Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Dignity in Older Adults With Schizophrenia Residing in Assisted Living Facilities

Darlene Robison, RN, MN, CPMHN; Gloria McInnis-Perry, PhD, RN, APN, CPMHN; Lori E. Weeks, PhD; Vicki Foley, PhD, RN

Abstract

There is a lack of nursing literature on older adults' perceptions of dignity, specifically those of older adults with schizophrenia. With the aging population, mental health services and support for older adults with schizophrenia will become a greater priority. The purpose of the current descriptive phenomenological study was to describe the meaning of the lived experience of dignity for older adults with schizophrenia residing in assisted living facilities. A purposive sample of eight older adults with schizophrenia residing in assisted living facilities participated in semi-structured interviews following the descriptive phenomenological psychological method. Five intertwined constituents were identified: (1) dignity is an intrinsic or self-regarding experience; (2) dignity is an experience that is reciprocal, extrinsic, and regards others, and is embedded in social relationships; (3) dignity can be eroded by ageism, stigma, discrimination, and alienation; (4) dignity can be interrupted when positive and negative symptoms of schizophrenia are present and misunderstood by others; and (5) dignity can be enhanced when oneself and others embrace a recovery-focused relationship. Implications for mental health nursing are provided. [Journal of Psychosocial Nursing and Mental Health Services, 56(2), 20–28.]

Abstract

There is a lack of nursing literature on older adults' perceptions of dignity, specifically those of older adults with schizophrenia. With the aging population, mental health services and support for older adults with schizophrenia will become a greater priority. The purpose of the current descriptive phenomenological study was to describe the meaning of the lived experience of dignity for older adults with schizophrenia residing in assisted living facilities. A purposive sample of eight older adults with schizophrenia residing in assisted living facilities participated in semi-structured interviews following the descriptive phenomenological psychological method. Five intertwined constituents were identified: (1) dignity is an intrinsic or self-regarding experience; (2) dignity is an experience that is reciprocal, extrinsic, and regards others, and is embedded in social relationships; (3) dignity can be eroded by ageism, stigma, discrimination, and alienation; (4) dignity can be interrupted when positive and negative symptoms of schizophrenia are present and misunderstood by others; and (5) dignity can be enhanced when oneself and others embrace a recovery-focused relationship. Implications for mental health nursing are provided. [Journal of Psychosocial Nursing and Mental Health Services, 56(2), 20–28.]

Dignity is difficult to define and measure because it is a highly abstract and subjective concept (Baillie, 2009; Clark, 2010; Jacobson, 2007), which is often taken for granted (Edlund, Lindwall, von Post, & Lindström, 2013). When older adults are not given opportunities to demonstrate their capabilities, they experience a lack of respect, indignity, and a weakened sense of value and worth. They also feel like a burden to others and question their existence (Shotton & Seedhouse, 1998). Little is known about the experiences of dignity in older adults with schizophrenia. However, it is recognized that older adults with schizophrenia are subjected to stigma and labeling, discrimination, negative attitudes and behaviors, therapeutic nihilism, and ageist bias that can affect their self-esteem and self-worth (Sorrell & Collier, 2011; Whitley & Campbell, 2014).

Approximately 85% of middle-aged individuals with schizophrenia were diagnosed in late adolescence or young adulthood (Folsom et al., 2006), and are known to have early-onset schizophrenia (Austin & Boyd, 2015). All cases diagnosed after age 45 are known as late-onset schizophrenia and account for 15% to 20% of all cases (Folsom et al., 2006). Cohen et al. (2008) identified another group known as very late-onset schizophrenia–like psychosis for individuals diagnosed after age 60. It has been argued that individuals with schizophrenia age more quickly and experience a high prevalence of comorbid conditions, such as cardiovascular disease, chronic obstructive pulmonary disease, gastrointestinal disease, liver disease, diabetes, and skin infections (Leuterwyler, Chafetz, & Wallhagen, 2010). For these reasons, as individuals with schizophrenia age, assisted living is required (Karim, Overshott, & Burns, 2004). Moreover, approximately 20% of individuals with schizophrenia live in assisted living facilities (Torrey, 2006). Assisted living facilities provide support for daily living to residents who cannot live independently. Supportive services include meals, laundry and housekeeping, as well as assistance with grooming, hygiene, and medication administration; more than one half of these facilities provide supervised housing to individuals with mental illness (Government of Prince Edward Island, 2017). Cabness (2009) examined the effect of integration into an assisted living facility on older adults with schizophrenia and found this major lifestyle change increased social losses and cognitive decline that could affect their autonomy. For some, the experience of having schizophrenia and residing in assisted living facilities caused problems of stigmatization, loneliness, and negative attitudes that devalued their dignity and autonomy (Granerud & Severinsson, 2003).

