Maintaining dignity is conceptualized as critical for the well-being of older individuals (Erikson, Erikson, & Kivnick, 1986). The concept of dignity in relation to the well-being of older adults has drawn much attention from health care providers and scientists (George, 1998; Jacelon, 2013; Walsh & Kowanko, 2002). The effect of dignity-preserving or dignity-diminishing care on an older adult’s dignity has been explored (Baillie & Gallagher, 2011); however, the role of the older adult in maintaining his or her dignity has not received the same attention. In the current grounded theory study, the strategies used by older adults to maintain or restore dignity were identified.
Several qualitative research studies have focused on older adults’ experiences of dignity and care in health care facilities (Baillie, 2009; Bridges, Flately, & Meyer, 2010; Hall, Longhurst, & Higginson, 2009; Lin, Tsai, & Chen, 2011; Matiti & Trorey, 2008; Webster & Bryan, 2009). Using a phenomenological approach, Webster and Bryan (2009) asked 10 older adults about their experience while hospitalized and found that promoting an older adult’s dignity includes respectful communication from staff. Participants indicated that how things were said (i.e., with respect) was just as important as what was said by staff. In another study, using case methodology, Baillie (2009) found that patient dignity was enhanced by staff behavior that provided privacy and helped patients feel comfortable, in control, and valued. Several studies have also explored how older adults’ experiences of environments support dignity at the end of life (Brown, Johnston, & Ostlund, 2011; Chochinov et al., 2006, 2011).
Although creating the environment to support the dignity of older adults and their responses to those environments has been well documented, fewer studies have explored older adults’ experiences of dignity in the community. The most noted study, the European Dignity Study (Tadd, 2004), was a large, multifaceted research study in which a subgroup of scientists used focus groups to “explore the salience and meaning of dignity for older people” (Calnan, Badcott, & Woolhead, 2006, p. 359). Dignity was important in the participants’ everyday lives. The themes regarding dignity included (a) identity and autonomy, (b) being shown respect from others, and (c) having respect for self. Older adults reported that dignity was often negatively affected in the context of health or social care.
Little research has focused on the strategies used by older adults to manage their own dignity. Only one study was found that explored how older individuals managed their dignity. As part of a grounded theory study, Jacelon (2003) found that older adults took an active part in managing their own dignity while in the hospital. However, no research was identified in which older adults managed dignity in the context of their everyday lives. Understanding the process individuals use to maintain their dignity may help health care providers in the hospital and community support the dignity of these individuals, and as Erikson et al. (1986) theorized, dignity is increasingly being related to positive health outcomes for older individuals.
Grounded theory methods are based on the theory of symbolic interaction. According to symbolic interaction, individuals construct meaning out of interactions in which they engage. Through interaction with self and others, individuals make sense of their life experiences through an interpretive process (Crooks, 2001) and act based on the meanings they attribute to a situation (Blumer, 1969). The interpretive process used to make meaning occurs in two phases. First, the individual appraises the situation he or she is experiencing and then determines the actions or strategies he or she will use. The purpose of the current study is to explore the strategies older adults use to manage attributed dignity based on the meanings they attribute to interactions with others.
Dignity is a fundamental condition of being human (American Nurses Association, 2001; Gaylin, 1984; Jacobs, 2001; Johnson, 1998; Laczniak, 1999; Pullman, 1999). It has no physical properties (Jacobs, 2001) or measurable characteristics, and it cannot be gained, lost, destroyed, or taken away by others (Randers & Mattiasson, 2004; Spiegelberg, 1971). Jacobson (2007) and Nordenfelt (2004) identified this type of dignity as menschenwurde. Dignity, the basic human characteristic, is manifested in the concept of attributed dignity (Jacelon, Connelly, Brown, Proulx, & Vo, 2004). Attributed dignity is a form of social dignity (Jacobson, 2007), which is susceptible to interactions with others.
The core concept of the current research is attributed dignity. Over the past several years, the current author has developed the concept through a series of qualitative and quantitative research studies. Attributed dignity is a concept with four factors and is defined as “an attributed, dynamic sense of self-value, self in relation to others, perceived value from others, and behavior that demonstrates respect toward others” (Jacelon, 2012). Jacelon and Choi (2014) defines the factors as follows: (a) self-value (i.e., a state-like characteristic) is the individual’s self-perceived value or self-estimate of the individual’s relative importance; (b) perceived value from others is the value an individual perceives he or she is attributed from other people; (c) self in relation to others is self reflection on how an individual interacts with others; and (d) behavior that demonstrates respect, which is self-explanatory, with the caveat that the behavior can be directed at self or others. “Attributed dignity is gained or lost in one’s own eyes during interactions with self and others” (Jacelon, Dixon, & Knafl, 2009, p. 203).
