Dignity in nursing homes: A qualitative descriptive study of older adults’ experiences

Introduction

The social and financial implications of an ever increasing aging population are of global concern. In China, with the increasing reduction in family size, the acceleration of aging, and the increased number of empty-nest families, the support of traditional family older adults care in older people care system has begun to decline. ¹ Historically, older adults have predominantly received direct care from their relatives, but this is no longer the case. ² Thus, the demand for institutional care services is increasing. Dignity is a crucial element of nursing, with impaired dignity leading to loss of self-worth, emotional imbalance, and poor physical and mental health.^3,4 Nursing home residents face an increased risk of decline in dignity and autonomy, as not only do they face the decline of physical and cognitive function but also the unfamiliarity and isolation of the care home environment. ⁵ In China, institutional older adult care is at a nascent stage, compared with other developed countries, resulting in deficiencies that impact the quality of life of the residents. However, due to the combined effect of the growing aging problem and the decline in the ability of families to support their relatives, more people will choose to retire to an institution in the future. Therefore, there is widespread interest in proposals detailing how to improve the quality of care and how to maintain the dignity of older adults in nursing homes.

Background

Dignity is a multi-dimensional concept; thus, there are many definitions of dignity in current literature. ⁶ It is generally believed that dignity can be divided into two categories: intrinsic and attributed. ⁷ Intrinsic dignity, also known as absolute dignity, is inherent and inalienable to human beings. Attributed dignity, also known as extrinsic dignity, is acquired and represents the value generated or lost by a person according to their life experience and achievements. It can be passed on to others through behavior and is influenced by cultural and external factors. ⁸ In the field of nursing, the definition of dignity was first proposed by Shotton and Seedhouse, who believed that if an individual’s abilities are effectively utilized, they will have dignity. ⁹ On the contrary, when you are in a situation of discomfort, or in a situation of incompetence or extraordinary vulnerability, your dignity will decline. This is similar to Mairi’s view that dignity exists when individuals are able to control their own behavior, environment, and the way others treat them. ¹⁰ Maintaining dignity is a core concept of nursing, and failure to do so can not only lead to psychological and spiritual pain for patients but can also cause distrust and conflict between care providers and their patients, causing the patients to feel stigmatized.^11,12 Nursing homes are unique environments where many older adults with complex needs will spend the remainder of their lives. Chronic diseases, disabilities, and age discrimination make older adults more likely to feel vulnerable and feel less dignified than those who are younger. ¹³ If the dignity of nursing home residents is not safeguarded, they may suffer from depression and even premature death. ¹⁴

Supporting older adults and ensuring their dignity during their twilight years is an important issue for both the state and family members alike. According to the literature, it can be seen that Western countries have been studying this issue for a considerable time and have taken the opportunity to discuss the implications of dignity in numerous researched fields and perspectives. As a result, they have formulated a well-established understanding of the concepts and needs involved. For example, Franklin, Nåden, Lohne, and Oosterveld-Vlug (and other academics) have conducted extensive research into the dignity of nursing home residents, including phenomenology studies from the perspectives of residents, family caregivers, and staff.^15–20 However, it is worth noting that current research into the dignity of older adults in nursing homes mostly focuses on the care of dementia and end-of-life patients. This of course ignores the wider older adults’ community as a whole as they go about day-to-day life. Research into institutional elderly care in China is only a recent phenomenon. As dignity is subject to cultural restrictions, ²¹ therefore, historical research conducted in the West cannot be considered wholly applicable to our aging-population; thus, further investigation is needed. This study has therefore adopted a qualitative descriptive method to explore the dignity experience of older adults (from nursing home residents’ perspective) in their daily lives, but in the context of Chinese culture. The study may serve as a starting point for further research that formulates intervention strategies.