Although the concept of dignity in older adults and the importance of preserving an individual's dignity are well-documented, there is a lack of nursing research on the subjective experience of dignity in older adults with schizophrenia in assisted living facilities. Moreover, this lack of research creates an ethical challenge for nurses in recognizing the importance of preserving the dignity of individuals' intrinsic worth (Canadian Nurses Association, 2017). More research related to older adults with schizophrenia and their unique experiences is needed (Sorrell & Collier, 2011). Most Canadian statistics describe older adults as those 65 and older, whereas the United Nations uses the cutoff of age 60 (Touhy, Jett, Boscart, & McCleary, 2012). In the current study, older adults were at least age 60.

The data elicited will help psychiatric–mental health nurses (PMHNs) understand dignity and develop and support nursing interventions that will enhance and/or preserve dignity in older adults with schizophrenia residing in assisted living facilities. The aim of the current study was to explore the lived experience of dignity in older adults with schizophrenia residing in assisted living facilities—specifically: What are the essential elements, known as constituents and structure, of the lived experience as verbalized by the older adult with schizophrenia residing in an assisted living facility?

Method

The current study was guided by Giorgi's (2012) descriptive phenomenological psychological method, which is a modified Husserlian approach that focuses on intentionality. Giorgi's (2012) method, with roots in philosophy and psychology, focuses on the lived experiences of individuals (Polit & Tatano-Beck, 2017), specifically examining human experiences through the descriptions provided by the individuals involved (Nieswiadomy, 2008). Giorgi's (2012) method aims to discover the meaning of a phenomenon as experienced by a human through the identification of constituents and structure (Koivisto, Janhonen, & Väisänenm, 2002), and fits well with phenomena that are concerning to psychiatric–mental health nursing. Using Giorgi's (2012) method gave a voice to individuals who needed to be heard: older adults with schizophrenia residing in assisted living facilities.

Participants and Setting

Seven males and one female between ages 60 and 68 volunteered to participate (Table 1). All participants were diagnosed with schizophrenia and resided in an assisted living facility. Six participants were never married, one was separated, and one was divorced. Seven participants had a high school education, one left school after grade seven, one completed university credits, two had undergraduate degrees, and two completed community college. Most participants had work experience. All interviews were conducted at a mutually agreed upon private location.

Participant (P) Demographic Characteristics (N = 8)

Table 1:

Participant (P) Demographic Characteristics (N = 8)

Ethics

Ethical approval was granted by the university and Provincial Health Research ethics boards. Assistance was then requested of community mental health teams and managers of assisted living facilities to provide a letter of invitation to potential participants who met the following inclusion criteria: at least 60 years old; diagnosed with schizophrenia in late adolescence or young adulthood; mentally stable; oriented to person, place, time, and circumstance; able to speak, hear, and understand English; and willing to share their experience of dignity. Anonymity and confidentiality were supported using codes versus personal identification information, securing all transcripts in a locked room at the university; a confidentiality form was signed by the transcriptionist and only the first author (D.R.) and supervisory team had access to the data.

Data Collection

Participants were first screened for eligibility and provided the purpose, procedure, consent, and demographic information form. All interviews were guided by a semi-structured questionnaire that specifically asked participants' understanding of dignity. Interviews were digitally audiorecorded and transcribed verbatim. Field notes of unstructured observations and reflective journaling were kept and used in the analysis phase. A pilot study of three interviews was supervised by the second author (G.M.-P.) to ensure adequacy of the study design and accuracy of the application of Giorgi's (2012) method. Consensus in coding was achieved between the researcher and first author, and no changes were required after the pilot study. The three piloted interviews were included in the results in the larger study.

