences
Index and Abstracts) and BHI (British Humanities Index);
CINAHL (Cumulative Index to Nursing and Allied Health
Literature), Social Services Abstracts, International Bibliography
of the Social Sciences (IBSS), Wilsonweb (Social
Sciences Fulltext and Humanities Fulltext), Web of
Knowledge Social Sciences Citation Index and Arts &
Humanities Citation Index, and b) hand-searched specialist
journals. Our intention was to carry out a preliminary
scoping of the potentially relevant literature so as to assess
and ascertain the nature and distribution of relevant studies
for breadth and depth. We excluded all review articles,
discussion papers, anecdotes, non-English language studies
and debates. Our inclusion criteria were primary
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empirical studies, older people and dignity, English language,
quantitative and qualitative research. Our search
covered all the dates from 1951 to April Week 02, 2007.
We used the following key words: dignity, older, geriatric,
gerontology, aging/ageing, senior citizen, OAP/OAPs,
pensioner, old or elderly or elder or elders.
From a total of 342 abstracts, we identified 49 empirical
studies which explored the concept of dignity within the
context of health and social care settings for older people.
Papers were selected on the basis of their potential to display
representative features of dignity.
The approach we employed to engage with philosophical
perspectives on dignity included electronic and hand
searches of philosophy and applied ethics journals and a
scrutiny of philosophy texts and chapters. Dignity is a
well-established concept in Western philosophy and
some of the writings predate electronic search strategies,
for example, Aristotle (384-322 BC) and in the 18
Immanuel Kant. We also identified readings from
bibliographies and reference lists in papers relating to
concept analysis.th Century,
3. What does dignity mean? The philosophy
literature
It seems generally to be accepted that the concept of dignity
means something like being of value or worth,
because of the presence of some necessary characteristics.
One of the earliest references to dignity is in Aristotle's
Eudemian Ethics [18] where it appears as one of fourteen
virtues or mean states of character between an excess of
unaccommodatingness and of deficiency or servility [18].
Dignity for Aristotle is thus a quality, an excellence or
moral virtue of the person, a quality that contributes to
human flourishing or happiness and one in which one
can err in terms of excess or deficiency. If an individual has
too little sense of her own worth she may be servile and if
too much she may not accommodate others and may be
guilty of the vice of arrogance.
A more recent account of dignity comes from the 18th
Century philosopher, Immanuel Kant, who argues that
some things have a price for which they can be exchanged
or for which their value can be traded, but some things are
beyond price and cannot be exchanged. For Kant these
have worth or dignity [19]. As Badcott argues, Kant holds
that human beings posses dignity because "they are
rational, autonomous creatures with intrinsic value who
can pursue and determine their own ends" [20]. For both
Aristotle and Kant dignity thus seems to be contingent
upon characteristics such as rationality and autonomy: it
would be difficult for someone who lacked rationality to
possess the Aristotelian moral virtues, while Kant's reference
to "intrinsic value" seems nonetheless to rest on the
possession of autonomy.
Some contemporary philosophical accounts also emphasise
individual capability or autonomy in relation to dignity.
Shotton and Seedhouse [13], for example, define
dignity in relation to the interplay between capabilities
and circumstances, pointing out that "we tend to lack dignity
when we find ourselves in inappropriate circumstances,
when we are in situations where we feel foolish,
incompetent, inadequate or unusually vulnerable". They
hold that dignity can be maintained where there are the
capabilities to respond to potentially undignifying circumstances
or where the circumstances are changed so
they are not undignifying. If, for example, an older person
felt that wearing an open-backed hospital gown was
undignified the person could either ask for an alternative,
or nurses could, as occurred in one of our local Trusts,
redesign the gown so it opened at the side rather than the
back. Elsewhere Seedhouse argues that "if a health worker
wants to promote a person's dignity she must either
expand her capabilities or improve her circumstances"
[21]. This perspective focuses on whether a person feels
dignified or undignified, rather than on whether others
perceive them as having dignity, thus making dignity a
subjective experience rather than a moral quality subject
to the judgement of others.
Pullman [22] distinguishes between an ethic of dignity
and an ethics (
care. He points out that autonomy "is crucial to certain
aspects of dignity, but should not be confused with the
whole of it" [22]. This discussion supports the inadequacy
of autonomy as the sole ethical focus of care, particularly
in relation to those who lack autonomy. Pullman's view
of an ethic of dignity does not, however, deny the importance
of autonomy as a value and he states that:
each autonomous citizen assumes some paternalistic
responsibilities to protect the dignity of others who
may never have the capacity, are not yet capable, or
who are no longer able, to care for themselves – recognises
and values our mutual interdependence. It is
respect for the basic dignity of humanity that elicits
our care and concern for the severely demented and
frail older person. In responding to their dignity we
express and enhance our dignity as well.
