Dignity is a complex and multifaceted concept. This article offers a definition and a model to help nurses promote it in practice and make decisions about care
Understanding the meaning of “dignity” is a prerequisite for all healthcare staff so they know what they need to do to promote it within their services. The Dignity in Care campaign, launched in 2006, marked the Department of Health’s commitment to ensuring services respect the dignity of those using them and ended tolerance of those that do not. This article proposes a definition so that the concept can be based on a common understanding and outlines a model based on existing research, which can be used to enhance dignity in health and social care.
Citation: Clark J (2010) Defining the concept of dignity and developing a model to promote its use in practice. Nursing Times; 106: 20, early online publication.
Author: Julie Clark was a PhD student at Thames Valley University at the time of writing this article.
- This article has been double-blind peer reviewed.
An increasing pressure is being put on health and social care providers to promote dignity in care. The Social Care Institute for Excellence, in partnership with the Department of Health, developed a practice guide for promoting dignity in health and social care settings (SCIE, 2006). This raised awareness of the importance of dignity and is accompanied by a number of tool kits that have been widely used in practice (DH, 2009). However, this literature arguably lacked a clear definition of dignity and the guidance has largely been based on research with older people and those who can articulate their views verbally (SCIE, 2006).
The definition and model proposed in this article draws on findings from research, including research with people with intellectual disabilities, some of whom were unable to articulate their views (Clark, 2008; Mirfin-Veitch et al, 2004). This article therefore fills in some gaps in existing knowledge and literature and adds to understanding of how dignity can be promoted in care.
Among frontline professionals, defining what promoting dignity means in practice has been challenging. Johnson (1990) suggested there is a tendency to assume that healthcare staff share an understanding of this. However, researchers have suggested that dignity probably means different things to different people (Matiti and Cotrel-Gibbons, 2006; Fenton and Mitchell, 2002). Nonetheless, there is no general agreement on what dignity actually means.
A standardised understanding is essential for the concept to be communicated, researched, used in practice, and to generate theory (Shotton and Seedhouse, 1998; Haddock, 1996).
The term “dignity” is derived from the Latin “dignus” meaning worthy (Mairis, 1994), and the Oxford English Dictionary (2002) defined it as “the state or quality of being worthy of honour or respect”. Despite the conciseness of this definition, dignity is a complex concept.
In the health and social care literature, numerous attempts have been made to define dignity. Franklin et al (2006) reviewed 14 studies that used different approaches to study it from a nursing perspective. However, none of these approaches adequately accounted for the complexity of the concept, although each had something to offer as part of an emerging picture. There have been no definitive answers, and dignity is therefore a word that has continued to be used in different ways (Haddock, 1996).
Dignity as a possession of capabilities and autonomy
Various theoretical perspectives have been taken to explain what constitutes dignity, and Haddock (1996) and Mairis (1994) are among those who essentially reduced the concept to the possession of capabilities and autonomy.
For example, Mairis (1994) said:
“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 as a multifaceted concept
Spiegelberg (1970) took a broader perspective, distinguishing between “dignity in general”, which is a matter of degree and is subject to be gained or lost, and “human dignity”, which belongs to every human being and cannot be gained or lost. Similarly, Gallagher (2004) proposed that dignity in nursing practice should be considered both objectively and subjectively. Dignity as an objective concept is the basis of human rights, where it is seen as a “value”, which a person has purely because they are human, and is therefore stable and enduring. Whereas dignity as a subjective concept includes the idea that it can be experienced and allows for individual differences to be taken into account.
“Subjective dignity” includes Gallagher’s (2004) and Spiegelberg’s (1970) conceptions of “self-regarding” and “other-regarding” dignity. The former refers to how a person feels about themselves and how they perceive themselves to be treated by others, whereas the latter refers to how others perceive and treat a person.
Therefore, dignity can refer to both an objective concept to which everyone has a right, as well as to a subjective concept that is socially constructed and made up of values and feelings that can be bestowed on others and experienced (Fig 1).
Defining dignity for practice
The DH’s Dignity in Care campaign aims to create a common understanding of what dignified health and social care services look like (see tinyurl.com/dignity-site), and to do this, defining dignity is essential. In the SCIE’s (2006) guide, a provisional meaning based on the standard dictionary definition was used, which describes dignity in relation to respect. The problem with this is that respect is equally abstract and difficult to define as dignity. This article offers a clearer definition, modified from Haddock (1996) and based on a systematic review of the literature:
“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.
A model of dignity
A model of dignity was constructed to represent the ideas presented in the definition. In this model, as suggested by Gallagher (2004) and Spiegelberg (1970), dignity has two dimensions: “self-regarding” and “other-regarding”. Both are subjective because they are about how an individual interprets either their own or someone else’s dignity to have been affected.