Data Analysis

Data were analyzed using Giorgi's (2012) method, which included (a) reading the entire description to get a sense of the whole; (b) re-reading the description to delineate meaning units; (c) transforming the meaning units from everyday language to psychological language, emphasizing the most descriptive meaning units of the perception of dignity for individuals with schizophrenia residing in assisted living facilities; and (d) synthesizing all transformed meaning units into a consistent structure of the experience. More than 500 large meaning units identified were transformed into 200 smaller meaning units of the constituent of dignity. Five essential constituents with corresponding meaning units (Table 2) emerged from the narratives and represented the meaning structure of the phenomena of dignity for participants: (1) dignity is an intrinsic or self-regarding experience; (2) dignity is an experience that is reciprocal, extrinsic, and regards others, and is embedded in social relationships; (3) dignity can be eroded by ageism, stigma, discrimination, and alienation; (4) dignity can be interrupted when positive and negative symptoms of schizophrenia are present and misunderstood by others; and (5) dignity can be enhanced when oneself and others embrace a recovery-focused relationship.

Typology of the Lived Experiences of Dignity in Older Adults with Schizophrenia

Table 2:

Typology of the Lived Experiences of Dignity in Older Adults with Schizophrenia

Phenomenological Trustworthiness

Giorgi (2012) believes that the use of phenomenological reduction (i.e., bracketing) and intuiting in the analysis of data is intended to establish the reliability and validity of the study. In contrast, Guba and Lincoln's (1989) criteria of credibility, dependability, confirmability, transferability, and authenticity are also widely accepted as ways to enhance the trustworthiness of a qualitative study (Polit & Tatano-Beck, 2017). Credibility of the data was enhanced by ensuring that only those who met the eligibility requirements participated, ample time and attention were given to the interview process, and adherence to Giorgi's (2012) analytical process was followed. All interviews were conducted by the first author who has 20 years of experience as a PMHN. A semi-structured interview guide was used and focused only on participants' experiences with the help of phenomenological reduction or bracketing. Interviews were digitally audiorecorded and transcribed verbatim and took approximately 1 hour to complete. According to Giorgi (2012), validity is enhanced when the researcher uses intuiting as the means to identify the phenomena of interest, which ensures that the true constituents are being identified. In addition to bracketing, the first author (D.R.) used intuiting and the process of free imaginative variation, which is the signifying, fulfilling, and identifying of acts during analysis (Husserl, 1970).

Confirmability (i.e., objectivity) and authenticity (i.e., rich identification) of the lived experience of the participant were enhanced by the rich descriptions of the lived experience shared by each participant, use of bracketing, and the rigorous audit trail kept throughout the research process. Dependability was enhanced by repeated discussions with the first author's supervisory committee regarding the meaning of the data to ensure that the findings reflected participants' voices and conditions of the inquiry rather than the researchers' biases, motivations, or perspectives. Transferability (i.e., applicability) in other groups or settings is not guaranteed, but the current authors believe the findings have meaning for individuals experiencing dignity while living with a mental illness or those living in other settings (Polit & Tatano-Beck, 2017).

Results

A typology of the Lived Experience of Dignity in the Older Adult with Schizophrenia was created through five essential constituents that emerged from the narratives and represent the meaning structure of the phenomena of dignity for participants along with meaning units identified for each constituent (Table 2). To identify quotes and protect participants' anonymity, identifiers P1 to P8 are used.

Constituent 1

Participants identified that when experiencing dignity, they had self-respect, respect for others, received respect from others, and felt like an equal. Self-respect and recognition of personal values enhanced participants' experiences of dignity. P1 explained, “I guess [dignity is having] self-respect for yourself and respect for that person and being treated with some kind of…golden rule—'do onto others as they do onto you'....” Similarly, P2 shared the following about self-respect and labeling: “…being respected as a person [means] you're a human being... called by your own name and not being called crazy.” Furthermore, participants described dignity as a sense of feeling happy, self-confident, helped, independent, understood, and being able to hold their head high. P5, who completed high school at night school later in life, described how this endeavor helped him feel successful in accomplishing something despite his diagnosis of schizophrenia, as well as how this mastery in life was a personal experience of dignity.

Participants also believed that experiencing dignity was a result of being treated as an equal in every aspect of daily life, which in turn made them feel good about themselves. P1 described how he felt accepted by family and staff, claiming, “This is a lovely house to live in and [everyone in] this house treats you with dignity.” Moreover, dignity was perceived as an attribute of the self, expressed as values and virtues that must be maintained to feel good. P4 described how his personal faith helped him maintain a sense of self: “...You know it's faith, hope, love, and charity, you know. I think love covers all dignity and respect...love.”

