Managing Dignity in Later Life: Global Influences ... · Life: Global Influences, Personal Strategies, Cellular ... Discuss the role of dignity as a form of resilience 2. ... environment

The Henderson Repository is a free resource of the HonorSociety of Nursing, Sigma Theta Tau International. It isdedicated to the dissemination of nursing research, research-related, and evidence-based nursing materials. Take credit for allyour work, not just books and journal articles. To learn more,visit www.nursingrepository.org

Item type Presentation

Format Text-based Document

Title Managing Dignity in Later Life: Global Influences,Personal Strategies, Cellular Effects

Authors Jacelon, Cynthia S.; Walker, Rachel; Bosse, Jordon

Downloaded 27-Jul-2018 11:02:51

Link to item http://hdl.handle.net/10755/601513

http://hdl.handle.net/10755/601513

1College of NursingCollege of Nursing

Managing Dignity in Later Life: Global Influences,

Personal Strategies, Cellular Effects

Cynthia S. Jacelon, PhD RN FAAN

Rachel Walker, PhD RN

Jordon Bosse, MS RN

Travel funding for this symposium was provided by:College of Nursing, University of Massachusetts

2College of Nursing

Introduction to Symposium

Dignity Matters: A Society-to-Cells

Perspective on Physiological & Cellular Effects of Threats to Dignity in Later Life

Modeling the Relationship Between Attributed Dignity and Health

Personal Strategies for Managing Dignity in the Course of Human Interaction


A Society-to-Cells Perspective on Physiological & Cellular

Effects of Threats to Dignity in Later Life

Dignity Matters:

Rachel Walker, Ph.D., RN1

Laura Samuel, Ph.D., ANP2

Sarah L. Szanton, PhD., ANP, FAAN3

1University of Massachusetts-Amherst College of Nursing2Johns Hopkins Bloomberg School of Public Health

3Johns Hopkins School of Nursing

Presenter Contact: [email protected]

4College of Nursing

Objectives

By the end of this presentation, attendees should be able to:

1. Discuss the role of dignity as a form of resilience

2. Identify factors at multiple levels of the environment that can impact the dignity of older adults

3. Describe a mechanism that connects dignity preservation or loss to physiological & cellular changes

4. Generate ideas about potential targets for nursing interventions to promote dignity in later life

5College of Nursing

DIGNITY

Threats

Physiological & Cellular Effects

(health disparities)

(loss of dignity)

Initial Focus was on Health Disparities

+

+

6College of Nursing

Dignity as a Form of Resilience

Personal Dignity (van Gennip et al., 2013)

3 of 4 ‘Varieties of Dignity’ (Nordenfelt, 2004)

• Merit

• Identity

• Moral Stature

Attributed Dignity (Jacelon et al., 2004)

These definitions are distinct from dignity in care:

• Practical Dignity (Shotton & Seedhouse, 1998)

• Dignitas (Pols, 2013)

• Dignity-conserving care (Chochinov, 2002)

• Dignity therapy (Chochinov et al., 2005)

7College of Nursing

Dignity as a Form of Resilience

Dignity

CHALLENGE

resistance

recovery

rebound

Figure 1, adapted from Szanton & Gill, 2010

8College of Nursing

DIGNITY

Challenges/Threats


Stressors

AppraisalAppraisal

• Primary Appraisal • Secondary Appraisal:

Is it a threat? Can I cope?

(Lazarus & Folkman, 1984)

9College of Nursing

DIGNITY

Challenges/Threats


Stressors

AppraisalAppraisal

• Primary Appraisal • Secondary Appraisal:

Is it a threat? Can I cope?

(resilient health potential)

Acute Stress Response(s):

• epi, cortisol

• HR, RR, glucose, digestion

Chronic Stress Response:

• cortisol (chronically elevated)

• inflammatory processes

10College of Nursing

Impacts of Chronic Stressors

Physiological

Neurochemical Imbalances

Hormone Imbalance

Glucose dysregulation, insulin resistance, & metabolic syndrome

Systemic Inflammation

Cellular

Epigenetic modifications

DNA damage & telomere shortening

Cellular replication abnormalities


DIGNITY

Threats


Stressors

Appraisal

So what factors influence dignity in

later life?

