Dignity as experienced by nursing home staff

Dignity-preserving care of people with dementia in different nursing environments: a qualitative systematic review

AIMS

To systematically identify, evaluate and synthesize qualitative evidence about the dignity-related nursing experiences of people with dementia in families and nursing homes, summarize the similarities and differences and analyse the causes and influencing factors.

METHODS

A synthesis of qualitative studies retrieved from eight databases that were published before September 2022. Two reviewers independently screened and selected studies. Inclusion criteria were established according to the PICOS principle. Quality assessment was guided by Joanna Briggs Institute's Qualitative Assessment and Review Instrument and the structured topic synthesis method was used to summarise studies eligible for inclusion.

RESULTS

Three key themes were extracted from 14 included studies; the living environment, relationship needs and self-awareness, which focused on improving the dementia-centred nursing environment, meeting the needs of the relationship-centred nursing network, and finally, improving the self-awareness of people with dementia to promote dignity.

CONCLUSION

This systematic review shows people with dementia need to integrate into society and maintain their dignity in a dementia-friendly environment that is respectful, inclusive environment that promotes freedom.

Healthcare Professionals' Perspectives on Dignity in Dementia: A Qualitative Analysis

In dementia care, the concept of dignity has garnered substantial attention from both researchers and policymakers. However, the concept often remains vague and open to interpretation, potentially leading to misunderstandings and suboptimal care for people with dementia. As healthcare professionals occupy a critical role in upholding dignity, exploring their viewpoints on this complex concept is paramount. In this study, we explore Danish healthcare professionals' views on the dignity of people with dementia and discuss these perspectives against existing theoretical accounts. We employed thematic analysis of data collected during facilitated discussions with a total of 99 healthcare professionals, including nurses and healthcare workers, during which we posed the question, "What is dignity to you?" and documented their perspectives. Through a systematic process of data coding and interpretation, we identified recurring patterns in their responses. This approach allowed us to uncover the depth and complexity of their viewpoints, providing valuable insights into the multifaceted nature of dignity as perceived by healthcare professionals. Our findings revealed that healthcare professionals possessed a nuanced understanding of dignity, recognizing both a subjective element and a universal aspect applicable to all individuals, aligning with theoretical interpretations. However, conceptual ambiguity remained a challenge.

Dignity in the care of older adults living in nursing homes and long-term care facilities

Depending on the fields and actors involved, dignity may involve, signify, and encompass different meanings. This fundamental right can be subjectively experienced and rooted in a person's perception of being treated and cared for. Care refers to a set of specific activities combined in a complex life-sustaining network, including long-term Care, which involves various services designed to meet a person's health or personal care needs. However, older residents' human rights have been disrespected and widened the gaps between theory and practice regarding the precarious protection of their rights and dignity inside long-term facilities and nursing homes. This paper aims to discuss threats to dignity and elucidate some strategies to promote and conserve dignity in care, including the person-centered practice in long-term care. Some barriers to the dignity of older residents involve the organizational culture, restraints of time, heavy workload, burnout, and lack of partnership between the residents, their families, and the long-term care homes' staff. Person-centered integrated care quality frameworks are core components of a good quality of care in these spaces in high-income countries. Unfortunately, the COVID-19 pandemic highlighted how weak long-term care policies were and demonstrated that much progress in the dignity of care in long-term care facilities and nursing homes is needed. In low- and middle-income countries, long-term care policies do not accompany the accelerated and intense aging process, and there are other threats, like their invisibility to the public sector and the prejudices about this service model. It's urgent to create strategies for designing and implementing sustainable and equitable long- term care systems based on a person-centered service with dignity to everyone who needs it.

Communication and engagement as potentiality in everyday life between persons with young onset dementia living in a nursing home and caregivers

Objectives

To explore communication and engagement in everyday situations between persons with young-onset dementia (YOD) living in a nursing home (NH) and the caregivers.

Methods

The study draws on ethnographic methods aligned with participatory design. Three residents with YOD living in a NH and eight staff members were recruited. A narrative approach was used for data collection and analysis.

Findings

Three narrative vignettes were developed representing everyday situations in which communication and engagement was enacted among residents and caregiver staff: (a) waiting for something to happen, (b) tensions about everyday communication, and (c) negotiating a combined living + working environment. The findings stress a paradoxical tension rooted in the NH as residence and workplace as well as place of calm and place of boredom. The everyday situations are interpreted differently from the perspective of the residents and staff.

Conclusion

The identified paradox of planned and spontaneous situations influences communication and engagement in everyday life, and the potentiality for active engagement embedded in contexts of units for residents with YOD. The degree to which everyday activities and encounters are redefined and renegotiated is an important part of caregiving practices in NH settings for residents with YOD.