While Pullman recognises the importance of autonomy,
he emphasises its limitations as a value ("it is a value, not
the value") and suggests the importance of dignity, particularly
where autonomy is lacking.
Beyleveld and Brownsword [23] develop the relationship
between autonomy and dignity further and demonstratesic) of autonomy in relation to long-term
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the tension that may exist between these two concepts.
They discuss dignity and the conditions in which human
rights can flourish. Where a person is autonomous dignity
can, they argue, be a "two-edged sword". It can either
empower and support dignity or constrain it. To illustrate
this, Beyleveld and Brownsword give the example of a
French response to the activity of dwarf-throwing [23].
The Council d'État affirmed that respect for human dignity
was one of the components of
the so-called attraction of dwarf-throwing in local
clubs should be banned. One of the dwarfs involved,
Manuel Wackenheim, argued that he freely participated in
the activity, that it secured him a monthly wage and enabled
him to engage in professional life. The Council d'État
responded that Wackenheim "compromised his own dignity
by allowing himself to be used as a projectile, as a
mere thing, and that no such concession could be
allowed" [23]. We return to this discussion of the relationship
between autonomy and dignity in the concluding
sections of this paper. Jacelon [24] brings these concepts
together, relating dignity to integrity. She describes personal
integrity as "a dynamic intrinsic quality of the self,
composed of health, autonomy and dignity".
A range of types or categories of dignity appear in the literature.
Sandman [25], for example, refers to human dignity
and contingent dignity. Badcott [20] writes of
emotional dignity and distinguishes between intrinsic
and extrinsic dignity: the former something that everyone
has just because they are human and the latter contingent
or extrinsic. Mann [26] distinguishes between internal
(how I see myself) and external (how others see me) components
of dignity. Spiegelberg [27] distinguishes
between: the expression of dignity by inward and outward
behaviour; dignity in general (a matter of degree); human
dignity (minimum dignity which belongs to every human
being qua human); intrinsic and extrinsic dignity; relational
and absolute dignity; and dignity in itself (intrinsic
worth) and ground for dignity and worthiness of respect.
Two theoretical accounts are particularly helpful in identifying
features of dignity and indignity in relation to
health and social care. The first, accommodating both
intrinsic and extrinsic or contingent features, is that by
Nordenfelt [28,29] (for a fuller account of Nordenfelt's
approach see Wainwright & Gallagher 2008). This framework
provided the philosophical backdrop to the Dignity
and Older Europeans Project [15]. Nordenfelt distinguishes
between intrinsic and contingent value, but he
divides the latter into three, and thus distinguishes four
concepts or varieties of dignity as follows:
•
an intrinsic dignity we all have to the same degree just
because we are humans.
•
certain roles or office or because they have earned
merit through their actions. They have rights on the basis
of merit and are, therefore, treated as having a special dignity.
•
on their moral stature that emerges from their actions and
omissions and from the kind of people they are. There are
degrees of this and it is dependent on subject's action so
may come and go.
•
related to one's identity as a person and is related to self
respect and concepts such as integrity, autonomy and
inclusion. This kind of dignity can be taken away from
people when, for example, they are humiliated, insulted
or treated as objects.
The concept of Menschenwürde is of particular relevance
to nursing practice as it emphasises the importance of
acknowledging the worth of all human beings, regardless
of their condition and is thus a counter to the criticisms of
rationalist models of dignity described above. Dignity of
merit and dignity of moral stature are interesting from a
nursing practice perspective. Clearly, for Nordenfelt, people
who attain high office or who demonstrate great moral
probity deserve respect on that account and, if for no
other reason than common courtesy nurses should give
all patients appropriate respect. However an appeal to
Menschenwürde could be said to override any claim to
particular respect for merit or moral stature in so far as
nursing practice is concerned. Health care professionals
are generally expected to treat all patients who come
before them, regardless of their moral character or civic
status. Given the view of Aristotle that dignity is one of the
moral virtues the moral account of dignity is clearly
important. Aristotelian virtue theory also reminds us of
the importance of dignity as a quality of the health care
professional. Nurses, by this account, would be expected
not only to respect the dignity of patients but also to
exhibit dignity in their own character. Dignity of identity
is also of particular interest to nurses, as it has the potential
to give the clearest guidance as to how we should treat
other people in practice, so as to preserve their dignity.
The importance of dignity of identity provides, for example,
a theoretical justification for providing individualised
care.
While Nordenfelt [28,29] identifies four positive types or
varieties of dignity, Mann [26] developed a provisional
taxonomy of dignity violations as follows:
•
they are not acknowledged or recognised and where peo
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ple feel unheard or disregarded. Mann suggests that an
extreme example is where prison and concentration
guards were instructed not to make eye contact with
inmates and to 'look only at the centre of their forehead'.