Constituent 2

Participants expressed the importance of being accepted by others. P4 explained:

It means respect of other people, consideration of my feelings, my thoughts, my actions...acceptance and understanding the sick person, that they are human like anybody else, they want to be loved and treated and handled with [care].

P1, who had been professionally employed prior to his schizophrenia diagnosis, explained the importance of acceptance to experience dignity: “…I would say that appreciation and dignity are almost the same. When you are appreciated and you are dignified, you have true dignity...”

Participants experienced dignity when strangers acknowledged them as a person. It was also evident throughout the interviews that inclusion by society contributed to well-being and allowed participants to feel accepted and valued. In the following dialogue, P1 described how a simple acknowledgement led to an experience of dignity:

…You get on a bus and you say “hello” and they say “hello” back to you and that is being like true to dignity or… getting on the bus and there are two or three people ahead of you and they let you go on ahead of them, that's like, why would they do that? It must be a thing with dignity.

Most participants described experiencing a sense of self when they felt accepted. For example, P3 discussed how living with others with mental illness aided in respecting each other: “We all treat each other with dignity here…just about living together with the same bunch of people over a number of years, ya know? It calls for treating each other with dignity.”

Participants described feelings of tolerance and belonging when family and friends understood and accepted their mental illness. P3 stated, “If someone treats you with dignity, you treat them with dignity and dignity is something that you draw upon in order to…alleviate a tense situation.” This participant also realized the importance of tolerance and acceptance when he recognized that some- times he had not been experiencing dignity: “I haven't been treated with dignity at times…it hurts your feelings.” P7 described how she felt when she was not understood or respected by family and staff: “Yeah, my sister doesn't always believe me about things. It's not a very good feeling that makes me feel weird. I feel frustrated. I just wish she would believe me.” Conversely, participants described how someone in their lives—a family member, friend, health care staff member, or higher power—gave them hope and encouragement to carry on when feeling rejected by others. P4 voiced the importance of being treated as a human being and being given encouragement from others:

...[It's nice] being helped by somebody who understands the illness and being talked to and having confidence and having guidance and words of wisdom and understanding with one another and [having] somebody...[to] talk your problems over with.

Constituent 3

Dignity was related to not having to endure derogatory labels that were a part of having schizophrenia, and the resulting alienation, self-devaluation, and not feeling worthy of dignity. Throughout this constituent, participants felt vulnerable, devalued, excluded, and alienated by society, which eroded their self-identity. P5 related to this constituent, explaining, “They say things they shouldn't…. ‘You done bad,’ ‘you done wrong,’ ‘you didn't do what I told you to do,’ ‘it's not what I wanted you to do.’” In addition, P4 described the discrimination that has occurred in his lifetime:

…Saying bad things about me, and saying I was an idiot, that I was a… crazy lunatic, and that...you know that I...my brains was burned out and that I was...well they say I'm better off dead than alive, that nobody come to my funeral if I die, and all those things. I mean those things are the opposite of dignity—it's disrespect.

P4 further expressed the importance of being understood and not condemned for having mental illness:

A lot of people around town...think that I shouldn't have my own room here [and] that I should be in a mental hospital. I don't care where they put me. They're not in my position.... Yes, it curses my dignity, it goes against everything I believe, all my beliefs, and all my concerns, and interests.

Living with the stigma of mental illness led participants to believe that they did not deserve to experience dignity. P3 initially associated dignity with a high-class person, saying, “You know I'm an ordinary fella…I'm not a high-class person…. Dignity is something that's situated with...to me at least, more important members of society.”

Constituent 4

Participants recognized how mental illness can permanently affect their sense of self, sanity, and well-being. Throughout this constituent, most participants described how they were judged for their bizarre behavior related to schizophrenia and lacked the necessary support to enhance recovery, and how their self-concept was permanently affected. P1 described how his experience with mental illness since his 20s affected his sense of self:

…[Mental illness] made me feel a bit worse on my dignity side. I thought I would never get anywhere…[it] didn't make me feel good; my self-esteem was bad.... I didn't have a lot of dignity in my life; it was all downhill.

Most participants expressed having fragmented relationships, such as when experiencing symptoms of schizophrenia (e.g., hallucinations, delusions, bizarre behavior, changes in mood). For example, P5 described how he lacked support from family when trying to complete his high school degree at night: “…They didn't quite understand me, my health, my issue…. It wasn't that they couldn't understand; they couldn't deal with it.”

