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Dignity in Healthcare

Dignity is derived from the Latin word dignitas (merit) or dignus (worthy). Associated words in English are dignitary and dignify. In the Collins English Dictionary dignity is defined as (i) the state or quality of being worthy of honour and (ii) a sense of self importance (to stand on one's dignity, beneath one's dignity). Accordingly, dignity can be understood as a personal attribute that is recognised by oneself and/or others and commands respect.

In the Charter of Fundamental Rights of the European Union, the first article states that the dignity of the human person must be respected and protected. Here the understanding of dignity is that it belongs to all persons, it commands respect but it also needs protection. Dignity can be violated. Hence, its inclusion in a charter of fundamental rights.

Beyond the understanding of respect and protection of human dignity is also the notion that human dignity should be promoted. There is some evidence within healthcare that one's health can actually improve and that one can cope better with illness when one isn valued and treated with respect. Therefore promoting dignity can lead to a better quality of life.

Dignity is sometimes associated with autonomy and having control over one's destiny. In terms of healthcare, and in particular in relation to older people, anecdotal evidence suggests that:

  • Older people's dignity and autonomy can be undermined in the health care setting.
  • Many healthcare professionals hold stereotypical, negative attitudes towards older people.
  • Tackling negative attitudes through exposure and education can help to preserve an older patient's dignity and autonomy.
  • Giving older people and their carers adequate information for them to make informed choices about care further increases autonomy.

What needs to be clarified, although it is alluded to in the above definitions, is that dignity is innate to the human person. So, even apart from its manifestation in the regard shown to it by others, one's dignity exists independently of others. In a sense dignity is tied to a person's very existence, what makes one human.

The Government health strategy, Quality and Fairness - A Health System for You, published in 2001 by the Department of Health and Children, included dignity as a key element. In terms of best practice in customer care, it says: "The vision adopted for the future health system places a high value on treating people with dignity and respect" (page 80). Also, in terms of staff, it says: "Strategies come and go, but the people who are an integral resource to the health system need to be appreciated, developed, motivated and effectively managed with respect and dignity if the desired vision, values, goals and objectives are to become reality" (page 53).

Older People's Views on Dignity

Definitions of Dignity

The predominant interpretation of dignity by participants over 65 was respect. Generally, this was spoken of in terms of treating others with respect and being treated with respect by others.

Respect was something many participants learned when they were young from their parents. It presented itself as a code of conduct on how to treat others and how to behave oneself. Once appropriated, it shaped one's character and gave one a sense of one's own dignity.

"Dignity is the way I was raised. We were reared with a set of codes, yes was yes and no was no. Respect, loyalty, good manners - being straight and honest, never be afraid to say hello or smile; your time is your character and your word is your bond, that is my dignity and I still hold it" (Male, Aged 65).

For older people to feel that they have a contribution to make to society is very important to them:

  • "Never feel that nobody wants you, always feel that you are you, that you have something to contribute to society in your own little way" (Female, Aged 80).
  • Some however expressed a doubt whether they could maintain their self-worth if they developed Alzheimer's. One participant reacted strongly to the suggestion that dying with dignity could justify euthanasia:
    "I don't think suffering pain will take away dignity. You may have anguish but you can have anguish and also have dignity at the same time" (Female, Aged 65).

Hospital Experiences

On the whole, older people were very positive in their views on how they were treated in hospital. Ambulance staff, doctors, nurses and paramedics were all commended:
"I come out of there feeling somebody is looking after me so I don't mind in the least going in" (Male, Aged 77).

Making time for their patients is particularly appreciated:
"The nursing staff up here work very, very hard. They do. But I always find time to talk to them or they to me and they have always treated me with dignity. It didn't matter whether they were just passing, you were acknowledged and you were treated like the person you are" (Male, Aged 73)

Nursing Home Experiences

There was general praise for nursing homes by the majority of participants. Unlike in the past when older people were sometimes institutionalised against their will, today people have choices and going into a nursing home is not seen as something negative because of the quality of life afforded to the residents. As one participant said on visiting a friend in a home:
"They treated her with respect and she looked it, always beautifully dressed" (Male, Aged 75).