An example from nursing practice might be the patient or
visitor who tries to attract the attention of a nurse, only to
have the nurse avoid eye contact and to ignore the attempt
at engagement.
•
people may be seen but only as a stereotypical member
of a group, for example, as a woman, student, Italian,
older person or a schizophrenic. As Mann [26] points out,
''group classification can be a source of pride'' but here, as
a type of dignity violation, being seen only as a group
member is pejorative and depersonalising, diminishing
the dignity of the individual.
•Being seen but only as a member of a group – In such situationsInjuries to dignity resulting from violations of personal space
– There are differences in the way we perceive personal
space and how we respond to people who enter our personal
space. Responses will vary according to the nature of
the relationship, whether permission has been gained and
how dignified people feel when someone enters their personal
space. There is much potential for dignity violations
should permission not be sought and gained.
•
occur if people are singled out, separated or distinguished
from the group and subject to criticism. Mann gives the
example of a child who is asked to stand in the corner at
school. Although Mann refers to the conscious ''singling
out'' of an individual, humiliation may equally follow
from not being recognised as an individual, as in each of
the previous three categories. Thus, although Mann calls
this a dignity violation it might also be seen as the result
of any other dignity violation. If we are not seen or seen
only as a member of a group, or if our personal space is
violated and we are thus treated as being of little worth,
humiliation would describe our affective response to the
experience and might also characterise how others would
describe our situation.
Mann's provisional taxonomy was informed by discussions
with students, anthropologists, sociologists and
bioethicists. What becomes clear from the discussion of
theoretical or philosophical perspectives on dignity is the
necessary engagement of philosophy with empirical data
about human experience and with the work of the social
or human sciences. This is an example perhaps of
Bhaskar's description of philosophy as underlabouring, a
role it plays "for the sciences, and especially the human
sciences, in so far as they might illuminate and empower
the project of human self-emancipation" [3].Humiliation – This final type of dignity violation may
4. Dignity as a nursing value
Nurses and other health care professionals are frequently
exhorted to respect the dignity of patients and clients.
Respect for dignity appears as a central value within nursing
codes. The preamble to the International Council of
Nursing Code [31] states:
Inherent in nursing is respect for human rights,
including cultural rights, the right to life and choice, to
dignity and to be treated with respect.
The Code for nurses in the United Kingdom [17] states :
Make the care of people your first concern, treating
them as individuals and respecting their dignity.
There is, then, agreement within nursing codes that
respect for dignity is an important value and that nurses
have obligations to respect the dignity of patients. However,
what this requires is not made explicit and there is no
agreement that dignity is a necessary component of ethical
healthcare practice.
It has been argued that the application of the concept of
dignity is lacking in normative or explanatory value.
Mann, discussing the Universal Declaration of Human
Rights complains that "the UDHR is largely silent about
the meaning or implication of dignity" [26]. Similarly,
Schulman [32] points out that such declarations do "not
offer clear and unambiguous guidance on bioethical controversies".
The Department of Health [33,34] website
notes that (in spite of all the Government rhetoric about
the importance of dignity), "There is no clarity about what
dignity is and what minimum standards for dignity
should be"; in spite of this DH states that it is their aim "to
create a zero tolerance of lack of dignity in the care of
older people". Sandman [25] is sceptical about the usefulness
of the concept of dignity in relation to palliative care,
arguing that it is "difficult to see that we deserve, owe or
are owed anything just for being human", but that it is
also difficult to find other criteria for human dignity that
are sufficiently inclusive to accommodate all people as
having equal worth, while excluding non-human animals.
For Sandman it is "far from obvious that we have
any use for the concept of human dignity" in nursing care.
Another criticism of dignity as a concept in healthcare ethics
comes from Macklin, who states that "Appeals to
human dignity populate the landscape of medical ethics"
[35] and points to references to dignity in human rights
declarations and bioethics reports. She argued that dignity
is a "useless concept in medical ethics and can be eliminated
without any loss of content". She goes on to say that
"in the absence of criteria that can enable us to know just
when dignity is violated, the concept remains hopelessly
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vague" and that it "means no more than respect for persons
or their autonomy". Macklin's paper in the British
Medical Journal in 2003 generated responses arguing for
and against the utility of dignity http://bmj.bmjjour
nals.com/cgi/content/full/327/7429/1419. If Macklin is
correct in saying that dignity equates with respect for persons
or their autonomy then it seems plausible that the
additional terminology of dignity is not necessary and we
should simply demand that people are treated with
respect. Without an analysis of respect [36] this is less than
helpful. However, from our review of the literature and
interdisciplinary discussions, we would argue that dignity
is fundamentally concerned with claims of worth or value,
with behaviour that justifies such claims and with treatment
by others that shows appropriate respect: dignity is
thus not reducible merely to autonomy or to respect. Further,
the negative implications of dignity can be avoided
and it serves an important function in nursing ethics and
is then a necessary and appropriate nursing value.