The perspective of professional caregivers working in generalist palliative care on 'good dying': An integrative review

In today's industrial societies, many people die receiving professional care. Although specialist palliative and hospice care have often been identified as ideal care approaches to promote good dying, more people die receiving generalist palliative care. This integrative review examines how professional caregivers providing generalist palliative care in hospitals, nursing or private homes define good dying. Furthermore, through comparative analysis of existing empirical studies, it explores conceptual aspects in researching good dying that better reflect the social complexity of this phenomenon. Three databases (Scopus, MEDLINE, and CINAHL) were searched for peer-reviewed studies published between January 2000 and April 2020. Studies were selected if they presented original empirical findings from qualitative or quantitative studies on the perspective of professional caregivers in generalist palliative care (nurses, physicians, surgeons, clergy, and other staff) on good dying or related concepts (e.g., good death, dignity in dying, or quality of life at the end of life). 42 studies were included in the review. They identified good dying as expected, accepted and prepared dying, as free from pain and suffering, as socially embedded, as being at peace with one's life and situation, as supported with individualised and holistic care, as based upon professional cooperation and communication, and as in a peaceful and private environment. The paper concludes that the perspective of professional caregivers in generalist palliative care shares many elements of good dying with societal and specialist palliative care discourses around good dying. Through comparing the different studies, the review found that studies that explicated who benefitted from ideals and practices of good dying, questioned the dichotomous categorisation of good/bad dying, or discussed the compatibility of elements of good dying, provided more nuanced perspectives on this topic. Thus, the review calls for a more systematic analysis of these aspects in research of good dying.

The Health Care Providers' Perspectives on End-of-Life Patients' Sense of Dignity. A Comparison Among Four Different Professionals' Categories

The studies on terminally ill patients' dignity as perceived by health care providers (HCPs) in palliative care are growing. The comparison of different HCPs' perspectives in particular is necessary to explore how HCPs perceive patients' dignity in order to promote reflection on this core issue. This study aimed to investigate the perspectives on end-of-life patients' sense of dignity among four different categories of professionals: nurse assistants, nurses, psychologists, and physicians. A sample of 306 HCPs completed the Patient Dignity Inventory-Italian Version (PDI-IT) adapted for them and an ad hoc semi-structured written interview. Their responses were then analyzed using frequencies of the answers to the PDI-IT, a multivariate analysis of variance, Pearson's correlation index, t tests, and content analysis. All HCPs scored the relevance to the dignity-related physical aspects highly, followed by the psychological distress. Nurse assistants and nurses provided higher scores on the psychological and existential and spiritual PDI subscales than the other HCP groups. The social sphere was evaluated as the least salient for the patients' sense of dignity. Physicians who attended a course on dignity considered the psychological and existential dignity dimensions more. Differences in role and expertise could lead to different HCPs' perspectives on dignity, while the multidisciplinary work could favor their aligning. Therefore, it is essential to encourage HCPs' communicative exchange and reflective awareness through training, i.e., courses, seminars, and focus groups. These developments could promote increasingly adequate patient-centered care.

Conceptualising trust in aged care

This article calls for a sociological understanding of the importance of trust to aged care. It connects existing theories of trust to empirical evidence from gerontology and nursing research. Trust is defined as a response to and management of social vulnerability. It is argued this makes trust a fundamental concept for understanding human service and social care institutions, including aged care. In light of Australia's Royal Commission into Aged Care Quality and Safety, as well as generational shifts in consumer expectations and care ethics, the article highlights four distinct yet interrelated forms of trust: interpersonal, institutional, organisational and public trust. All of these forms are shown to be critical in conceptualising and evaluating the perceived trust deficit facing contemporary aged-care systems, and existing evidence shows how these forms of trust can reinforce, conflict and misalign with each other. Efforts to rebuild trust in aged care at an organisational and institutional level should ensure mechanisms facilitate rather than hinder the formation of interpersonal trust relations between individual service users, their families and aged care staff. Broader social policy reforms must also consider and address the way cultural understandings of ageing, and media representations of aged care, have diminished the public's trust in the sector, and how the cycle of scandals, reviews and piecemeal reforms contributes to this.

Dignifying and undignifying aspects of care for people with dementia: a narrative review

Background

The progressive disease trajectory makes people with dementia increasingly vulnerable and gradually more dependent on others which can lead to admission to a nursing home. Special interest in dignity in people with dementia has led to a growing body of knowledge towards promoting or hindering their dignity.

Aim

The aim of this narrative review was to synthesise dignifying and undignifying aspects of formal and informal care for people with dementia within nursing homes.

Method

The electronic databases CINAHL, SCOPUS, PSycInfo and PubMed were systematically searched with the terms ‘dementia’ and ‘dignity’, complemented with the use of snowballing and reference check. A total of 789 unique items were found. The search and selection process was structured by the PRISMA framework, and both authors formulated the criteria of eligibility. A methodological check was performed using the critical appraisal tool of Hawker. This process led to inclusion of 29 articles which were reviewed with the help of the guidelines for narrative synthesis by Popay et al.

Findings

The emerged dignifying and undignifying aspects of formal and informal care are characterised by either a successful or unsuccessful process of adjustment towards changing abilities, preferences and care needs of people with dementia. Three themes appeared as undignifying aspects of care: ‘Stigmatisation and objectivation’, ‘Scarcity and hastiness’ and ‘Impending estrangement and misunderstanding’. Four themes were identified as dignifying aspect of care: ‘Personalisation’, ‘Respect, attentiveness and encouragement’, ‘Attention for physical care and bodily gestures’, and ‘Foster belonging’. Literature synthesis showed mostly relational aspects of care concerning dignity in people with dementia. Formal and informal caregivers are important in maintaining and promoting their dignity.