(resilient health potential)


Society-to-Cells Perspective on Factors Influencing Dignity through Person/Environment ‘Fit’

SOCIETY

COMMUNITY

FAMILY/INTERPERSONAL

INDIVIDUAL

PHYSIOLOGIC

CELLULAR

(Adapted from Szanton & Gill, 2010)

Safety in Environment Natural Ecosystems

Race/Ethnicity/Nationality Attitudes towards Aging Gender

Opportunities to Use Knowledge & Skills Laws & PoliciesBuilt Environment/Accessibility/Walkability Diversity Institutions/Programs

Social Support Transportation Social Capital

Sense of Safety & Protection Roles & Responsibilities

Feeling Valued/Respected Connectedness Behavior Modeling

Engagement Dignity-conserving care GenerativityView of Self/Identity Autonomy Capability Function Spirituality

Awareness Sense of Meaning

Dignity-conserving & coping strategies View of World Sex

Neurochemical Activity Cardiorespiratory Function Cognition Muscle Strength

& Senses

Inflammation Metabolism & Glucose Regulation Hormonal Balance

DNA Repair Oxidative Stress

Epigenetics Tumorogenesis/Cell Death


DIGNITY

Threats


Stressors

Appraisal

Person/Environment Fit:

• Societal Self

• Relational Self

• Individual Self• autonomy/capability

• use of strategies

(Jacelon, 2014; Lawton, 1997;

van Gennip et al., 2013; Vlug et al., 2011)


• neurochemistry• hormonal balance• metabolism• inflammation/healing• epigenetics• DNA repair/cellular

aging/tumorogenesis

Acute & Chronic

Stress Reaction Processes• HPA Axis activation

• Inflammatory cascade

Appraisal• Primary Appraisal:

Is it a threat?• Secondary Appraisal:

Can I cope?


DIGNITY

Threats


Stressors

Appraisal

Person/Environment Fit:


• neurochemistry• hormonal balance• metabolism• inflammation/healing• epigenetics• DNA repair/cellular

aging/tumorogenesis

Acute & Chronic

Stress Reaction Processes• HPA Axis activation

• Inflammatory cascade

Appraisal• Primary Appraisal • Secondary Appraisal:

Is it a threat?Can I cope?

Examples of Stressors• aging-related changes• illness aspects• impairment/injury• loss or isolation• financial strain• role changes• food insecurity• discrimination

(dignity may affect whether certain

stressors even appraised as such &

improve ability to cope)

• Potential targets for

nursing interventions to

promote dignity at each

level of the environment


Conclusions

Later life involves potential for growth as well as new types of vulnerability

Dignity can be conceptualized as a resource & form of resilience to both internal & external stressors

Dignity is a product of interactions between persons & multiple levels of their environments


What This Model Adds

Potentially-testable mechanism linking dignity (not as an event such as loss, but as a resource & form of resilience) to physiological & cellular changes

Direction for dignity-promoting interventions at societal, community, family/interpersonal, & individual levels, by improving person/environment ‘fit’


Funding & Support

John Hopkins University Institute for Clinical and Translational Research (ICTR) Clinical Research Training Program, National Center for Advancing Clinical & Translational Sciences (NCATS, TL1TR001078, PI: D. Ford)

Johns Hopkins School of Nursing Center for Innovative Care in Aging

There are no conflicts of interest to report


Chochinov, H. M. (2002). Dignity-conserving care--a new model for palliative care: helping the

patient feel valued. JAMA, 287(17), 2253-2260.

Chochinov, H. M., Hack, T., Hassard, T., Kristjanson, L. J., McClement, S., & Harlos, M. (2005).

Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin

Oncol, 23(24), 5520-5525. doi: 10.1200/JCO.2005.08.391

Gallagher, A., & Seedhouse, D. (2002). Dignity in care: the views of patients and relatives. Nurs

Times, 98(43), 38-40.