Constituent 5

Participants expressed the need for support from others to ensure hope was instilled and dignity was experienced. Participants spoke favorably about those in their lives who helped them maintain stability by supporting, encouraging, accepting, and respecting them as someone with a mental illness. P1, who spoke highly of the assisted living staff where he resided, explained: “…C. treats me with dignity here...and she wouldn't let me give up and she wouldn't let me quit…. When people around you say ‘don't give up’…they are great.”

Most participants described feeling empowered and experiencing personal growth and accomplishment when others treated them as an equal and were included in meaningful social activities. P4 voiced the importance of being treated as human and given encouragement from others. He also described what gave him hope, claiming, “It's people that give you encouragement....” P6 mentioned he had a friend outside the assisted living facility who treated him with dignity and helped him experience a feeling of inclusion.

Discussion

In the current study, five intertwined constituents of the phenomenon of dignity from the perspective of eight older adults with schizophrenia who resided in assisted living facilities were revealed. The first constituent revealed that dignity is a complex concept enhanced when participants' personal values are recognized by others. This finding is consistent with those of previous studies that suggest dignity is subjective (Haddock, 1996), universal (Maris, 1994), innate, part of autonomy (Woolhead, Calnan, Dieppe, & Tadd, 2004), self-respect (Griffin-Heslin, 2005), a human right (Clark, 2010), spiritual (Sulmasy, 2013), and given little consideration unless an individual becomes vulnerable or can anticipate its loss (Maris, 1994).

Participants explained that dignity was an attribute of the self, expressed as values and virtues that must be maintained to feel good about themselves. Acceptance of oneself and others resonated throughout the interviews, and participants described situations in which they were honored, recognized, and given a purpose in life. These findings support the concept of absolute dignity, which represents the spiritual dimension characterized by holiness, human worth, freedom, responsibility, duty, and serving others; and relative dignity, which mirrors absolute dignity but its values are influenced by culture and are hierarchical (Edlund et al., 2013). Personal faith was also an attribute that helped participants feel accepted and maintain a sense of self. Nordenfelt (2004) identified dignity of menschenwurde, which refers to the “human value of dignity that all humans have or assume to have because of being human” (p. 70). Given that humans are equal, this dignity should have the same value for everyone and no one should be treated with less respect than anyone else and it cannot be taken from someone as long as he/she is living.

A second constituent identified in the current study was being accepted by others—commonly known as extrinsic dignity or how others treat you (Gallagher, 2004). Nordenfelt (2004) described dignity as an identity, which is attached to the individual's integrity but can be lost due to the acts of others, injury, illness, and age. Jacobson (2007) views dignity as a fundamental human value and as social dignity that is grounded in human dignity which is experienced, bestowed, or earned through interaction in social settings. The current study supports the concerns that when dignity is not met, the individual does not experience self-esteem or autonomy, and loses a sense of hope (Periyakoil, Noda, & Kraemer, 2010). Indignity was found in circumstances where one was perceived to be invisible, depersonalized or objectified, humiliated, or abused, or in the use of narrow and mechanistic care practices (Arino-Blasco, Tadd, & Boix-Ferrer, 2005), and there was a disregard for human rights and lack of older adult–focused policies (Woolhead et al., 2004).

A third constituent identified in the current study was related to the erosion of dignity and self-identity. Participants expressed feeling vulnerable, devalued, excluded, and alienated by society largely related to the derogatory labels that were a result of living with schizophrenia. Being subject to stigma and labeling, discrimination, negative attitudes and behaviors, therapeutic nihilism, and ageist bias affected their self-esteem and self-worth (Black & Dobbs, 2014; Whitley & Campbell, 2014), leading to alienation from others (Reavley & Jorm, 2011) and decreased self-esteem, increased devaluation, discrimination, and exclusion. The current study revealed that living with the stigma of mental illness resulted in participants believing that they did not deserve to experience dignity. Participants downplayed their personal existence by identifying themselves as “ordinary,” “commonplace,” and “not high-class.”