Reciprocal Dynamics of Dignity in End-of-Life Care: A Multiperspective Systematic Review of Qualitative and Mixed Methods Research

Background:

Preserving terminally ill patients’ dignity and well-being through dignified and holistic care has become the overarching goal in palliative care services. However, dignity is a multifaceted concept with a wide range of interpretations under different cultural contexts.

Aim:

The aim of this review is to understand the variations in subjective interpretations and constitutions of dignity in palliative or end-of-life care via an integrative worldview.

Design:

This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline and used SPIDER tool to screen for appropriate and relevant articles for analysis.

Data Sources:

Four major databases were searched including CINAHL, ERIC, Medline, and PsycARTICLES between 2009 and 2018. Forty-eight qualitative studies that examined dignity from the perspectives of patients, family caregivers, and health-care professionals were selected for full text data analysis using thematic synthesis.

Results:

Analysis of the various concepts of dignity revealed 18 themes that were further categorized into 7 conceptual categories: (1) self-determination, (2) existential liberty, (3) relational connectedness, (4) caregiving revitalization, (5) mindful humanity, (6) patient–family care, and (7) sustainable culture. These 7 categories span across individual, familial, and institutional dimensions, forming a new Dynamic Reciprocity of Dignity model.

Conclusions:

The Dynamic Reciprocity of Dignity model highlights the importance of adopting a systemic lens to address dignity-related needs and concerns at the end of life, while providing insights on how compassionate care and self-compassion can serve as the foundation of dignified care, which in turn serve as a buffer against patients’ existential suffering as well as caregivers’ burnout and fatigue. Recommendations for clinical practice and future research directions are discussed.

Respectful care of human dignity: how is it perceived by patients and nurses?

OBJECTIVE

Dignified care protects the patient's rights and provides appropriate ethical care while improving the quality of nursing care. In this context, the opinions of nurses and patients who receive nursing care about dignified care are important. The aim of this study was to explore the opinions and experiences of Turkish patients and nurses about respectful care of human dignity.

METHODS

This descriptive cross-sectional study was conducted in Turkey. Participants were inpatients at cardiology, neurology and neurosurgery clinics and nurses working in these clinics. The data for the study were collected from face-to-face interviews using questionnaires. The percentages of characteristics and preferences of the participants were calculated, and the results were analysed using statistical tests.

RESULTS

A total of 150 patients and 78 nurses participated in the study. The patients stated that the protection of their rights was the most important factor for dignified nursing care. The nurses stated that being careful to not expose the patients' body and being respectful of the patients' privacy were important in dignified nursing care. The age of the patient, duration of the disease, number of hospitalisations and length of time the nurses had been working at the clinic caused significant changes in the factors considered important in dignified care.

CONCLUSIONS

Our findings provide a perspective on dignified care in the Turkish healthcare setting. There were some differences between patients and nurses in the factors considered important for dignified care. The discussion with patients and nurses related to care and practices that protect or detract from human dignity can provide insights to ethics.

A qualitative study of assistant nurses' experiences of palliative care in residential care

AIM

To explore assistant nurses' experiences and perceptions of both positive and negative aspects of providing palliative care for older people in residential care facilities.

DESIGN

A qualitative explorative study.

METHODS

Critical incidents were collected through semi-structured face-to-face interviews and analysed by performing a qualitative content analysis.

RESULTS

A total of 40 critical incidents from daily work was described by assistant nurses. The results showed that close cooperation between unlicensed and licensed professionals was crucial to provide good care but was sometimes negatively affected by the organizational structure. The availability of professionals was identified as a critical factor in providing good care at the end of life in a consultative organization. The most prominent findings were those that indicated that, especially in a consultative organization, there seems to be a need for clear roles, comprehensive and clear care plans and a solid support structure to ensure continuity of care.

What is palliative care? Perceptions of healthcare professionals

Background

Despite increased attention and knowledge in palliative care, there is still confusion concerning how to interpret the concept of palliative care and implement it in practice. This can result in difficulties for healthcare professionals in identifying patients whom would benefit from palliative care, which, in turn, could lead to a delay in meeting patients’ needs.

Aim

To explore healthcare professionals’ perceptions of palliative care.

Method

Data were collected through twelve interprofessional focus group interviews in community care and hospital wards in south Sweden (n = 74). All interviews were analysed with latent content analysis.

Results

Three domains were revealed: first, a blurred conceptual understanding as participants described palliative care using synonyms, diagnoses, phases, natural care and holism; second, a challenge to communicate transitions concerned the importance of how and when the transition to palliative care was communicated and documented; finally, a need for interprofessional collaboration was described as well as the consequences for severely ill persons, relatives and healthcare professionals when it was not established.

Conclusion

The perceptions about how to interpret palliative care differed as well as when palliative care should be offered and decided, which might have practical consequences. How long a person has left to live is of great significance for decision‐making, caregiving and preparation in palliative care. The challenge is to use interprofessional communication to promote understanding and collaborate across varied care levels. Integrating palliative care across diverse care levels could be one way to reduce the ambiguity of palliative care.