5. What promotes and diminishes dignity in
practice? Learning from empirical findings
A dialectical relationship between theoretical analysis and
empirical studies in relation to dignity, and the underlabouring
role of philosophy, is, arguably, particularly
important in relation to the care of older people. In discussing
how sociological theory informs their empirical
study, Calnan et al [9] argue that:
Theoretical accounts have offered a general understanding
of the social significance and importance of
dignity and suggest that older age may threaten dignity
by structuring and limiting the opportunities for participation
and/or social recognition. Micro-sociological
research has shown how older people negotiate
their identity, in the face of its erosion by the aging
body and disability and the domination of health and
social care workers.
Any plausible account, therefore, of what promotes and
diminishes dignity in practice should be grounded in theoretical
accounts of dignity and ageing from philosophy
and sociology, together with the analysis of empirical
data. This might involve, for example, exploring the conceptual
relationship between dignity and other values,
such as autonomy and respect; the varieties or types of
dignity and dignity violations and the way in which older
people construct their identities and experience dignity in
their lives.
Empirical studies of dignity have investigated the views of
older people in nursing homes [1] and the views of hospitalized
older people [12,37,38]. The most comprehensive
European study of older people and dignity, which
resulted in a large number of publications, theoretical and
empirical, was led by Tadd and colleagues [8,14,15,39-
41]. This study obtained the views of older people, young
and middle aged people and health and social care professionals.
The majority of the studies we located were European
or American. One exception was the work of Lee and
colleagues [42] in Hong Kong where the views of older
people were obtained regarding their views of privacy and
dignity and what supported or undermined these values.
This work is ongoing and is being replicated in the UK.
The empirical studies are all qualitative in nature and the
methods of data collection include interviews, focus
groups and observation.
In one of the publications relating to the Dignity and
Older Europeans study [39], it was reported that older
people in the United Kingdom viewed dignity as a multifaceted
concept with the following components: dignity
of identity; human rights and autonomy. The data suggests
how each of the components can be maintained or
compromised by the behaviour of the person themselves,
the behaviour of staff and by the environment. In relation
to dignity of identity, for example, there is reference to
'they let themselves go' and to staff referring to older people
in a derogatory way, for example, as 'cotton buds',
'wrinklies' or 'geriatrics'. Mixed sex wards were considered
undignifying. In relation to human rights, examples are
given of the right to choose in relation to end of life care
and to rights in terms of adequate pensions. In relation to
autonomy, there is emphasis on independence and control
over one's life. Professionals' views of dignified care
within the European study [41] shared the themes of
autonomy and maintenance of identity and also included:
a holistic and person-centred approach; participation,
communication and respect. Professional views of undignified
care have similarities with the dignity violations
outlined by Mann [26], that is, invisibility, depersonalized
care, treatment as an object, humiliation and abuse
and mechanistic approaches to care. Another paper from
the study [8], reporting the perspectives of those who
work in health and social care, highlighted the importance
of identity, human rights and autonomy and
pointed to challenges regarding resources and a task oriented
approach. A gap was identified between what providers
are able to deliver and what they would like to
deliver. Differences were noted in time frames between
older people and staff – the former being time-rich and
the latter time-scarce.
A Swedish study [10] suggested three themes that illustrate
positive and negative aspects of ageing and vulnerability
in relation to dignity. They were: the unrecognizable
body; fragility and dependence; and inner strength and a
sense of coherence. Empirical data from the studies cited
provide rich perspectives from older people on their views
and experience of dignity and indignity and suggest fac
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tors or components that contribute to or detract from dignity
in practice.
There are many similarities among the various empirical
studies. Findings from the 'Dignity and Older Europeans'
study and from the Seedhouse and Gallagher [12,38]
study supported the significance of: staff behaviour and
attitudes; the environment and culture of care; and
resources. These themes are also apparent in the recent
Department of Health Survey, which obtained the views
of professionals and members of the public over a ten
week period (from June to September 2006) regarding
dignity in care. The findings were published on the
Department of Health web-site. http://tinyurl.com/
5un23j. The survey generated over 400 responses, 240
from healthcare professionals and the remainder from
members of the public. The DH survey is interesting, not
because it is necessarily rigorous research – we know little
about how it was analysed, the nature of the (selfselected)
sample, or the implications of internet access,
for example – but because it represents a kind of official
account and has been presented as the background to
future policy work and to exhortations to the professions
to do better. Reports relating to the survey published
[33,34] outlined ten of the 'most commonly raised issues
in the survey' and two 'minor issues' (ibid p.5). The ten
most common issues are as follows:
1. Clarifying what dignity is – findings suggested that
there is no clarity about what dignity is and what minimum
standards should be. Responses suggested a range of
meanings, for example, privacy, courteous treatment, having
choices about care and consideration for cultural and
religious needs.