Methods

We used a qualitative and descriptive design to achieve the objectives of our study. We collected data through semi-structured interviews and reported results according to the established standards for reporting qualitative research (SRQR). ²² Qualitative descriptive research is a study method that describes the characteristics of a phenomenon as opposed to the underlying causes/mechanisms. It is based on recognizing the diversity, interactivity, and inseparable nature of human communication and shared experiences. ²³ This method is applicable to nursing research and helps researchers to understand the experiences and perspectives of patients, relatives, and professionals. We used semi-structured face-to-face interviews and a content analysis to describe individually expressed, superficial, and obvious experiences. ²⁴ Content analysis is a systematic classification and coding technique that can better understand the phenomena being studied. ²⁵

Participants for this study were drawn from a pool of residents living in either of two private nursing homes in Shenyang, Liaoning Province, between September and November 2022, using purposive, maximum variation sampling methodology (i.e., older adults with different baseline variables). The investigator had no prior acquaintance with any of the participants. The determination of sample size was based on the principle of information saturation, that is, when there is duplication or information saturation in the interview data, and no new topics appear during analysis, sampling is stopped. ²⁶

Participants were (1) aged≥ 60 years (China is a developing country, so setting 60 years as the minimum age for participants in the study); (2) staying in the nursing home for at least 6 months; (3) no cognitive impairment and able to communicate verbally in Chinese; (4) able to provide written informed consent. Whereas, participants were excluded if they were (1) suffering with a serious mental or physical disease; (2) unconscious, incapacitated, or unwilling to participate.

All interviews were conducted face-to-face by two investigators and based on the questions presented in Table 1. The first author conducted the interviews, while the other investigator was responsible for recording and time management. Prior to each interview, its purpose and significance were explained to each interviewee, who was also informed that the whole conversation would be recorded. All interviews were scheduled in advance, conducted in the interviewee’s room (or location of their choice). The interview was based around the interview guidelines; however, the exact content and order of questions were flexible, being adjusted by the participants’ answers. The answers were contemporaneously annotated to record changes relating to the participants including expression, tone, intonation, movement, and behavior and mood of the interviewee. Considering the physical strength and energy of older adults, we allowed approximately 30 to 50 minutes for each interview. Interviews were digitally audio recorded.

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Table 1.

Interview guidelines.

No.	Questions
1	Can you talk about your feelings when you first moved into the nursing home? How did you spend that time?
2	How do you feel about living here now? Can you tell me about your feelings?
3	During your stay in the nursing home, did you feel your dignity was preserved? Can you give me an example?
4	Have you ever been disrespected or had your dignity violated? If so, can you give an example?

Data analysis

After the interview, each audio file was stored on a computer in a specific file and labeled using codes P1 to P20 instead of the participants’ names. Each recording was transcribed verbatim within 24 hours of completing the interview. With the aid of another researcher, the author promptly imported the transcribed data into the software Nvivo12.0. Content analysis method was utilized by the researchers for analysis and coding. Firstly, the first author and the other investigator independently read through the documents carefully and ensured data immersion. The two analysts identified repetitive words, concepts, and phrases and then open coded the content of transcribed text manually. Subsequently, the codes were grouped into categories that reflect the dignity characteristics of older people. The codes and categories of each transcript were constant compared between the analysts, and distinctions were discussed and resolved to reach a consensus. Finally, themes and sub-themes were extracted by analyzing and interpreting these corresponding categories and codes. Data saturation was reached after coding 20 documents.

A SRQR checklist was used to guide our methodology and ensure our research was precise. The whole interview was recorded objectively without any inducement intervention. The original data were impartially analyzed by two investigators, who suspended their personal views, immersed in the text data, and read it repeatedly. Also, the first author kept writing a reflective diary throughout the research in order to fully immerse herself in the research. The transcribed text was returned to the participants for verification to ensure the stability of the results. When two analysts independently conduct data analysis and topic extraction, if there was a disagreement, the research group or a third researcher would discuss together to reach a consensus, so as to improve the credibility of the research results. Using SPSS 24.0 to analyze general demographic data.