Nineteen participants responded to flyers advertising the study at local senior centers in the northeastern United States. Participants included eight Black women, nine White women, and two White men, ranging in age from 65 to 90 (average age = 76.7). Two women and one man were married; all others were single, divorced, or widowed. Participants lived in rural and suburban areas. Annual income ranged from $10,000 to more than $70,000. All participants had attended at least some high school, several had attended college, and some had earned doctorates. Participants lived alone, with children, or with spouses in apartments or single-family or multi-family homes. Some lived in homes that they owned, and others lived in apartments (Table 1).
Demographics of the Study Sample (N = 19)
The social process of managing attributed dignity is described below, including the characteristics of situations; the process of making meaning out of situations affecting attributed dignity, including appraisal and action; and the strategies used by participants to repair attributed dignity. Following the description of the process, the findings are compared to earlier research exploring hospitalized older adults’ strategies to maintain attributed dignity.
The Process of Managing Attributed Dignity
Participants described a process of managing attributed dignity that began with an interaction with another individual. Participants appraised the interactions using the property of attributed dignity (i.e., self in relation to others). This appraisal had a direct effect on participants’ perceived value from others, and an indirect effect on participants’ self-value (Figure 1). During interactions that enhanced the participant’s attributed dignity, the participant’s perceived value from others is congruent or greater than his or her own self-value. In this case, when initiating behavior demonstrating respect, the individual used interactive strategies during the interaction. During interactions that had a negative effect on the individual’s perceived value from others, individuals used introspective and active strategies directed at enhancing their own self-value and/or interactive strategies to respond to the individual initiating the threat (Figure 2).
The process of managing attributed dignity during interactions that enhance attributed dignity.
The process of managing attributed dignity during interactions that threaten attributed dignity.
Characteristics of Interactions That Positively Affect Older Adults’ Attributed Dignity. Participants described situations in which their attributed dignity was enhanced as situations where other individuals treated the participants with honor or respect. For example, one participant told the following story:
The Minister asked me to be a stewardess. That was something that I liked. We take care of communion and help to do that. Right now we all sit together, even if it’s not the first Sunday when we have communion, we all sit together and I like that. Because my mother was a stewardess years ago, so I’m proud to be a stewardess in my church.
In a second example, a participant said:
When I had my hip done, I ended up in intensive care because of the medication that they didn’t know I was allergic to. I was just so sick that day. I was intubated. I couldn’t even put my glasses on because I was all swollen from that medication…. This young nurse came into my room and she says, “You don’t remember me, do you?” I said, “No.” She said, “I’m Rose. I was the nurse that administered that needle to you. I know it wasn’t my fault, but I felt so bad. Before I left that night, I came into intensive care; I just had to touch you to make sure you were alright. I went home and I prayed all night for you.” I never forgot that. I felt wonderful that she thought enough about me [to come see me]; she didn’t even know me.
In both of these examples, the participants believed they had been singled out for an honor or that the individuals with whom they were interacting respected them.
Characteristics of Situations That Adversely Affect Older Adults’ Attributed Dignity. Older adults’ attributed dignity was diminished when, during interactions with other individuals, older adults appraised the congruence between their perceived value from others and their self-value and found that the perceived value from others was not as positive as their self-value. One woman gave the following example of ageism, which led to her appraisal of being undervalued by another individual:
One thing I cannot stand about a doctor is they’ll say, “Well at your age”—what do you mean at my age? Don’t tell me at my age I shouldn’t want certain things. Now that upsets me. I don’t understand why people think that the older you get that you don’t want the same things that younger people want. I say at my age I want to be functional, and functional to me means to be able to do whatever I want.
Several Black participants told stories about interactions where racism was perceived:
Say if something costs $10.25 and I give you $20.25 in your hand so you’re going to give me back $10 and I’m holding my hand out and you put it on the counter. It’s almost like [I want to say] “Do you think the black is transferable?”
Another participant explained:
If I were in a situation where there were six people in a room being assigned tasks and there were tasks of varying sophistication levels, and they said, “Okay you’re going to do the filing and the vegetable counting and the whatever…,” my dignity might be insulted.
In these situations, older adults perceived that the other individuals’ ideas of the older adults’ value was less than the individual’s self-value. In the first situation, the woman thought the physician was diminishing her value and limiting her aspirations because she was older. In the second situation, the woman perceived that the cashier was treating her without respect because she was Black. Finally, the man was a highly educated president of a corporation before he retired and thought that being assigned a menial task was not consistent with his self-value.