End-of-life care in a nursing home: Assistant nurses’ perspectives

Background:

Worldwide, older persons lack access to palliative care. In Sweden, many older persons die in nursing homes where care is provided foremost by assistant nurses. Due to a lack of beds, admission is seldom granted until the older persons have complex care needs and are already in a palliative phase when they move in.

Objective:

To describe assistant nurses’ perspectives of providing care to older persons at the end of life in a nursing home.

Research design:

Data were collected in semi-structured individual interviews and analyzed with inductive qualitative content analysis.

Participants and research context:

Seven assistant nurses from a nursing home in Sweden were randomly selected.

Ethical consideration:

The research was approved by the local ethics committee.

Results:

Three main categories emerged; “Death a natural part of life”; “The older person’s well-being”; and “Care in the moment of death”; and seven sub-categories. The assistant nurses described themselves as knowing the older persons well enough to provide good end-of-life care. This was achieved by making small-talk while providing daily care. Relying on experience-based knowledge, they strove to provide end-of-life care built upon respect and engagement with the ambition to strengthen older persons’ dignity, for example, by lowering the tempo of care at the end of life, in spite of organizational restrictions.

Discussion:

The assistant nurses offered attentive end-of-life care, focusing upon bodily care. The existential needs of the older persons were not foregrounded.

Conclusion:

To develop their work, and to promote an ethical foundation for such care, assistant nurses might need support and education to be able to offer a care more in line with the aims of palliative care. Furthermore, the organization of care needs to promote, not impede, the realization of this development.

Human dignity and autonomy in the care for patients with dementia: differences among formal caretakers from various cultural backgrounds

OBJECTIVES

To explore whether gaps exist between caretakers from different ethno-cultural groups (Israeli-born Jews [Sabras], Israeli Arabs [Arabs], and migrants from Russia [Russians]) regarding their perceptions of autonomy and human dignity of patients with dementia.

DESIGN

A mixed-methods research scheme was used, comprised of qualitative and quantitative methods, utilizing semi-structured interviews and self-reported questionnaires. Twenty formal caretakers participated in the qualitative portion, and approximately 200 caretakers were included in the quantitative portion. All participants were recruited from three nursing homes and one hospital in the Galilee region (Israel).

RESULTS

The qualitative portion of the study yielded eight themes encapsulated in the concept of autonomy and ten themes entailed within human dignity, in the context of care for patients with dementia. By utilizing these themes in the quantitative portion, substantial differences in nursing homes were found in the attitudes to autonomy and dignity of patients with dementia between Russian and Arab as well as Sabra caretakers (index score for autonomy: 2.97, 4.07, and 4, respectively; index score for dignity: 3.17, 4.1, and 4.07). A multi-variable regression, focusing on caretakers from nursing homes, showed the most significant influencing variables on the indexes of autonomy and dignity were ethno-culture Arab/Russian (0.84, 0.62) and the patient's family (0.29, 0.30). Regarding the autonomy index, being a female caretaker also had a significant influence (0.24). In the hospital, no influence emerged for the ethno-culture variables, and neither type of institution showed any influence of religion or religiousness as well as societal or community norms.

CONCLUSIONS

Contrary to past research, in nursing homes, significant differences were found between certain ethno-cultural groups (Arabs and Russians) regarding their stance toward the dignity and autonomy of patients with dementia. Arab caretakers' fostering of more encompassing conceptions of dignity and autonomy, irrespective of institutional setting, provides better grounds for person-centered care.

Dignity and autonomy in the care for patients with dementia: Differences among formal caretakers of varied cultural backgrounds and their meaning

BACKGROUND

A key message in the World Health Organization report on dementia (2012) emphasizes this disease as a top priority in public health and the need to improve professional attitudes to patients with dementia, while acknowledging that the workforce in dementia care is becoming increasingly diverse culturally.

AIMS

To trace whether there are substantial gaps between formal caretakers from different cultural groups (Israeli born Jews [Sabras], Israeli Arabs [Arabs] and migrants from Russia [Russians]) regarding their stances on the human dignity and autonomy of patients with dementia, as well as understand the meaning of these gaps.

DESIGN & METHOD

quantitative analysis utilizing questionnaires that were filled-out by approximately 200 caretakers from the different cultural groups, working in a nursing home or a hospital.

RESULTS

In nursing homes, substantial differences were found in the attitudes to human dignity and autonomy of patients with dementia between Russian and Arab as well as Sabra caretakers. In the hospital, there was no influence for the ethno-culture variable on dignity or autonomy.

CONCLUSION

Contrary to past research, in nursing homes, significant differences were found between certain ethno-cultural groups (Arabs and Russians) regarding their stance towards the dignity of patients with dementia. Arab caretakers hold a conception of dignity and autonomy that resonates strongly with person-centered care and outweighs institutional settings as well as may be related to the fostering of virtues.

