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Dignity is an important and contributing factor to self-respect and to high or low ...

to promote feelings of wellbeing for elderly patients

Dignity exists when an individual is capable of exerting control over his or her behaviour, surroundings and the way in which he or she is treated by others. He or she should be capable of understanding information and making decisions. According to these definitions, to have dignity, a person needs to have certain competencies. This suggests that some people, for example those with severe intellectual disabilities or advanced dementia, may not have dignity, an assertion with which few would agree. Because of the lack of inclusiveness in these definitions, Pullman (1999) suggested that dignity should be separated from autonomy, and that it is dangerous to assume that people who lack capacity for autonomous choice also lack human dignity.

Dignity as a right
Dworkin (1995) asserted that humans have a right to dignity because they are human. The view that dignity is a fixed feature that everyone possesses has been challenged on the grounds that, if it is fixed, then there is nothing that can be done to take it away (Statman, 2000). Conversely, Shotton and Seedhouse (1998) stated that dignity is something that is experienced and sensed, and from a humanistic and experiential perspective, anyone who has had their dignity violated would reject the idea that it cannot be taken away. In the perspectives of dignity discussed so far, it has been reduced to a single concept, which has failed to account for its complexity. This article proposes that dignity needs to be defined in a broader and more inclusive way, which incorporates the ideas that it can refer to a right, an experience and something that can be bestowed on others. Dignity is a fundamental human right. It is about feeling and/or being treated and regarded as important and valuable in relation to others. Dignity is a subjective, multi-dimensional concept, but also has shared meaning among humanity. In this definition, dignity is both an objective right and a subjective concept that can be experienced. Its definition as having a shared meaning among humanity suggests that dignity is also an inter-subjective concept (see Fig 2). This assertion is based on research that shows, despite individual variations, a generally high level of agreement between care recipients about some of the kinds of things reported to be dignified (SCIE, 2006). This shared meaning can be seen as resulting from the establishment of social norms which are learnt and acquired through socialisation, and therefore inter-subjective ideas about dignity are largely culturally dependent, and cannot be applied across different cultural groups. This has important implications for practice, discussed later. It might therefore be concluded that loss of dignity is not an inevitable consequence of dependency, and this is because dignity can be maintained by providing opportunity for control and choice.

Why is dignity so important?

For service providers and caregivers to give priority to dignity, it may be important for them to be aware of the devastating impact that its loss can have. Studies on dignity in healthcare settings have given some indications about the kinds of emotional reactions people experience when their dignity is compromised, including anger, anxiety, humiliation and embarrassment (Lundqvist and Nilstum, 2007; Franklin et al, 2006). In another study, faecal and urinary incontinence affected emotional wellbeing, and the authors argued that the negative impact cannot be underestimated (Buckley et al, 2007). According to Haddock (1996), dignity is connected to the self-concept and self-esteem, and Burns (1979) suggested self-esteem can be measured as an indication of whether a person possesses dignity. The extent to which a person is treated with dignity can therefore not only give rise to an immediate emotional response but also have a more profound and enduring effect. This means the subjective experience of dignity includes how the person is made to feel at the time, and also how they are made to feel on a longer term basis.

Dignity, self-esteem and health

The impact of dignity on self-esteem is important because the latter is thought to underpin psychological and physical health (MacInnes, 1999). Low self-esteem is associated with negative emotional effects (Smith and Petty, 1996), and can lead to depression and anxiety. Symbolic interactionism is a theoretical perspective of social psychology, in which the self is a process, rather than a structure, that develops through interaction. Self and other are sustained by interactive relations, and it is within and through these relations that concepts of self and other evolve (Carpendale and Mller, 2004). Therefore, we see ourselves as others see us, and in symbolic interactionism the way others see is called the ascribed status. This suggests that individuals experience a positive sense of self worth if they are thought about or treated positively by others. Self-esteem is therefore raised if others regard us with high esteem and treat us with dignity, whereas it is lowered if we are regarded without esteem and treated without dignity.

Implications for practice

This article has implications for practice in any service providing health and social care. For frontline staff to be able to deliver care with dignity, their employer must support them, which means appropriate training and policies need to be in place. When planning and delivering care, staff should consider individual preferences in the way that care is delivered and, where possible, discussions can take place with patients/clients about these. The properties of dignity in the model can be used to help service users

articulate what is important to them in relation to maintaining dignity. Assessment of dignity should be integral to care planning and person centred planning processes. In cases where patients/clients are unable to inform staff of how they would like care to be delivered, staff must draw on their understanding of inter-subjective dignity and apply their knowledge of cultural and social norms. Maintaining dignity is not a science, but relies on understanding, empathy and compassion. Caregivers may need to make judgements, sometimes in difficult and challenging circumstances, and it is therefore essential they have knowledge and skills to help them in this. The notion of dignity as an inter-subjective concept is important here because it suggests that a set of social and cultural norms could be developed from which caregivers can learn generally accepted ways of promoting dignity. At times, some aspects of dignity may be compromised because of a need to provide urgent or necessary care. There may also be conflict between self-regarding and other-regarding dignity. As far as possible, this should be dealt with through multidisciplinary team working and by developing care plans and procedures.

This article provides a definition of dignity and a starting point from which healthcare professionals can begin to understand how they can promote it. It also proposes a model which nurses and others can apply in clinical practice.

Privacy is important to everyone and is not less so because one is in residential care. Residents are entitled to their privacy and unnecessary invasion of this right will be avoided. All Residents are able to dress, wash and use the toilet in private, even when needing assistance. Residents are able to meet family and friends, doctors, etc... in private if they wish. Privacy and the desire for solitude at any time, is always respected.

We appreciate that residents may have given up a great deal of their independence to come into a shared living situation like Charnley House. Residents may prefer to be independent in certain self-care situations in order to maintain dignity and self respect. This will be encouraged by providing tactful human or technical assistance when needed. Independence in any task however small will be maintained if possible and will be promoted. All residents will be assisted to make their own decisions wherever possible.

Charnley House will encourage choice, participation and activity so that Residents may achieve their potential physical, intellectual, emotional and social capacities. It is understood that this potential may change over time. Residents will also have the choice to refuse to participate and to remain solitary if they wish, without embarrassing confrontation. The term 'activity' can also be extended to cover self-care thus enabling Residents to retain dignity and self-esteem. Watching TV and listening to the radio can be sources of enjoyment and education as well as providing a link to the world. We appreciate that peoples' decisions may change over time. We respect all residents' religious, ethnic and cultural diversities.

Charnley House will strive to uphold the dignity of Residents even though assistance and support may be needed in many ways. Residents will be treated as individuals and their thoughts, beliefs and emotional needs will be respected. Residents have the right to live in a manner and in circumstances which correspond, as far as is possible, with what is normal for those who still live in their own homes. Our staff are sensitive to the needs, feelings and wishes of the Residents. All relationships should be courteous and respectful, hopefully in both directions. All Residents will be called what he/she wishes. It is reasonable to wish to be addressed in different way by different people and this is respected. We will support resident's dignity by:

Having a zero tolerance of any and all kinds of abuse Supporting people with the same respect you would want for yourself or a family member Treating each person as an individual by offering a personalised service Enabling people to maintain the maximum possible level of independence, choice and control Listening and supporting people's right to privacy Ensuring people feel able to complain without fear of retribution Engaging with family members and carers as care partners Assisting people to maintain confidence and a positive self-esteem Acting to alleviate people's loneliness and isolation

We endeavour to provide a high quality of care service by treating each resident as a special and valued individual.