2. Complaining about services – it was reported that 'the
overwhelming majority of people who completed the survey'
felt that It is difficult to make a complaint about services,
that the complaints system is not adequate and needs
to be more accessible, simpler, quicker to respond, more
independent and more powerful.
3. Being treated as an individual – responses suggested
that people were not listened to or treated as an individual
and that they were being cared for as a group. Suggestions
for good practice included: talking to people as individuals
and not stereotyping them; encouraging independence
and giving people time and choice.
4. Privacy in care – People reported not having enough
privacy when receiving care. The environment is important
here ensuring that curtains and private rooms available
and also protecting privacy of information.
5. Assistance in eating meals – It was reported that there is
not enough assistance available or time allocated to service
users to eat meals.
6. Access to lavatory/bathroom facilities – There is often
insufficient access to lavatory/bathroom facilities with
staff unavailable to help and alternatives, such as commodes,
offered that people found embarrassing and
undignified.
7. Being addressed by care staff appropriately – Responses
emphasised the importance of using proper titles and not
calling people 'love', 'dear', 'poppet' and so on.
8. Maintaining a respectable appearance – Lack of care,
time and resources and laundry damage were said to contribute
to people not appearing well-groomed.
9. Stimulation and a sense of purpose – it was felt that lack
of stimulation can speed decline and make people feel
isolated, therefore, having stimulating activities and a
sense of purpose (when in a care home or at home alone)
are important.
10. Advocacy services – People suggested that there are
insufficient advocacy services for vulnerable adults and
that these would support people in making complaints.
The two other issues that were identified as "common
issues" and in relation to which there were "a smaller
number of comments about" were labelled "minor
issues". This appears to be unfortunate and inappropriate
terminology given the potential of these issues to diminish
dignity for service users, as the two items were:
1. Language barriers between care staff and service users –
Responses pointed to difficulties in communication and
cultural differences in care.
2. Mixed-sex facilities – Being placed in mixed-sex facilities
makes many people feel uncomfortable
The NHS depends on a large number of staff from outside
the UK, for whom English is not their first language, while
the patient population also represents considerable ethnic
diversity. Language barriers have the potential to create
problems and an inability to communicate effectively
may lead to problems for the maintenance of dignity.
Placing patients in mixed-sex facilities may only have generated
a smaller number of comments but it can hardly be
dismissed as a minor issue, given the amount of attention
paid to it by government ministers and political parties
and in the media in recent years, an issue we return to later
in this paper.
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6. Dignity themes
The examples of poor care identified from the Department
of Health data are graphic and are not dissimilar to
examples cited elsewhere. However they are too specific to
be useful in a more general consideration of dignity in
care, for which we would argue a thematic analysis is
more helpful. We compared the Department of Health
[33] findings to earlier empirical work and to theoretical
frameworks. Following an analysis of both we concluded
that concerns about dignity could be organised in four
common themes:
• environment of care;
• staff attitudes and behaviour;
• culture of care; and
• specific care activities.
The first theme,
which care is given and the conditions which may lead to
patients not being treated as being of worth. The environment
of care, and most particularly the physical environment,
includes issues of privacy and of the nature of the
institution. This theme is evident in previous empirical
work, as discussed above. In the Department of Health
report four of the twelve issues identified related to the
environment of care. Privacy in care, access to lavatory/
bathroom facilities, stimulation and a sense of purpose
and mixed sex wards all have the potential to impact on
patient dignity
As a social convention, if we feel that the users of a facility
are important people we take some trouble to ensure the
accommodation is of good quality. An unsatisfactory
environment of care thus implies a failure to recognise the
worth or value of the patient or service user. Where there
are gaps in curtains, lack of privacy for examinations,
insufficient access to toilets and bathrooms, mixed sex
wards, and drab and shabby accomodation both basic
human dignity or Menschenwürde and dignity of identity
[28,29] are compromised. Violations of personal space
and humiliation, as outlined by Mann [26], are also
potential dignity violations.environment of care, sets up the context in
Staff attitudes and behaviour:
reported by respondents in several studies that reflect the
way individuals responded to patients, showing a lack of
respect, intolerance, impatience, and being patronising.