Appraising the Situation
Applying the attributed dignity component self in relation to others, older adults appraise dissonance between their perceived value from others and self-value. One participant explained this part of the process as:
If my dignity is attacked, threatened, undermined, it’s an assessment each time. “How much power does this person have over me? Is it worth a confrontation? What will the repercussions be if I challenge this person? Will it put me in a position where my dignity is even more diminished?”
Based on the answers to these questions, older adults decide which strategies to use to repair their attributed dignity.
Taking Action: Strategies Used to Protect, Restore, or Maintain Attributed Dignity
Following the appraisal of a situation, through the component of attributed dignity of behaving with respect, older adults used three types of strategies to minimize the effect of the threat to attributed dignity: (a) introspective, (b) active, (c) or interactive. Introspective strategies have an immediate effect on the individual’s self-value. Active strategies remove the older adult from the situation or seek outside assistance to remediate the situation, which also effects self-value. Interactive strategies are used to respond directly to the individual who has diminished the older adult’s perceived value from others.
Introspective Strategies. Introspective strategies are aimed directly at repairing the damage done to the individual’s self-value. They enhance self-value by bolstering the individual’s sense of self-value with respect to the other individual in the interaction. Two types of introspective strategies were identified. The first was consider the source; the second was take it to God. Individuals who used the consider the source strategy reported making an evaluation about the importance of the insult and the individual who caused the insult to attributed dignity. One participant reported:
My mother taught us to consider the source and consider what you want to fight for and what you want to back off of. I kind of think…is this going to bother me down the road, do I need to address this, do I need to react, or do I just respond and say okay?
This quote demonstrates the appraisal made by the older adult when deciding which action strategy to use. When considering the source, the older adult did not respond to the affront to attributed dignity by confronting the other individual; in this case, the appraisal of the threat to attributed dignity did not reach the level of requiring an interactive or active response from the older adult. The older adult determined that the source of the affront to attributed dignity was not worthy of reply. By determining that the other individual was not worthy of response, the older adult bolstered her own self-value.
Similarly, another woman said:
I recover [my self-value] because I know that first of all, that person doesn’t really realize who I am. If they don’t realize who I am, they can just say, well you know, “I don’t really care for this person.” That’s how they’ll do it.
In this case, the older adult considered the source of the insult to dignity as coming from an individual who would not have acted that way if he or she really knew her. She is excusing the individual’s behavior and thereby discounting the threat to her attributed dignity.
Several Black participants said that when their dignity was offended, they would take it to God.
It happened [to my mother] as a product of getting old, that she was treated with disrespect all the time and…what she usually did was turned inward and prayed to get some guidance on how to handle the situation and usually was restored by her God.
Another participant explained:
I know that my Father in heaven cares for me. I just leave it all in His care. He said He would never leave me; He’d always be with me no matter what happens. And in the long run, that person that offended me…it’s a test, and God wants you to know that your life is not going to be a bed of ease.
Active Strategies. Participants reported using active strategies to remove oneself from the situation or report the behavior. Using either active strategy had the effect of enhancing the individual’s self-value by removing oneself from the noxious interaction or validating his or her position by reporting the other’s behavior to an authority. One participant described how she would remove herself from the situation by explaining: “I might walk away, I might say something and then walk away. Say, ‘Well I don’t think that’s right,’ and then walk away. But just stand there and fuss and argue, I don’t think I would do that.”
In the situation above, the older adult used the interactive strategy of maintaining her position (see explanation below) and then followed with the active strategy of removing oneself from the situation.
I mean, I was kept waiting for an hour and a half in a physician’s office. So I complained at the desk, I said, “Why didn’t you at least tell me there was an hour and a half wait?” I said to the doctor, “I’ve been waiting for an hour and a half; why didn’t you at least tell me?” I was aggravated and, actually since that episode, I’m thinking about changing doctors.
The second active strategy identified was report the situation. Several participants reported that if their attributed dignity was diminished during an interaction, that they would report it to an individual of authority.
If it was a church, I would speak to the Minister or maybe the president of the organization that I was in. I wouldn’t talk to that person; the person that did that [offended my dignity]. I don’t think that would be nice, maybe somebody else might, but I would go to my president or maybe my pastor and talk with him.
In this situation, the older adult restored her attributed dignity by reporting the offensive behavior to a higher authority who may be able to remediate the situation. By reporting the situation, the older adult enhanced her self-value by seeking support from an individual of perceived authority.
Interactive Strategies. When older adults appraise the interaction with another individual as sufficiently threatening to respond directly and immediately to the other individual, they use interactive strategies. The first interactive strategy reported was maintaining one’s position. The second strategy reported was getting mad.
