This study has been undertaken with the objective of defining and discussing a very common problem that the patients and users of nursing care face today in the world-the lack of dignity. Dignity in care is a particularly relevant concept especially in the case of the terminally ill and the bedridden. It is a complex matter and requires more than a superficial analysis in order to achieve a comprehensive understanding. While a dictionary might attempt to equate dignity with self respect and imparts to the word an air of politeness and formality, in a practical sense, dignity can comprise a whole myriad structure of feelings. Dignity in care is a qualitative term and cannot be easily measured or linearly understood. A lack of dignity can only be perceived.
According to Cutcliffe and McKenna (2005, p.80), it is important to distinguish between human dignity and contingent dignity. Human dignity is that quality which human beings possess by virtue of higher order qualities such as ethics and egalitarianism and retain so long as they live. We can find resonance in the UN's Universal Declaration of Human Rights, adopted in 1948. The preamble to the aforementioned document states, "Whereas recognition of the inherent dignity and of equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the worldâ€¦." Human beings also possess an inherent contingent dignity. It is this contingent dignity that differentiates between people. A very shy person will have a different perception of dignity versus a gregarious or a rational human being. Contingent dignity is an indestructible part of our personalities and cannot be defined in linear terms. This view also finds agreement with literature (Damron-Rodriguez, 1998 cited in Jacelon & Henneman, p.1).
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Gaining critical insight into what dignity stands for in the minds of individual patients and the terminally ill is the first step in getting closer to treating them with more self respect and in a manner befitting their ideals. Treating a patient with dignity might not always be possible in a modern world where time is under constant pressure. Nurses are always overworked and stretched and have very little energy to be qualitatively involved in the well being and care giving of the patient. Terminally ill patients who are strapped to endless tubes and artificial life support machines also do not invoke a feeling of being 'human'. Nurses need to look beyond the illness and treat the person as the individual he is (Nordenfelt, 2006, p.160). Nordenfelt (2006, p.160) further expands on what he means by this concept. He says that a 'patient's or older person's right of self determination is central in the design of care'. Nurses and care givers must be able to allow their patients to continue living under the same moral ideals and lifestyle choices, as long as they want to. Even for the terminally ill, it is important that they be given a chance at an 'appropriate death', which is to mean that a patient must be allowed to die with dignity. Dignity as a nursing objective is thus, closely intertwined with another qualitative aspect, 'quality of life'. This objective must rank even higher than the most basic of self preservation objectives.
Impediments to Ensuring Dignity in Nursing Care
One of the greatest difficulties that caregivers face while providing their wards with dignity is the extent of individualisation that is required (Nordenfelt, 2006, p.160). This can be understood in consonance with the contingent dignity mentioned before. What one patient deems dignified could be insulting to another. Similarly, there could be changes arising even due to cultural differences and geographical locations. Even though the fundamental drivers behind ensuring dignity, worthiness and its maintenance, remains the same for almost all patients irrespective of other variables, the degree can be higher or lower and differ from case to case (Cutcliffe and McKenna, 2005, p.88) . Determining the psychosocial personality of a patient, especially of someone who might not be able to communicate effectively, is a steep challenge for any caregiver. Reconciling and bringing about a congruence between the 'understanding and expectation of dignity of one party' with the 'understanding and provision of dignity' from the second party is fundamental in providing dignified patient care (Cutcliffe and McKenna, 2005, p.88).
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Secondly, it is not just enough that the nurses or caregivers act in a manner that ensures maximum dignity for the patient. Rather there must be a holistic dignified clinical environment for the patient to be treated in. A creation of such an environment requires multi disciplinary co-operation and co-ordination. Teams of doctors, physicians, nurses and therapists must work together to ensure that the patient's sense of self worth is not degenerated. Putting the sole onus of creating a dignified clinical environment on the nurse is in reality a futile exercise (Jacelon and Henneman, 2004, p. 7).
Today's doctors, physicians, therapists and nurses operate in extremely stressful environments. They do not have the time to interact in detail with every patient and this lack of communication results in patients feeling undervalued and unworthy. This sense of dejection sometimes can be so acute that it severely affects their healing process.
Nursing Theories and Models In Study
An empirical model for the care of the terminally ill was developed as a result of several months' research and study by the Department of Psychiatry of the University of Manitoba, Winnipeg in 2001. In this model, three major sets of attributes were defined that contributed most to the feeling of dignity and better quality of life specifically for a terminally ill patient. These three attributes were illness related concerns, dignity conservation and social dignity inventory. This model helped researchers and stakeholders alike to understand the concept of dignity and how the terminally ill interpreted this concept.
Several nursing theories have been discussed at length in Barbara and Cherry's 'Contemporary Nursing: Issues, trends and management" (2005, p.p. 58-60) and these may be used to effectively illustrate the empirical relevance of the points discussed above.