Staff attitudes and behaviour included infantilising and
patronising approaches, respondents to the DH survey
saying for example, "the use of endearments such as
sweetheart, darling, poppet should be banned from
health care language. These terms are predominantly used
in communicating with older people and it is inappropriate,
demeaning and patronising". Patients felt that care
that contributed to dignity required appropriate use of
language, empathy, kindness and showed that the nurse
knew the patient as an individual.
This was a strong theme in other reports of empirical work
we examined. In the Dignity and Older Europeans Project
[16] older people emphasised the importance of carers
and others showing respect and recognition. This theme is
also evident in at least four of the issues identified in the
Department of Health [34] report: being treated as an
individual; being addressed by care staff appropriately;
maintaining a respectable appearance; and language barriers
between care staff and service users. Staff attitudes
and behaviour have the potential to enhance dignity in
these areas when care is individualised and people not
stereotyped, when appropriate terms of address are
agreed, when time and care is invested in helping people
to dress and be groomed as they see fit; and when communication
is improved to facilitate collaborative and
patient-centred care.
From a theoretical perspective concerns in this area would
seem to reflect Menschenwürde and dignity of identity. By
the accounts of Nordenfelt and others, we should treat the
unconscious, demented or confused patient with as much
respect, tolerance, patience and empathy as we would any
other person, because such patients remain human beings
with human dignity. Dignity of identity and self respect
are violated by behaviour that is disrespectful of dignity
because such behaviour results in low self esteem, loss of
self respect and feelings of lack of worth. This also resonates
with dignity violations outlined by Mann [26]: not
being seen, being seen but only as a member of a group
and humiliation.this theme concerns factors
The culture of care
the shared beliefs and values concerning the nature, style
and organisation of care that may prevail in an area. This
is related to what is often called the "Ward Philosophy",
although we prefer the term "culture" to capture the sense
of shared beliefs and values. Thus respondents wished for,
but were often denied, the opportunity to be involved in
their care, to express their autonomy, to be allowed to give
or withhold consent, and to be treated as individuals, in
an atmosphere that respected cultural differences and
offered confidentiality. Having accessible and transparent
complaint processes, often denied according to the
Department of Health report is also suggestive of the environment
of care. If the culture of care is positive rather
than defensive and focused on therapeutic goals and
patient/service-user well-being then complaints processes
will be views in constructive terms. Similarly the availability
of advocacy services, an improvement suggested by theindicates factors that suggest in general
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Department of Health survey [33], would be viewed
favourably.
Concerns regarding the culture of care seem particularly to
reflect dignity of identity, as these are the concerns of the
autonomous, rational individual seeking to preserve self
respect and self-identity. They are underpinned by concern
for human dignity, as this provides the basis for
efforts to involve patients as much as possible even when
this is difficult, and to provide individualised care wherever
possible even if this has to be inferred from secondary
information, about for example a patient suffering from
advanced dementia. Budgetary constraints, a concern with
performance targets, prioritising the institutional objectives
over the needs of patients, trying to discharge
patients as quickly as possible and staffing arrangements
that result in many different nurses caring for the patient
over any given period were all cited by respondents as
examples of care that lacked dignity. The theme of the culture
of care is supported by references to holistic and individualised
care and to participation, to the failure to
provide holistic and individualised care relates to menschenwürde
and to dignity of identity. In this theme we get a
sense of an organisational climate in which the institution's
goals take priority over the objectives of practice.
The fourth and final theme relates to the wide range of
care activities
thwart dignity, for example, to actual procedures or
actions, such as bathing, toileting, feeding, dressing and
so on. Respondents to the DH survey [33] mentioned
these frequently as examples of undignified care, describing
patients being left in soiled beds or clothing, not given
help with meals or drinks, not being dressed appropriately,
or being placed in situations where privacy was
ignored, and similar concerns have been raised in many
other reports, for example in the media. Such indignities
by definition would be inflicted on the most dependent
patients, often on those who lacked capacity through
dementia. This theme relates particularly to the DH [33]
issues relating to assistance in eating meals, privacy and
access to lavatory and bathroom facilities.
Attention to small details of care and to individual preferences
in relation to care activities are highlighted as being
of much significance and suggests how the different
themes may be interdependent. Gallagher [44], for example,
describes the preference of an older female patient for
a cup and saucer. To young people accustomed to drinking
from a mug or a Styrofoam cup from a coffee shop this
may seem foolishness, but to a woman of a certain generation
and social class, who would never dream of using a
cup without a saucer, and would be ashamed to serve tea
to a guest in this way, this would be a significant matter.