Identifying Markers of Dignity-Conserving Care in Long-Term Care: A Modified Delphi Study

Ensuring that people living in nursing homes (NHs) are afforded with dignity in their daily lives is an essential and humane concern. Promoting dignity-conserving care is fundamentally important. By nature, however, this care is all-encompassing and holistic, and from current knowledge it is challenging to create explicit strategies for measuring dignity-conserving care. In practice the majority of current NH indicators of quality care are derived from information that is routinely collected on NH residents using the RAI-Minimum Data Set (MDS). In this regard, issues that are more tangible to resident dignity such as being treated with respect, compassion, and having opportunities to engage with others are not adequately captured in current NH quality of care indicators. An initial set of markers was created by conducting an integrative literature review of existing markers and indicators of dignity in the NH setting. A modified Delphi process was used to prioritize essential dignity-conserving care markers for use by NH providers, based on factors such as the importance to fostering a culture of dignity, the impact it may have on the residents, and how achievable it is in practice. Through this consensus building technique, we were able to develop a comprehensive set of markers that capture the range and diversity of important dignity-conserving care strategies for use in NHs. The final 10 markers were judged as having high face validity by experts in the field and have explicit implications for enhancing the provision of daily dignified care to NH residents. These markers make an important addition to the traditional quality indicators used in the NH setting and as such, bridge an important gap in addressing the psychosocial and the less easily quantified needs of NH residents.

The rote administrative approach to death in senior housing: Using the other door

Understanding death in long-term care (LTC) facilities and the preexisting standards and policies pertaining to the death experience in LTC is essential. Qualitative interviews were conducted with 10 administrators of CCRCs and data analyzed through content analysis. Results of the current study reveal that administrators spoke of approaching death in their facility similar to any other procedural task, removal of the residents' bodies varied by community, and coordination responsibilities ranged from maintenance crews to management. Notification practices for residents and staff were also inconsistent. Differences existed in internal cultures on providing forms of respect. These practices were standard for some facilities while others were flexible to accommodate family requests. The majority of the sites did not offer additional training on death and dying for staff members. Findings suggest the need for consistency regarding how senior housing administrators approach the death of a resident and provide support for staff members.

Dignity in long-term care: An application of Nordenfelt's work

BACKGROUND

The concept of dignity is recognised as a fundamental right in many countries. It is embedded into law, human rights legislation and is often visible in organisations' philosophy of care, particularly in aged care. Yet, many authors describe difficulties in defining dignity and how it can be preserved for people living in long term care.

OBJECTIVES

In this article, Nordenfelt's 'four notions of dignity' are considered, drawing on research literature addressing the different perspectives of those who receive, observe or deliver care in the context of the long-term care environment.

METHODS

A review of the literature was undertaken using the terms 'nursing homes', 'residential care' or 'long-term care'. The terms were combined and the term 'human dignity' was added. A total of 29 articles met the inclusion criteria from the United Kingdom (14), United States (2), Australia (1), Sweden (3), Hong Kong (2), Norway (3), Nordic (1), Taiwan (1), Netherlands (1). Ethical Considerations: Every effort has been made to ensure an unbiased search of the literature with the intention of an accurate interpretation of findings.

DISCUSSION

The four notions of dignity outlined by Nordenfelt provide a comprehensive description of the concept of dignity which can be linked to the experiences of people living in long-term care today and provide a useful means of contextualising the experiences of older people, their families and significant others and also of staff in long-term care facilities. Of particular interest are the similarities of perspectives of dignity between these groups. The preservation of dignity implies that dignity is a quality inherent in us all. This links directly to the exploration and conclusions drawn from the literature review. Conversely, promoting dignity implies that dignity is something that can be influenced by others and external factors. Hence, there are a number of implications for practice.

CONCLUSION

We suggest that two of Nordenfelt's notions, 'dignity of identity' and 'dignity of Menschenwüde', are a common thread for residents, family members and staff when conceptualising dignity within long-term care environments.

Exploring nurses' personal dignity, global self-esteem and work satisfaction

BACKGROUND

This study examines nurses' perceptions of dignity in themselves and their work. Nurses commonly assert concern for human dignity as a component of the patients' experience rather than as necessary in the nurses' own lives or in the lives of others in the workplace. This study is exploratory and generates potential relationships for further study and theory generation in nursing.

RESEARCH QUESTIONS

What is the relationship between the construct nurses' sense of dignity and global self-esteem, work satisfaction, and identified personal traits?

PARTICIPANTS AND RESEARCH CONTEXT

This cross-sectional correlation study used a stratified random sample of nurses which was obtained from a US University alumni list from 1965 to 2009 (N = 133).

ETHICAL CONSIDERATIONS

University Institutional Review Board approval was achieved prior to mailing research questionnaire packets to participants. Participation was optional and numerical codes preserved confidentiality.

FINDINGS

Statistical results indicated a moderately strong association between the nurse's sense of personal dignity and self-esteem (rx = .62, p = .000) with areas of difference clarified and discussed. A positive but moderate association between nurses' personal dignity and nurses' work satisfaction (rx = .37, p = .000) and a similar association between self-esteem and nurses' work satisfaction (rs = .29, p = .001) were found. A statistically significant difference was found (F = 3.49 (df = 4), p = .01) for dignity and categories of spiritual commitment and for nurses' personal dignity when ratings of health status were compared (F = 21.24 (df = 4), p = .000).

DISCUSSION

Personal sense of dignity is discussed in relation to conceptual understandings of dignity (such as professional dignity) and suggests continued research in multiple cultural contexts.