Shotton and Seedhouse (1998) suggested that dignity can be thought about as having different levels ranging from “dignity maintained” to “devastating loss of dignity”. These levels are included in the model because they show that dignity can be lost to a greater or lesser extent in relation to both self-regarding and other-regarding dignity.
The right to dignity
The model is underpinned by the idea that every law abiding person has the right to dignity purely because they are human. Including “other-regarding” dignity in this model is valuable for practice because it illustrates that dignity can be lost, even when a person is not aware of it being violated, for example if they have a severe learning disability. In such instances, it may only be other people who regard a person’s dignity as having been violated. Health and social care providers and workers have a duty to maintain dignity, even if there is a question mark about a person’s capacity or awareness about what is happening to them.
This is because the right to dignity is enshrined in law by the Human Rights Act 1998, which includes the right to freedom from degrading treatment and the right to respect for privacy. The Nursing and Midwifery Council (2008) code of conduct places responsibility on nurses to “make the care of people your first concern, treating them as individuals and respecting their dignity”.
In cases where a person is not able to communicate how they would like care to be delivered, caregivers must maintain dignity by drawing on social and cultural norms which apply to the person they are caring for. This is represented in the model’s third column and is referred to as inter-subjective dignity (Fig 2).
To explore the nature of subjective and inter-subjective dignity further, concept analysis was carried out, from which a number of properties were identified.
Properties of dignity
The sources of these properties come from existing research and theoretical papers, including patient reports about what dignity means to them (Clark, 2008; Franklin et al, 2006; Nordenfelt, 2004; Widang and Fridlund, 2003; Fenton and Mitchell, 2002; Jacobs, 2001; Shotton and Seedhouse, 1998; Haddock, 1996; Dworkin, 1995; Mairis, 1994).
The method of concept analysis involved putting together a list of all ideas about what dignity encompasses, grouping them together conceptually, and cross referencing them. Properties and ideas supported by more than one source were retained, and those that only appeared once were discarded. These properties help to describe what is involved in promoting dignity and therefore go a step towards putting dignity into practice. Research has suggested that although there is some general agreement about the kinds of things considered to be dignified, there are also individual differences. This is why it is important, when possible, to consult people receiving care individually about how they would like care to be delivered.
Subjective dignity - rushing and efficiency
Individual perceptions of what causes dignity to be violated depend on personal values and preferences. The extent to which each property of dignity is prioritised may be different for different people. For example, research shows people vary in how they like intimate and personal care to be carried out. Mirfin-Veitch et al (2004) found people with intellectual disabilities wanted carers to take time during intimate care to interact with them. However, as a wheelchair user, Vasey (1996) described how she liked intimate care to be completed quickly and efficiently.
Therefore, when relying on others to provide such care, some people may find the experience degrading, and therefore want it to be over as soon as possible. Whereas others may feel valued and that they are being treated as a person rather than an object if caregivers take time.
These accounts suggest the amount of time taken for intimate care is important for maintaining dignity, but whether it is more dignified to carry it out quickly or slowly depends on individual preferences. However, it is probably not just speed but also the manner that is important, because there is a difference between efficiency and rushing, and the latter is probably less likely to maintain dignity.
An added complication is that if people prefer an aspect of care to be carried out quickly, such as brushing teeth, this might have a detrimental effect on their health and hygiene. This also has implications for maintaining dignity, because of the way that other people regard someone who does not have a clean, healthy and hygienic mouth. Because dignity is a multi-dimensional concept comprising a number of different properties, a single interaction could maintain dignity in some ways but not others. Caregivers must therefore consult those receiving care and weigh up the advantages and disadvantages of various courses of action and find a solution which meets health needs while maintaining dignity as far as possible.
Dignity and dependency
There is also significant variation in what people regard as undignified in relation to dependency. Some disabled people said they experienced indignity and shame in having to depend on others (Buckley et al, 2007; Franklin et al, 2006). However, Rock (1988) found from her own experience as a disabled person, and from discussion with other disabled people, that independence can be seen as a variable self-concept which relates to control and choice rather than any absolute measure of competence.
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.
Humour and dignity
Those providing care need to consider that an action perceived as maintaining self-regarding dignity may not maintain other-regarding dignity. For example, while the positive value of humour for relieving anxiety and discomfort in nurse-patient interactions has been documented, White et al (2003) pointed out that joking and teasing may be misunderstood by recipients and cause distress and humiliation. Therefore, carers must consider the impact of their actions from recipients’ perspective, and not make assumptions without checking with them.
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 Müller, 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.
This article can contribute to national, local and service policies and the training provided on dignity by offering:
- A clear and inclusive definition of dignity
- An explanation of why it is important
- A model that can be used as a tool in practice to promote it
The model can be used:
- To guide caregivers in making decisions about how to maintain dignity
- In supervision as a tool for reflection on practice
- As a tool for asking patients/clients about what is important to them
- As a way of benchmarking standards of good practice
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