When using the strategy maintaining one’s position, the individual responded to the threat to attributed dignity by maintaining his or her position and restating it to the other individual. One participant described the process as:
Depending on the seriousness of the situation, I try to refrain from ugly outbursts, but I speak up. I will try to intercede on my own behalf, speak calmly and rationally, and let them see a little bit of me and explain if I disagree, why I disagree.
Regarding the second strategy (i.e., getting mad), when the interaction was sufficiently odious, the older adult became angry. During an interaction with a health care technician, one participant with significant respiratory disease reported getting mad and how she acted:
It was some type of breathing test. The tube was hooked up to some machine and she [the technician] had me breathe [into the tube] many times, and she would say, “Harder, harder, harder, HARDER!” I finally had to push the machine away and say to her, “I can’t do it any harder than I am,” and she said, “But you have to.” I said, and I was rather sharp about it, “You’re telling me to breathe hard and I’m breathing as hard as I can.” I said to her, “If you want me to breathe harder, this test is over.”
Another participant described losing her temper with a woman who was working at an information desk.
There was this one time where this woman was sitting at a table, and I was trying to explain to her what I needed or what I wanted, and she was just looking at me as if, you know, “Why don’t you just go away old lady, and leave the time to us?” I mean, you know, she was just disgusted with me. My comment to her was, “May you live a long, long time.”
In both of these examples, participants tried to do their best, and the individuals they were interacting with did not convey that they valued the older adults’ efforts. The first situation had to do with physical performance; in the second case, the participant appraised that she was undervalued as a result of ageism.
Variation in the Process Based on Participant Characteristics
Participants selected the strategies they used based on appraisal of the situation. Each participant had one or two strategies they were most likely to use, singularly or in combination. One participant explained:
I think that [how I respond to a threat to dignity] depends on the situation…. You know it’s kind of different with a friend versus a professional…so, I think it just depends on the situation and the circumstance…. So some of this has to do with how close the person is to you and some of it has to do with… the risk associated with my actions.
No obvious patterns of use of strategies were noted in relation to demographic information (i.e., sex, age, income level), except those strategies related to race. The one strategy that was mentioned by one group only was take it to God. One half of Black female older adults mentioned they relied on God or religion when their dignity was offended. Even upon probing among White women and men, God was not mentioned.
Comparing the Current Study to Previous Research
The three types of strategies (i.e., introspective, active, and interactive) were originally identified as strategies used by older adults to manage personal integrity, of which dignity was one property, during hospitalization (Jacelon, 2003, 2004). Although the categorization of strategies was similar, the actual strategies varied between hospitalized older adults in the earlier study and the community-dwelling older adults in the current study. The introspective strategies used by hospitalized older adults were aimed at improving self-value, as were introspective strategies in the current study. The introspective strategies identified in the study of hospitalized older adults included the strategies life reviewing and adjusting attitude. In life reviewing, the older adult thought about a time in which he or she was successful and compared that time to the current situation, thereby reminding him- or herself that they have self-value. Using the strategy adjusting attitude, older adults worked to maintain a positive attitude toward hospital staff regardless of how they were treated (Jacelon, 2003).
In the hospital, a power differential was noted between the older adult and the staff member with whom the older adult was interacting. One hospitalized participant explained, “It was just like you were at everybody’s mercy” (Jacelon, 2003, p. 548). This power differential affected the appraisal process, and older adults used strategies that they perceived would minimize the likelihood of retribution from health care staff. Therefore, the hospitalized individuals did not use active strategies. Instead, the interactive strategies they used were covert and focused on the interaction as opposed to the more overt, assertive interactive strategies that were used by the community-dwelling older adults. The hospitalized older adults did not assert themselves during the interaction, but rather used managing image and managing information to affect staff members’ perceptions of older adults, thereby improving the likelihood that interactions would be perceived as positive by health care providers. Community-dwelling older adults used strategies where they challenged the authority of the other individual (Table 2).
Strategies Used by Older Adults to Maintain or Restore Attributed Dignity
The active strategies used by community-dwelling older adults were designed to remove themselves from the dignity-offending situation or gain help from an authoritative figure to change the other individual’s behavior. The hospitalized individuals could not remove themselves from the situation, and the power differential between hospitalized older adults and care providers prevented older adults from reporting behaviors that were offensive.
The purpose of the current research was to expand the emerging middle range theory of attributed dignity by exploring the strategies used by older adults to manage their attributed dignity when it was threatened. Based on symbolic interaction, older adults construct meaning out of interactions with other individuals and then choose strategies to use based on their appraisal of the situation causing a threat to dignity. The chosen strategies are aimed at the individual’s self-value or at the individual with whom he or she is interacting.