Ethical considerations

The research protocol has been approved by the Research Ethics Committee of the author’s institution (2021-26). During the study, interviewees strictly followed the principle of informed consent and respected participants’ choice of whether or not to participate. All of the participants signed an informed consent form. All data were anonymized, encrypted, and destroyed upon completion of the study.

Results

A total of 20 nursing home residents were included in this study. The participants were between 67 and 92 years, with an average age of 82.95 (±6.35) years. The duration of residency varied from 6 months to 10 years, with an average occupancy of 3.90 (±3.35) years. Demographic data are presented in Table 2.

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Table 2.

Participants’ characteristics (N = 20).

Characteristics	All residents
Sex
Male	6
Female	14
Age, mean (SD) [range]	82.95 (6.35) [67–92]
Length of stay in nursing home(years), mean (SD) [range]	3.90 (3.34) [0.50–10.0]
Marital status
Married	3
Single	17
Level of education
Elementary school	7
Junior high school or high school	12
College/bachelor’s degree	1
Main reasons for living in a nursing home
To reduce the burden of their children, and voluntarily move in	7
Children or spouses unable to take care of	11
Other	2
Number of children
1–2	13
3–4	6
≥5	1
Living circumstances
Single room	13
Double room	7
Activities of daily living (ADL), mean (SD) [range]	17.10 (2.88) [14–21]
Completely normal (ADL = 14)	8
Mild damage (ADL = 15;21)	12

Five themes about the dignity experience of older adults in nursing homes were constructed, namely, self-esteem, perceived value to society, interpersonal relationships, autonomy, and acceptance and adaptation. Furthermore, eight sub-themes were identified: sense of self-worth, becoming a burden, being respected, belonging, relationships with others, respectful behavior toward others, control of daily life, and participation in decision-making. Table 3 provides an overview of the themes and sub-themes.

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Table 3.

Overview of themes and sub-themes.

Themes	Sub-themes
Self-esteem	Sense of self-worth
	Becoming a burden
Perceived value to society	Being respected
	Belonging
Interpersonal relationships	Relationship with others
	Respectful behavior toward others
Autonomy	Control of daily life
	Participation in decision-making
Acceptance and adaptation

Discussion

Moving to a nursing home can greatly impact the lifestyle and outlook of the new resident. When older adults suddenly transition from independent living to collective living in nursing homes, where they need to rely on others, their dignity may be threatened, making them feel vulnerable.^27,28 In this study, we identified five themes and eight sub-themes relating to the dignity of older adults in nursing homes.

Self-worth plays a vital role in maintaining dignity. When individuals cannot feel their own value, they will have a sense of “uselessness,” resulting in the loss of dignity. ¹⁶ In this study, when older adults begin to age and can no longer contribute to society or take care of their children/spouse and need to rely on others, they feel that they are a burden and experience a declining sense of dignity. This is similar to the results reported by Söderman and Oosterveld-Vlug, who believe that when individuals feel that they are a burden to others, their dignity is damaged and they can even lose the will to live.^29,30 The root cause of this kind of psychology may be related to the absence of a social role, the decline of self-recognition, and the decrease in social belonging in the older people. In addition, the contrast between previous independent living versus institutionalization often increases frustration and affects individual dignity.

After moving to nursing home and experiencing separation from the familiar environment of their previous existence, it is natural that these older adults feel vulnerable. In this study, some older adults felt abandoned by their families and society and had no sense of belonging. This is consistent with the study of Rehnsfeldt, who believes that the sense of home is integral to dignity. ³¹ It is suggested that nursing homes should create a family atmosphere for residents, cultivate a sense of belonging, and make them feel at home. Creating this sense of belonging should enable older adults to undergo behavioral adaptation: considering themselves part of the collective, actively participating in collective activities, and constantly improving their self-value during the process of interaction. ³²