While the loss of a certain amount of independence did result from being in an institution, e.g. one could not always make a cup of tea when one wished, there was also a realisation that if one remained with relatives (depending on how well one was treated) one could also lose a lot of independence, and have to put up with noisy children and not being able to watch the TV programme one wanted.

Adjusting to life in a home can however be difficult, especially for those who lived for a long time on their own:
"It is hard to change or adapt. You are away from home. Your friends are gone. That is what I find hard. I can't get out or move about. The visitors get fewer the longer you are away" (Male, Aged 82).

After a period of time, older people generally settle in and the positive aspects of being in a home, being cared for and having company, are better appreciated. But, that is not to say that being in a home is a return to life as it was before:
"I remember visiting a woman in a home about 30 years ago and I asked would you rather be here or at home and she said, 'sure this is not like home, I don't own anything here'. That's what she found hard" (Male, Aged 82).

Professionals' Views on Dignity

Definitions of Dignity

As was the case with the older people's focus groups, the preferred word by professionals as a substitute for the word dignity was respect. Other words used were empathy, freedom and individuality.

What Does it Mean to Treat Someone With Dignity?

Treating people with dignity implies treating them with courtesy and kindness, but it also means:

  • Respecting their rights.
  • Giving them freedom of choice.
  • Listening and taking into consideration what they say.
  • Respecting their wishes and decisions, even if one disagrees.

Treating people with dignity implies being sensitive to people's needs and doing one's best for them, but it also means:

  • Involving them in decision-making.
  • Respecting their individuality.
  • Allowing them to do what they can for themselves.
  • Giving them privacy and their own personal space.

Treating an older people with dignity implies treating them as a person, but it also means:

  • Treating them the same as everyone else.
  • Treating them as an adult, not as a child.
  • Treating them as part of the community.

Some of the practical implications of treating an older person with dignity include, for example, taking time to explain things:
"It is their life, so they should be told everything" (Care Attendant).
"You actually explain to somebody with dementia what is happening to them every time you do something, every time they are going to be moved into a hoist, instead of just doing it to them and frightening them" (Social Worker).

Conclusion

Respect is the key word used to describe dignity by older people. The three things that stand out in relation to treating older people with respect are: Equality, Choice and Belonging. Older people want to be treated the same as everyone else, they want to have choices about their care and they want to feel that they have something to contribute to society. They do not want to be discriminated against, have their independence undermined or be thrown out on the scrap heap.

In terms of health care, older people would like their sicknesses treated seriously and not to be discounted because of their age. For those living alone, they would like more visits, as they often feel isolated and alone. In fact, many look to the professional services of GPs and the police to check in on them. The expectations placed on the medical profession may be misplaced, but meeting this need is a real quality of life issue for older people.

Health care professionals tend to emphasise independence as one of the most important aspects of dignity. This is possibly due to their training in a holistic approach to care of the elderly and their professional role of promoting patient autonomy. Respect was the word most often used in regard to patient management. The views of the health care professionals reinforced many of the views expressed by older people.

It is still an open question whether dignity for older people is more respected or less respected today than in the past. What is clear is that ageist attitudes still exist in society. Legislation may be part of the solution but it is not the entire solution. Much more attention needs to be given to preserving the dignity of older people and promoting their dignity in every way possible. For those who care for older people, their dignity too needs to be recognised, not just in terms of the important role they play in healthcare but because they too as individuals have their own dignity to preserve. However, until ageism in all its forms is addressed at a societal level, the indignities sometimes experienced by older people in care settings will simply continue to reflect what is happening to older people in the wider society.

This is an extract from the report "Dignity in Healthcare", which was written by David Stratton for Age Action Ireland. The entire report is available on the website, www.ageaction.ie. This extract has been printed with the kind permission of Age Action Ireland.

1 Kate Lothian, Ian Philp (2001) "Maintaining the dignity and autonomy of older people in the healthcare setting", British Medical Journal 322:668-670.
Sheffield Institute for Studies on Ageing, Community Science Centre, Northern General Hospital, Sheffield S5 & AU