The fourth constituent revealed in the current study was the experience of being judged and alienated because of the bizarre behaviors resulting from mental illness. Noiseux and Ricard (2008) found that for individuals with schizophrenia, living with mental illness was like “a sense of having their souls invaded and of being trapped in an extended descent into hell” (p. 1153), causing a permanent impact on one's hopes and dreams and leading to social ostracism. Conversely, in the current study, the symptoms of mental illness affected participants' sense of self, sanity, well-being, and significant relationships, specifically when experiencing hallucinations, delusions, bizarre behavior, and mood changes. One participant recognized his own symptoms of illness and when he verbalized increased religiosity it caused him to experience isolation and negative consequences. Tsai, Lysaker, and Vohs (2010) concurred that the stigma of negative symptoms of schizophrenia in young individuals is a significant barrier to function, as these symptoms can cause impairment in attention and decrease the ability to express emotion and experience pleasure and engagement in their environment, resulting in social withdrawal. In the current study, one participant described how he felt misunderstood and had difficulty expressing his point of view or being taken seriously because his disorganized thinking impacted his ability to work in his chosen profession, while experiencing hallucinations affected his sense of self, self-esteem, and dignity.

The fifth constituent of the current study was that dignity was enhanced when participants and others embraced a recovery-oriented relationship, one that optimized the psychosocial functioning of the older adult with schizophrenia. Participants spoke favorably about individuals in their lives who helped them maintain stability while living with schizophrenia by supporting, encouraging, accepting, and respecting them as a person with mental illness. They also expressed a need for support from others to ensure hope was instilled and dignity was experienced. Recovery is considered to be self-directed (Lee, 2005), person-centered, empowering, strength-based, supportive, respectful, void of stigma and discrimination, and requiring time (American Psychological Association, 2012). The importance of equality and social engagement was conveyed by participants as essential to dignity. One participant described an experience of how good he felt about himself when someone would simply greet him when he was walking on the street or when he entered a public place. It was noted that inclusion in meaningful social activities enhanced dignity and allowed participants to embrace recovery. Perry, Henry, Sethi, and Grisham (2011) explored how social exclusion affects individuals with schizophrenia and identified the possibilities of ostracism related to the stigma associated with mental illness. They found that individuals with schizophrenia, who were chronically exposed to social rejection, began to accept alienation and isolation and stopped seeking social relationships, which caused further isolation. Noiseux and Ricard (2008) suggest individuals with schizophrenia are constantly trying to find a way to fit into society by modifying their social and physical environments.

Most of the current findings support previous literature on the understanding of dignity and what it is like to live with schizophrenia. This research expands the understanding of dignity in older adults with schizophrenia by highlighting the effects of its symptoms on the experience of dignity, how others' negative perceptions alienate and devalue the affected individual, further stigmatizing them, and how dignity is nurtured when embraced by all.

Limitations

The main focus of descriptive phenomenological research is to describe the lived experience of a phenomenon and not seek generalizability; therefore, large samples are not necessary to study a phenomenon as long as the constituents of the lived experience are captured. Nonetheless, several limitations are acknowledged. The current study focused primarily on adults with schizophrenia residing in assisted living facilities. The results of a study with younger adults living independently or supported by family members might uncover different meanings of dignity. Adults diagnosed with late-onset schizophrenia could have a different experience of dignity than the population used in the current study. As this study included primarily male participants, the lived experience of dignity in older female adults with schizophrenia could yield different results, and thus a replication of this study is warranted using a larger number of female participants. Future research should consider older adults from a higher socioeconomic background or a different cultural background.

Implications

The current findings have implications for mental health nursing in understanding theory and practice that supports dignity in older adults with schizophrenia. Specifically, when providing nursing care for older adults with schizophrenia, there must be ongoing education and use of research to ensure nurses are aware of the importance of alleviating stigma and discrimination, enhancing the recovery of individuals with mental illness rather than focusing on their illness, and lastly understanding the essence of dignity for older adults with schizophrenia. These findings also give direction for future nursing research and new knowledge on how dignity can be interrupted when positive and negative symptoms of schizophrenia are present, misunderstood, and permanently affect sense of self, sanity, and well-being.

To practice holistic nursing and enhance quality of life, nurses are required to incorporate the individual's perspective of dignity. To improve the dignity of the individual with schizophrenia, nurses must be aware of the importance of establishing a therapeutic nurse–client relationship, centered on trust and respect while using a recovery perspective to care. Nurses must also be aware of the client's exposure to constant rejection, alienation, derogatory labeling, and stigma. Noiseux and Ricard (2008) stress the need for nurses to decrease the stigma that clients with schizophrenia endure by considering the potential of the client rather than focusing on the negative and positive symptoms of the illness. It is also vital for nurses to help individuals identify their own well-being, support their sense of self, and identify sources of motivation and support.