CONCLUSION

The relationships measured show that nurses' sense of dignity has commonalities with self-esteem, workplace satisfaction, spiritual commitment, and health status; the meaning of the findings has ramifications for the welfare of nurses internationally.

First-Line Nursing Home Managers in Sweden and their Views on Leadership and Palliative Care

The aim of this study was to investigate first-line nursing home managers’ views on their leadership and related to that, palliative care. Previous research reveals insufficient palliation, and a number of barriers towards implementation of palliative care in nursing homes. Among those barriers are issues related to leadership quality. First-line managers play a pivotal role, as they influence working conditions and quality of care.

Nine first-line managers, from different nursing homes in Sweden participated in the study. Semi-structured interviews were conducted and analysed using qualitative descriptive content analysis. In the results, two categories were identified: embracing the role of leader and being a victim of circumstances, illuminating how the first-line managers handle expectations and challenges linked to the leadership role and responsibility for palliative care. The results reveal views corresponding to committed leaders, acting upon demands and expectations, but also to leaders appearing to have resigned from the leadership role, and who express powerlessness with little possibility to influence care. The first line managers reported their own limited knowledge about palliative care to limit their possibilities of taking full leadership responsibility for implementing palliative care principles in their nursing homes.

The study stresses that for the provision of high quality palliative care in nursing homes, first-line managers need to be knowledgeable about palliative care, and they need supportive organizations with clear expectations and goals about palliative care. Future action and learning oriented research projects for the implementation of palliative care principles, in which first line managers actively participate, are suggested.

Nursing students' perceptions of patient dignity

BACKGROUND

Respecting patients' dignity has been described as a fundamental part of nursing care. Many studies have focused on exploring the concept of patients' dignity from the patient and nurse perspective, but knowledge is limited regarding students' nursing perceptions and experiences.

OBJECTIVE

To explore the issue of patients' dignity from the perspective of nursing students.

RESEARCH DESIGN

A qualitative study was employed with the formation of four focus groups and the participation of nursing students. Data were analysed via a thematic content analysis of the discussions.

PARTICIPANTS AND RESEARCH CONTEXT

Thirty-four nursing students of a Cyprus University participated in the four focus groups. Each group was homogenous in terms of the year of study and heterogeneous in terms of clinical practice in various wards.

ETHICAL CONSIDERATION

The study's protocol was reviewed and approved by the Cyprus National Bioethics Committee. Ethical standards were followed throughout the study.

FINDINGS

Several factors that maintain or compromise patients' dignity emerged. These factors were grouped into five themes: (a) patients' preferences, verbal abuse and regarding a patient as a unique person; (b) privacy and confidentiality; (c) loss of autonomy and need for help; (d) discrimination and (e) attribution and reciprocity.

DISCUSSION

Different understandings of the perceived concept of dignity and the factors that maintain or compromise patient's dignity were expressed through the eyes and the feelings of nursing students. Students highlighted the importance of promoting patient dignity as an important component of nursing care.

CONCLUSION

Nurse educators can use the findings of this study in order to tailor nursing programmes to emphasise the importance of respecting patients' dignity. In addition, nurse ward managers can use the findings as means for persuading nurses to change current behaviour.

Long-Term Care of the Elderly in Uruguay

Objective: To explore the perception of care of the elderly in long-term centers. Design: Qualitative study through participant observation and 23 in-depth interviews with administrators, caregivers, and residents between January 2011 and January 2012 in nine long-term care centers in Uruguay. From analysis, three care-perception factors emerged: (a) meaning of care, (b) experience of care, and (c) care continuity. Conclusion: Care of the elderly in nursing homes is perceived as a duty. There is an exchange of feelings and recognition of the caregiver is needed. However, the need for technical or specialized training is not mentioned. Recognition of the task of care provision, duty as a moral determinant, the exchange of affection and solidarity between staff and the elderly allows care continuity despite the centers’ lack of resources. Clinical Relevance: This study contributes information that may help improve the care conditions of elderly institutionalized people.

An integrative review of dignity in end-of-life care

BACKGROUND

Dying with dignity is regarded as a goal of quality end-of-life care. However, the meaning of dying with dignity is ambiguous, and no comprehensive synthesis of the existing literature has been published.

AIM

To synthesize the meaning of dying with dignity and to identify common aspects of dignity in end-of-life care.

DESIGN

This is an integrative review article. Methodological strategies specific to the integrative review method proposed by Whittemore and Knafl were followed to conduct data analysis. The matrix method was used to summarize characteristics of included articles.

DATA SOURCES

Five electronic databases were searched in October 2012, with no date restriction: PubMed, CINAHL, PsycINFO, Academic Search Premier, and Social Sciences Abstracts. Theoretical reports, and both qualitative and quantitative empirical reports, focused on dignity in end-of-life care were included.

RESULTS

Themes of dying with dignity are as follows: a human right, autonomy and independence, relieved symptom distress, respect, being human and being self, meaningful relationships, dignified treatment and care, existential satisfaction, privacy, and calm environment. Factors influencing dignity include demographic, illness-related, and treatment-/care-related factors, as well as communication. Models of dignity in end-of-life care and instruments to measure dignity were reported. Interventions to support dignity stressed physical, psychological, and spiritual supports not only to dying patients but also to family members.