Participants were asked to talk about situations that supported or threatened their dignity. Similar to participants in Jacobson’s (2009b) grounded theory study, current participants found it easier to discuss situations that diminished their attributed dignity rather than situations that had a positive effect on their dignity. Although participants could talk about any interaction, many chose examples in which the interaction was with health care providers. This tendency suggests that interactions with health care providers frequently put an individual’s dignity at risk. These findings lend credence to the efforts to change the health care system in ways that are more supportive of dignity. The current movement toward patient-centered care (American Geriatrics Society Expert Panel on the Care of Older Adults With Multimorbidity, 2012; Mezey & Mitty, 2011) should improve the interactions between older adults and health care providers. In addition, teaching health care providers to talk to older adults with respect, provide privacy, and engage in partnerships with older adults to promote self-value will enhance dignity.
The current study is the first to focus on older adults’ management of dignity. Previous studies, as noted in the background section of the current article, focused on older adults’ assessment of the effectiveness of the health care provider’s interventions to support dignity. The change in focus from the care provider to the older adult managing his or her own attributed dignity is consistent with newer ideas of self-management of health (Jacelon, 2010). Self-management is a process in which “individuals have agency in taking care of their health; they make decisions of what to do or not to do about their health, any chronic conditions that they may have, and any symptoms that they may experience” (Arcury et al., 2012, p. 571). This change in focus does not negate the efforts to create dignity-preserving care environments and services; it explains the older individual’s response to interactions within that environment.
Characteristics of Situations Affecting Attributed Dignity
Any interaction between individuals can affect the attributed dignity of either individual. Dignity, an intrinsic quality of being human, is always “in need of social confirmation and vulnerable therefore to social denial” (Bromell, 2013, p. 288). The key to an interaction affecting attributed dignity is the appraisal of the interaction by the older adult. The current findings are consistent with the findings of Webster and Bryan (2009) in terms of the older adult’s sensitivity to ageism and how things are said, as much as the actual words affecting attributed dignity. Behavior also affected the older adult’s attributed dignity, as described above in the example where a shopkeeper was giving a Black woman change. Many older participants told stories of ageism and racism that affected their dignity.
Baillie and Matiti (2013) identified discrimination based on race or age by health care workers as affecting the dignity of patients in United Kingdom hospitals. Jacobson (2009a) developed a theory of dignity violation in which an individual’s dignity is violated by another individual during an interaction in part when a power differential exists between participants. This power differential could exist because one person is a member of a vulnerable or minority group (Jacobson, 2009a), as in situations of racism and ageism.
The process of managing attributed dignity is based on the process of making meaning described by Blumer (1969). Participants selected strategies based on their appraisal of the situation. Strategies focused on maintaining or bolstering the individual’s self-value or on changing the dynamics of the interaction.
Consistencies were noted among the stories of participants regardless of sex, age, income, or living situation. All participants told stories about interactions in which the behavior of the other individual was perceived as dissonant with the individual’s self-value. The major differences among participants were the stories told by Black participants, which involved racism and their use of the strategy taking it to God.
Community-dwelling and hospitalized older adults in an earlier study (Jacelon, 2003) used introspective and interactive strategies in response to interactions that affected their attributed dignity. Community-dwelling older adults also used active strategies. Although hospitalized older adults in the previous study used similar categories of strategies, the actual strategies were not similar. The hospitalized individuals did not use active strategies, as no opportunity existed to remove themselves from the situation compared with community-dwelling older adults. Hospitalized older adults perceived a high risk of retribution if they reported the offending interaction. Therefore, they used introspective strategies focused on changing their perception of the situation, as well as interactive strategies that were aimed at their side of the interaction. In the hospital, the older adults’ focus for introspective strategies was inward; they used life reviewing to identify another time in their lives when they were in similar situations. This strategy had the effect of enhancing self-value by reminding the older adult that he or she had survived difficult situations before and would survive hospitalization as well. Hospitalized older adults also focused on adjusting attitude. Hospitalized participants reported that it was important to maintain a positive attitude toward the staff, no matter how the older adult’s dignity was damaged (Jacelon, 2003). Older adults in the community could appraise the situation and use introspective strategies to compare themselves favorably to the individuals with whom they were interacting.
Hospitalized older adults managed their images so that staff would like them, and they managed the information shared so as not to say anything that would negatively effect the staff’s opinion of them. The interactive strategies used by community-dwelling older adults were aimed at changing the nature of the interaction. The older adult could maintain his or her position or get mad at the other individual in the interaction because the risk of retribution was small.