If not providing a saucer was just laziness or thoughtlessness
on the part of the nurse then the responsibility is
hers. But if the institution has chosen, perhaps as some
cost control measure, to remove crockery from the ward
and to serve all drinks in plastic cups from dispensing
machines, then the disrespect is institutionalised and
nurses will have great difficulty overcoming this. In this
context the first appeal would be to Menschenwürde, as
depriving conscious or unconscious patients of adequate
privacy or care for hygiene, nutrition, or elimination
seems a straightforward violation of human dignity.
Attention to the nuances and preferences of individual
patients also points to the importance of dignity of identity
and to nursing responses that engage with patients in
their care.
What becomes clear in the comparison between survey
findings of the Dignity in Care survey and other empirical
data is that the data can be understood both within a philosophical
framework such as that of Nordenfelt [28,29]
and from the microsociological perspective of writers such
as Woolhead et al [39]. What is also clear is that findings
from the survey replicate findings from previous empirical
studies and echo earlier examples of political rhetoric.
Frank Dobson (at that time Secretary of State for Health in
the UK Government) in 1998, for example said that "no
older person in hospital should go without the fundamental
care that contributes to recovery – to be helped to
eat and drink; to lie in a clean dry bed and to be treated
with respect..." The Health Advisory Service 2000 [45] had
pointed to deficits in relation to dignity and privacy for
older people in acute wards and good practice guidance
was subsequently published (Dignity on the Ward; Promoting
Excellence in Care) supporting themes discussed
in this paper. These remarks sound very like the recent
statements from the Department of Health and from current
and recent Ministers and Civil Servants, almost ten
years later.specificthat have the potential to promote or
7. Operationalising Dignity – Implications for
everyday practice
We acknowledge the problems of reaching any definitive
philosophical account of the concept of dignity. It is probably
not possible to develop a set of necessary and sufficient
conditions or an account of the essentials of human
dignity. Nevertheless we would argue that it remains a
useful concept within its own limitations. A minimal
account would suggest that it draws attention to a kind of
value or worth that is part of our normative account that
should shape our relations with and our treatment of
other people. At the very least, the concept of dignity calls
for an acknowledgement of worth and a concomitant
expectation that we should treat people appropriately,
with respect for their worth as people.
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The empirical data can be read as supporting this position.
The concerns expressed by patients and health professionals
draw attention to situations in which people felt that
they had or had not been treated as being of worth and
had or had not been shown appropriate respect for their
dignity. The interest in the detailed analysis of patients'
construction of their identity and their accounts of their
experience comes in the way they choose to exemplify the
kind of treatment that does or does not count as dignified
in their view. These range from straightforward neglect, as
when a patient is left in a soiled bed, to being given proper
opportunities for engagement and full participation in
decisions about care. It is not surprising that much of
what is described as contributing to dignity in care could
be grouped under the heading of individualised care.
To operationalise dignity in everyday practice nurses
should focus on the four themes discussed in this paper
(environment of care; staff attitudes and behaviour; culture
of care; and specific care activities). What is also
required is the exercise of practical wisdom on the part of
policy makers, managers and practitioners. This will enable
them to tolerate uncertainty and ambiguity in individual
perceptions. There is, for example, a potential conflict
between autonomy and dignity. The conflict between the
putative right of a French Dwarf to be thrown around a
nightclub and a view of the public interest as prohibiting
such activities even when freely chosen is perhaps an
extreme example [23]. However, if an older person
chooses to ignore conventional standards of hygiene and
resists attempts to persuade him to have a bath, a consideration
of his best interests will have to balance the value
of his autonomy and independence against some account
of the dangers of self neglect, the distress or offence caused
to others and his human dignity. It is interesting to note,
for example, that the powers that exist in the UK to
remove someone living in unsanitary conditions from his
home under the National Assistance Act (1948) require
that the removal must be necessary to prevent injury to
the health of others or to prevent a serious nuisance to
other people: the removal is to protect others rather than
to protect the individual concerned. Although the Act is
rarely used, this would suggest that the sensibilities of others
can be held to be valid grounds for over-riding the
autonomy of an individual, whose actions or behaviour
may be thought to lack dignity, given sufficient risk or nuisance
to others.
8. Conclusion
Macklin pointed out that "appeals to human dignity populate
the landscape of medical ethics" [35]. Dignity cannot
be compartmentalised as but one component of
nursing ethics but, rather, is inextricably connected with
all of nursing practice. All that nurses do and that nursing
aspires to is concerned with promoting, preserving and
engaging with human worth or value. It could be argued
that the recognition of the worth of others is the only necessary
grounds for the existence and maintenance of a
nursing service in any society. That something is acknowledged
to be of worth and is in some danger of failing to
flourish is what provides us with the starting point for
nursing. Nursing means to nourish or nurture and to
nurse something or someone is by definition to recognise
and respond to claims of worth.