By advocating for changes that address barriers preventing clients from exercising greater choice and control, nurses have the opportunity to assist individuals in experiencing life with greater dignity. Nurses can support health care environments that promote dignity and create healthier interactions between older adults and health care providers while possibly reducing ageism and racism (Jacelon, 2014). Nurses can achieve this by enhancing hope and empowering clients to take on a more active role in self-management. Nurses can teach clients how to increase self-efficacy by helping them recognize their strengths and abilities to attain personal goals, develop a positive sense of self beyond their mental illness (Mueser et al., 2002), and support them in the expansion of their social networks.

Conclusion

The current findings describe the complex intertwined nature of dignity in older adults with schizophrenia. The five constituents identified support what the existing literature on dignity purports: it is intrinsic, extrinsic, and reciprocal; embedded in social relationships; and can be eroded by ageism, stigma, discrimination, and alienation. Although dignity is interrupted when the individual experiences positive symptoms of schizophrenia, it can still be enhanced when he/she and others embrace a recovery-focused relationship.

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Participant (P) Demographic Characteristics (N = 8)

VariableP1P2P3P4P5P6P7P8
GenderMaleMaleMaleMaleMaleMaleFemaleMale
Age (years)6161636865676360
Years in assisted living29101434225208

Typology of the Lived Experiences of Dignity in Older Adults with Schizophrenia

ConstituentMeaning Unit
Dignity is an intrinsic or self regarding experience.• Participants identified that when experiencing dignity, they were treated with self-respect; treated others as they would treat themselves; and received respect from family, friends, and society.
• Participants described dignity as a sense of feeling happy, self-confident, helped, understood, and being able to hold their head high.
• Participants described how being able to think independently and having the opportunity to make personal decisions were vital to having a sense of autonomy and self-determination.
• Participants believed that experiencing dignity was a result of being treated as an equal in every aspect of daily life, which made them feel good about themselves.
• Participants explained that dignity is an attribute of the self expressed as values and virtues that must be maintained to feel good about themselves.
Dignity is an experience that is reciprocal, extrinsic, and regards others, and is embedded in social relationships.• Participants expressed the importance of being accepted as a human by others through not being ignored, ridiculed, and/or humiliated.
• Participants experienced dignity when strangers acknowledged them as a person rather than someone with a mental illness.
• Participants described experiencing a sense of self when they felt accepted rather than excluded by others.
• Participants described feeling tolerance and belonging when family and friends understood and accepted their mental illness.
• Participants described how someone in their lives (e.g., family, friend, health care staff member, a higher power) gave them support.
Dignity can be eroded by ageism, stigma, discrimination, and alienation.• Participants identified that their lived experiences of dignity were compromised when they endured derogatory labels as a result of having schizophrenia.
• Participants experienced feelings of alienation when others knew they had a mental illness.
• Living with the stigma of mental illness led participants to believe that they did not deserve to experience dignity.
Dignity can be interrupted when positive and negative symptoms of schizophrenia are present and misunderstood by others.• Participants experiencing symptoms of schizophrenia recognized how mental illness can permanently affect their sense of self, sanity, and well-being.
• Participants expressed having fragmented relationships due to lack of support, especially when experiencing acute symptoms of hallucinations, delusions, bizarre behavior, and/or changes in mood.
Dignity can be enhanced when oneself and others embrace a recovery-focused relationship.• Participants expressed the need for support to ensure hope was instilled and dignity was experienced.
• Participants described feeling empowered and experiencing personal growth and accomplishment when others treated them as equals.
• Participants experienced dignity when they were included in meaningful social activities.
Authors

Ms. Robison is Clinical Nursing Instructor, Dr. McInnis-Perry is Associate Professor, Faculty of Nursing, University of Prince Edward Island, and Dr. Foley is Coordinator of Regulatory Services, Association of Registered Nurses of Prince Edward Island, Prince Edward Island; and Dr. Weeks is Associate Professor, School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Darlene Robison, RN, MN, CPMHN, Clinical Nursing Instructor, Faculty of Nursing, University of Prince Edward Island, 550 University Avenue, Charlottetown, Prince Edward Island, C1A 4P3, Canada; e-mail: djrobison@upei.ca.

Received: June 08, 2017
Accepted: August 14, 2017
Posted Online: October 09, 2017

10.3928/02793695-20170929-01

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