Sister Callista Roy's Adaptation Model was first published in 1974. This model stipulated that the nurse would have to instrumental in helping clients adapt to changing external circumstances. The changes experienced by the clients could be due to a variety of reasons which might not all be related to their illness and disease. Patients need to be assured well enough that their prevailing "illness environment" will be adequately integrated with the human element, who is the only agent that interacts with the external environment, in their care. This effective integration will enable them to adapt better to their changed wellness positions. By addressing the "biopsychosocial" needs of the client or patient, the nurse or primary caregiver can assist in the creation of an environment that will provide him with the dignity and self respect that he desires. A nurse must attempt to regulate and change any 'peripheral stimuli' to ensure that the client's adaptation process is not sabotaged. The consequence of an efficient adaptation process would be that the patient is placed in a healthy, dignified and nurturing healing environment.
The King's Theory was first proposed by Imogene King in 1971 and proposed that the ultimate goal of nursing was to enable patients attain and maintain better health or, where that was not possible, to enable them to die with dignity (cited in Funnel, Koutoukidis and Lawrence, 2008, p.p. 20). King identified communication as the cornerstone of the healing process that would help patients set appropriate goals and keep realistic expectations. These views were resonated in the model proposed by Roper, Logan and Tierney in 1985. Here the experts spoke of a need to not distinguish between a model for nursing and a model for living. It laid out five main concepts that was the fundamental base of an ideal model for living for a client. They were activities of living, factors affecting activities of living, Lifespan, dependence-independence and the nursing process. The nursing process must factor in that while some basic 'activities of living' might be performed independently by clients in some instances, they might require the assistance of the caregiver in others. Orienting the patient's consciousness towards a scenario of dependability helps them be mentally prepared and their sense of self worth is preserved.
The John Watson sponsored Model of Human Caring (1978, cited in Barbara and Cherry, 2005) propounded that the core of the nursing science was the building of transpersonal relationships. Watson makes one fundamental assumption in this model-that every human being requires care as part of the healing process when confronted with an 'insult to their environment or persona'. Watson speaks about the healing process which successfully integrates the transpersonal relationships between patient, nurse and the pervading environment. A feeling of harmony and well being will prevail when an individual has successfully managed to eliminate conflicting emotions of disharmony and illness. The nurse must deliver care and promote the building of transpersonal relationships if a sense of balance has to be restored in the client's mind as to how he must be and how he is currently. This sense of balance will ultimately lead him along the path to recovery and wellness. Watson's Model of Human Caring thus, addressed the well being of a patient in not only physical and emotional terms but even on the metaphysical space. Watson's Model of Human Caring received more concurrence with the Bruner and Wrubel Model(1989, cited in Funnel, Koutoukidis and Lawrence, 2008, p.p.22). This model also emphasized the importance of caring in the nursing process and how it helped patients relate to other human beings in their environment.
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Most post modern nursing models thus, place a lot of emphasis on caring. Caring reinforces a patient's feeling of self and restores his dignity. Nurses today are encouraged to 'establish presence' by means of eye contact , body language, listening and a positive demeanour (Funnel, Koutoukidis and Lawrence, 2008, p.24). Patients can be confronted with uncomfortable and scary situations which they might not have faced before in their lives. Nurses who integrate care into their approach along with building a sense of mutual support, concern and respect, find it easiest to guarantee dignity to their clients within the confines of the clinical environment and beyond.
The nursing process cannot entirely remove itself from the core concept of caring and dignity if it has to deliver in its goals and objectives, even though the success of these initiatives will require multi disciplinary collaboration within a clinical environment. The nurse must constantly strive to gain insight into a patient's emotional and metaphysical needs in order to ensure that he is treated with as much dignity as possible. Dignity means ensuring that the individual within the person is not stifled and is preserved. Accepting and visualizing a patient for the human being he is will be the first step in creating a dignified healing environment for him.
In their quest to provide a dignified healing environment, nurses might also have to interact and establish transpersonal relationships with the family of the client. This will also help in better adapting and reconciling between the external environment and the illness environment of a client. This congruence will hasten the recovery process and bring about greater balance in the client's life.
While time pressures are immense, it must be understood that even the smallest of gestures will be appreciated and will go a long way in ensuring the emotional well being of a patient. Sacrificing qualitative aspects like dignity and care and focussing only on alleviating medical symptoms is a short sighted way to achieving healing. Dignity in caring, be it for the terminally ill or otherwise, irrespective of age and economic and cultural differences, is the foundation of a healthy nursing process. With the strides made in modern medicine, the concept of nursing itself is in a constant state of flux with newer theories being published. By combining, theories and models with practice and experience, nurses can critically evaluate their own processes and improve the delivery of care to their clients.