Dignity can rely on strong interpersonal characteristics. In this study, older adults mentioned that establishing good relationships with caregivers, peers, and family members plays an important role in maintaining dignity. This may be related to the fact that a good relationship means being understood, trusted, and accepted, as well as being able to provide emotional support, which can serve as a buffer when dignity is threatened. This view is consistent with research results of Western countries.^20,30 Quite often, residents are located far from relatives and have limited communication with the outside world. The people who have the most contact with them are mainly their caregivers but also residents’ companions. Older adults need to rely on these individuals for every aspect of their life here. Their attitudes and behaviors directly affect the dignity of the residents in their care.^33,34 This suggests that the support of caregivers has a significant impact on the daily life and dignity experience of older adults. However, in China, the gentleness of caregivers is generally low to medium, with great variation in quality. ³⁵ Therefore, how to further enhance the humanistic care awareness and improve the humanistic care ability of nursing staff is also an urgent need to maintain the dignity of older adults. In addition, some of older adults in the study said that although most of their relatives and friends had passed away, their happiness and sorrow were still closely related to their family. Therefore, nursing homes can strengthen communication with residents’ families, promote interaction between older adults and their children and grandchildren, help them establish emotional relationships, and rebuild supportive social networks.

In this study, the majority of older adults stated that maintaining autonomy, reducing dependence on others, and ensuring self-sufficiency in daily life were important for their dignity. These results are consistent with Heggestad and Cai.^36,37 Some older adults believe that although their basic daily needs have been met, factors such as rigid institutional rules and regulations, lack of social support environment, and difficulty in adapting to nursing home life can also pose a threat to their dignity. The reason may be related to the institutionalized management, which makes older adults unable to keep their original living habits and hobbies, and have very limited opportunity to make independent decisions in daily life. It is suggested that in the future, the managers of institutions should ensure the autonomy of older adults flexibly, avoid paternalistic intervention, and comply with their wishes and values on the premise of daily management. It is worth noting that, in traditional Chinese culture, individuals have strong family ties, and individuals can be restricted by family affection and interdependence. Therefore, when faced with decision-making, older adults are often not used to making decisions in isolation but through discussion with their closest kin. They are not used to autonomously pursuing their own interests; thus it may be necessary to awaken a sense of consciousness regarding autonomy, so as to protect their dignity from violation.

Acceptance and adaptation. Studies have shown that older people, who can adapt to and accept their life in nursing homes, have a higher sense of dignity than those who cannot accept this reality. ³⁸ In this study, the majority of older adults stated that after the transition, they could integrate into collective life, establish relationships with others, and share life experiences or events, which helped them adapt to and accept the life in a nursing home as soon as possible. Some older adults also express that they have no other choice but to compromise and passively accept, and even after living for a long time, they still cannot adapt here. These older adults have negative attitudes, prefer to be alone, and rarely participate in group activities. It is suggested that nursing staff in nursing homes should pay more attention to the psychological, spiritual, and social needs of older adults while completing their physical care. In addition, nursing homes can organize more meaningful activities, through participation, older adults can feel self-worth, form a new identity, and thus give new meaning to life.

Limitations of the study

This was the qualitative study to explore the thematic features of dignity experiences of older adults committed to nursing homes in mainland China. We collected the voices and feelings about dignity directly from participants. However, our study only interviewed residents of two nursing homes in Shenyang, so the analysis of the “dignity experience” of older adults is unlikely to be comprehensive and has certain limitations. Follow-up studies can further expand the geographic scope to ensure results are representative.

Conclusion

This study conducted in-depth interviews with 20 older adults to explore the dignity experience of older adults in their daily life in the nursing home, in the context of Chinese culture. Analysis of the response revealed five themes and eight sub-themes, including self-esteem, perceived value to society, interpersonal relationships, autonomy, and acceptance and adaptation. Nursing homes can preserve the dignity of older adults by guaranteeing their autonomy, paying attention to their inner needs and life experience, providing social support, and helping older adults to find self-worth and life meaning, thus improving the delivery of high-quality care services for older adults.

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