Ten years have passed since Frank Dobson made his
remarks about the requisite quality of care for older people.
We could perhaps have also referred to Barabara
Robb's reports published forty years ago, in 1967, under
the title of "Sans Everything" [46]. The point is that in
spite of the time that has elapsed the problem of dignity
in care seems if anything to have become more severe.
While it is tempting to speculate, our analysis has not
been directed at the determination of causes. We can suggest,
however, that our four themes might help to pose
fruitful questions for further research. To give brief examples
for each in turn:
• environment of care
The physical environment of care is topical in the UK at
the time of writing, as the debate continues about the provision
of single- or mixed-sex accommodation. To many
people, to judge from comments in the media, sharing
hospital wards with people of the opposite sex, when all
concerned are unwell, would seem to be a grave affront to
dignity. Janet Street Porter [47], a UK newspaper columnist,
wrote movingly of her dying sister "enduring the
indignity of being placed on a mixed ward, attached to an
oxygen cylinder, unable to escape the attention of a naked
man masturbating at the end of her bed" http://tiny
url.com/3x9pbr. Outside of Intensive Care and Coronary
Care Units single sex wards used to be the norm throughout
the NHS. A current government health minister has
recently described them as an aspiration that cannot be
achieved. Lord Darzi [48], responding to questions in the
House of Lords, said that "medicine has moved on and, as
it has, the design of wards in the health service is based on
the disciplines, expertise and competencies of the staff
working in those wards... Transforming a ward into a single-
sex ward is not achievable. That aspiration cannot be
met" http://tinyurl.com/2xpau8. Discussion continues
regarding mixed-sex accommodation. The English Health
Secretary, Alan Johnson, recently appeared to be modifying
the Government's position [49]. This and other issues
about the design and building of in-patient accommodation
offer rich areas for research, in terms of health policy,
hospital architecture and of professional practice.
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• staff attitudes and behaviour
There have been significant changes over the last 20 years
in terms of nurse education, staffing levels and skill mix.
The increased dependency on greater numbers of unqualified
staff or staff with lower qualifications to support
reduced numbers of registered nurses, difficulties of
recruitment, reliance on overseas recruitment, the use of
temporary staff and general changes in society all represent
challenges to establishing and maintaining appropriate
attitudes and behaviour among nursing staff.
Particular problems arise in the care of older people. Management
attitudes in the 1980s and 1990s, when there was
a concerted drive to separate what were thought by managers
to be unskilled tasks such as care related to hygiene
and elimination, which did not require a qualified nurse,
from those more technical tasks that did, may have contributed
to the problem. There is evidence of the relationship
between skill mix and the quality of care, but specific
work is required to investigate the particular problems of
undignified practice.
• culture of care
The culture of care is complex and is influenced by many
factors, some of which will overlap with other issues, such
as attitudes and behaviours of staff. The culture of care is
also in part a product of the wider institutional culture
and this in turn is influenced by government agendas. A
popular belief is that government targets have had perverse
effects on the way care is managed, for example
when pressure to meet targets for maximum waiting times
in the emergency department results in patients being
moved inappropriately from ward to ward, placed in
mixed sex accommodation, or discharged prematurely.
Studies that explored the impact and unintended consequences
of a target-driven culture might illuminate problems
such as these.
• specific care activities
The performance of specific care activities, such as bathing,
toileting, feeding and so on, brings together and
could be seen perhaps as the expression of the other three
themes. The ability to provide dignified care for the highly
dependent patient will be affected by the physical environment,
by the attitudes of the staff and by the prevailing
culture. Studies that took such activities as a focus and
explored the conditions and circumstances that resulted
in good or poor practice could help us to understand how
complex circumstances interact to impact on a very direct
way on the patient experience of care.
There are still gaps in our understanding of dignity, for
example, in relation to different perspectives of people in
different cultural groups, but enough is known to focus on
operationalising respect for dignity in nursing practice.
This will require resources for research, education and for
action-oriented practice development activities that make
a difference to the dignity of patients and staff. Although
dignity has been identified as a complex phenomenon,
promoting it in everyday practice is neither mysterious
nor unachievable. Operationalising dignity requires Government
investment and professional will to commend
and reward dignity-promoting practice and to respond
speedily and constructively to those practices and behaviours
that diminish dignity.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AG led the development of the paper, undertook review of
theoretical literature, completed drafts, circulated to the
team and incorporated comments. SL reviewed the literature
relating to empirical research. PW read and contributed
to the development of drafts of the paper. IRJ and DL
read and commented on drafts of the paper.
Acknowledgements
The authors would like to thank Professor Ann MacKenzie for her help and
support with the development of the paper and the three reviewers who
offered insightful and helpful comments.
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