CONCLUSION

This review clarified the meaning of dying with dignity and synthesized common aspects of dignity in end-of-life care. Further research is needed to evaluate the meaning of dying with dignity across cultures and to explore individualized dignity-based care.

Applying a palliative care approach in residential care: effects on nurse assistants' experiences of care provision and caring climate

BACKGROUND

A palliative care approach aims to integrate psychosocial and existential as well as relationship aspects in the care and is an approach that can be used in residential care. Nurse assistants are the ones who are closest to the residents but have limited prerequisites for working in accordance with the palliative care approach. We aimed to investigate the effects on nurse assistants' experiences of care provision and the caring climate of an intervention applying a palliative care approach in residential care.

METHODS

An intervention involving nurse assistants (n = 75) and their leaders (n = 9), in comparison with controls (n = 110), was evaluated using a questionnaire at three points in time.

RESULTS

In the intervention group, positive effects were seen concerning the nurse assistants' reports of the care provision in that they focused more on the residents' stories about their lives and on communicating with the residents about what gave meaning to their lives. Also, negative effects were seen when the nurse assistants rated that the residents' needs for medical and nursing care had not been met at the facility directly after the intervention. No effects were seen concerning the caring climate or the prerequisites of providing more person-centred care.

CONCLUSION

The intervention seemed to have encouraged the nurse assistants to focus on relationship aspects with the residents. So as not to jeopardise the NAs' well-being and to support NAs in keeping themselves involved in existential issues, their support most certainly needs to be continuous and ongoing. However, in spite of the leaders' involvement, the intervention was not sufficient for changing the organisational prerequisites for more person-centred care.

Reflections on the ethical dilemmas involved in promoting self-management

Due to their understanding of self-management, healthcare team members responsible for depressed older persons can experience an ethical dilemma. Each team member contributes important knowledge and experience pertaining to the management of depression, which should be reflected in the management plan. The aim of this study was to explore healthcare team members' reflections on the ethical dilemmas involved in promoting self-management among depressed older persons. A qualitative design was used and data were collected by means of focus group interviews. The results revealed one main theme: 'Lack of trust in the community health care system's commitment to bringing about effectiveness and change, based on three themes; 'Struggling to ensure the reliable transfer of information about depressed older persons to professionals and family members', 'Balancing autonomy, care and dignity' and 'Differences in the understanding of responsibility'. Lack of engagement on the part of and trust between the various professional categories who work in the community are extremely counterproductive and have serious implications for patient dignity as well as safety. In conclusion, ethical dilemmas occur when staff members are unable to act in accordance with their professional ethical stance and deliver an appropriate standard of care.

Nursing home staff's views on residents' dignity: a qualitative interview study

Background

Maintaining dignity is an important element of end-of-life care and also of the care given in nursing homes. Factors influencing personal dignity have been studied from both nursing home residents’ and staff’s perspective. Little is however known about the way nursing home staff perceive and promote the personal dignity of individual residents in daily practice, or about staff’s experiences with preserving dignity within the nursing home. The aim of this study is to gain more insight in this.

Methods

A qualitative descriptive interview study was designed, in which in-depth interviews were performed with 13 physicians and 15 nurses. They expressed their views on the personal dignity of 30 recently admitted nursing home residents on the general medical wards of four nursing homes in The Netherlands. Interviews were transcribed and analyzed following the principles of thematic analysis.

Results

According to both physicians and nurses, physical impairment and being dependent on others threatened the residents’ dignity. Whether or not this led to a violation of an individual resident’s dignity, depended - in staff’s opinion - on the resident’s ability to show resilience and to keep his/her individuality. Staff mentioned treating residents with respect and taking care of their privacy as most important elements of dignity-conserving care and strived to treat the residents as they would like to be treated themselves. They could often mention aspects that were important for a particular resident’s dignity. But, when asked what they could contribute to a particular resident’s dignity, they often mentioned general aspects of dignity-conserving care, which could apply to most nursing home residents. By attempting to give dignity-conserving care, physicians and nurses often experienced conflicting values in daily care and barriers caused by the lack of resources.

Conclusions

Tailoring dignity-conserving care to an individual nursing home resident appears hard to bring about in daily practice. Both attention to solve contextual barriers within the nursing home as well as more awareness of staff members for their own values, which they take as a reference point in treating residents, is needed to promote personal dignity in the nursing home setting.

Interdisciplinary Team Collaboration during Discharge of Depressed Older Persons: A Norwegian Qualitative Implementation Study

In order to deliver effective care, it is necessary to organise interdisciplinary activities for older persons who suffer from depressive disorders. This paper evaluated the interdisciplinary team members' perceptions of cooperation in the discharge planning of depressed older persons based on the Chronic Care Model (CCM). A qualitative implementation design was used, data were collected by means of multistage focus groups, and a thematic analysis was performed. Three themes emerged: lack of effective team leadership in the community, the need to change the delivery system, and enhancing self-management support for depressed older persons as well as the participation of their families. It was concluded that nurse managers must find ways of supporting the depressed older persons by better structuring the care, increasing cooperation with organisational leadership, and creating an environment characterised by trust and mutual respect. Distrust can have serious implications for discharge planning collaboration. The development of a common vision of transparency in the organization is important as is a policy of change among leadership and in clinical practice.

Care of the old-A matter of ethics, organization and relationships

The world stands on the threshold of a demographic revolution called global ageing. According to the World Health Organization (WHO), the population aged 60 and over is expected to increase from today's 650 million to an estimated 2 billion by 2050. Alongside demographic changes, dramatic changes can also be observed in older people's services. The shift has resulted in reduced government spending on caring for ill and frail older people in health care. Today, many governments have developed strategies to keep older people living well in their private home for as long as possible and have replaced long-term care institutions with residential homes. The aim of this study was to illuminate the meaning of caring for older people as experienced by health care students and professionals working in this field. Interviews were carried out with 17 women and one man, aged 21–65 years; six were Registered Nurses (RN), six were Enrolled Nurses (EN) and six were nursing students. The interviews were analyzed with a phenomenological hermeneutical approach and provided three themes and eight sub-themes: Ethical moral self with sub-themes “meeting the needs of the old”, “pliability towards the old”, and “difficulties in meeting aggressiveness”; Organizational and co-workers ethical moral actions with sub-themes, “co-workers who are offensive”, and “supportive and non-supportive leaders”: The relation with the old persons and their relatives with sub-themes “fellowship and closeness in the relation”, “uncertainty and fear in the relation”, and, “demands from the older persons’ close relatives”.

Having to focus on doing rather than being-nurse assistants' experience of palliative care in municipal residential care settings

BACKGROUND

Palliative care should be provided, irrespective of setting to all patients facing a life-threatening illness and to their families. The situation and needs of older people differ from those of younger people since they often have several co-existing diseases and health complaints. This implies an extensive need for care and for longer periods of palliative care. The main providers of palliative care for older people are nurse assistants, who are also those with the shortest education.

AIM

The aim of this study was to illuminate nurse assistants' experience of palliative care for older people in residential care.

DESIGN

The study had an explorative, descriptive design.

SETTINGS

Thirteen residential care units in three different districts in a large city in southern Sweden.

PARTICIPANTS

Twenty-five nurse assistants selected to represent variations in age, gender workplace and work experience.

METHODS

Data were collected from six focus-group interviews and subjected to content analysis to gain an understanding of the phenomenon.

RESULTS

The nurse assistants described palliative care as a contrast to the everyday care they performed in that they had a legitimate possibility to provide the care needed and a clear assignment in relation to relatives. Palliative care also meant having to face death and dying while feeling simultaneous that it was unnatural to talk about death and having to deal with their own emotions. They emphasised that they were in need of support and experienced leadership as invisible and opaque, but gained strength from being recognized.

CONCLUSION

In order to support nurse assistants in providing high quality end-of-life care, more focus is needed on the trajectory of older peoples' dying, on the importance of involving relatives throughout the period of care provision, and on support when encountering death and dying. There is also a need for engaged care leaders, both registered nurses and managers, to recognize the work of nurse assistants and to support care provision for older people within the framework of palliative care philosophy.

A discourse of silence: professional carers reasoning about death and dying in nursing homes

Nursing homes are a setting in which death and dying is common. How death and dying is articulated and the actions that take place in a nursing home constitute a discourse that guides the staff in their work. The aim of this study was to explore the discourse of death and dying in nursing homes from the perspective and understanding of the staff. The study draws on Foucault's discourse analysis. Data are from five focus-group discussions held with 28 staff of four different nursing homes in Sweden. The findings show that the discourse had three characteristics: (a) dying was silent and silenced, (b) emotions were pushed into the background, and (c) attentiveness to death arose after the moment of the elderly person's death. The structure of the discourse was characterised by a movement between two positions, avoiding and confronting death, the main focus being on avoidance. The articulation and practices of silence highlight a need to regard dying as a process that requires attention. One way to ensure appropriate attention could be to instil the philosophy of palliative care in nursing homes, including training and support for the staff in their work. The study demonstrates that nursing-home staff need more knowledge and support to enable them to feel that they do a good job.

Nursing home residents' views on dying and death: nursing home employee's perspective

AIM

To reveal nursing home employees' views on dying and death among older people they cared for.

BACKGROUND

Palliative care stakeholders recently included more groups in their definition of palliative care; older people constitute one such group. Consequently, palliative care systems, which will serve a large, aging cohort, will require new skills. The first stage in skills acquisition is to gather current views on dying and death.

DESIGN

Qualitative descriptive study that uses focus group discussions for data collection; 20 employees in 4 Swedish nursing homes participated.

METHOD

Data were analysed using qualitative content analysis.

RESULTS

The following categories were conceptualised: alleviating suffering and pain; finding meaning in everyday life; revealing thoughts and attitudes about death; taking care of the dead person's body; and coping with the gap between personal ideals and reality.

CONCLUSIONS

A deeper understanding of the palliative care philosophy is needed to further develop and tailor care for the dying persons in nursing homes.

RELEVANCE TO CLINICAL PRACTICE

To get public support for palliative care, the silence surrounding dying and death must be broken. Employees must receive education to prepare for all aspects of their work, and management must account for employees' situation when planning the care.