Jacelon, C. S., Connelly, T. W., Brown, R., Proulx, K., & Vo, T. (2004). A concept analysis of

dignity for older adults. J Adv Nurs, 48(1), 76-83. doi: 10.1111/j.1365-2648.2004.03170.x

Lawton, M. P. (1997). Assessing environments for older people with chronic illness. Journal of

Mental Health and Aging, 3(1), 83-100.

Lazarus, R., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer

Publishing Company.

Nordenfelt, L. (2004). The varieties of dignity. Health Care Anal, 12(2), 69-81; discussion 83-89.

doi: 10.1023/B:HCAN.0000041183.78435.4b

Pols, J. (2013). Through the looking glass: good looks and dignity in care. Med Health Care and

Philos, 16, 953-966.

Szanton, S. L., & Gill, J. M. (2010). Facilitating resilience using a society-to-cells framework: a

theory of nursing essentials applied to research and practice. ANS Adv Nurs Sci, 33(4), 329-

343. doi: 10.1097/ANS.0b013e3181fb2ea2

van Gennip, I., Pasman, H., Oosterveld-Vlug, M., Willems, D., & Onwuteaka-Philipsen, B. (2013).

The development of a model of dignity in illness based on qualitative interviews with seriously

ill patients. International Journal of Nursing Studies, 50, 1080-1089.

Vlug, M., de Vet, H., Pasman, R., Rurup, M., & Onwuteaka-Philipsen, B. (2011). The development

of an instrument to measure factors that influence self-perceived dignity. J Palliat Med, 14(5),

578-585.


Modeling the RelationshipBetween

Attributed Dignity and Health

July 2015

Jordon D. BosseRN, MSN

PhD Student

Cynthia JacelonPhD, RN-BC CRRN, FAAN

Associate Professor

Lisa ChiodoPhD

Assistant Professor


Background

Dignity is:

• Critical for successful aging (Erikson, Erikson, &

Kivnick, 1986)

• Related to health status (Walsh & Kowanko, 2002)

and quality of life (George, 1998)

• Important for mental health (Cassity-Caywood &

Huber, 2003)

• Important for independence (Jacelon, 2003;

Tadd, Bayer, & Deppe, 2002)

• Helps individuals adjust to declining health (Jacelon, 2001)


Jacelon Attributed Dignity Scale (JADS)

“An attributed, dynamic sense of self value, self in relation to others, perceived value from others, and behavior that demonstrates respect toward others” (2012)

“Attributed dignity is gained or lost in one’s own eyes during interactions with self and others” (2009)


JADS Factors

Self-value (SV)

• perceived self value

• individual’s relative importance

Perceived Value from Others (PVO)

• “the value an individual perceives he or she is attributed from other people”

Self in Relation to Others (SRO)

• “self reflection on how an individual interacts with others.”

Behavior that Demonstrates Respect to Others (BRO)

• is self explanatory, with the caveat that the behavior can be directed at self or others (2014)


Attributed Dignity (Path Analysis)


Purpose

Evaluate Theoretical Model of Attributed

Dignity


Methods

Sample 229 older adults (65-95, Mean =76.6, SD = 7.6) Quota sampling 74% women

Setting Senior Centers in Western New England

Measures JADS SF12v2 (Physical Health & Mental Health)

Demographics (e.g., age, race, education, income, living

situation)


Methods

Data Analysis

Structural Equation Modeling (Lisrel 9.1)

Theoretical model used to identify starting model

Modification indices suggested alternative paths

Alternative models evaluated


Age

χ2= 388.46 df=325, p< .01 RMSEA= 0.029

All paths significant

Direct path Indirect path

SRO

Age

BRO SVSF12

Mental

0.90

0.89 0.83 0.41 0.92

-0.21

Live with?

Sex

-.014

-.29

SF12Physical

PVO

Final Model: The Influence of Dignity on Physical and Mental Health


Comparing Models

Path Analysis Model SEM Model

Differences could be due to inclusion of outcome variables!


Implications

Perceived value from others is critical to maintaining dignity

Improving SV can improve mental health

• Women may benefit more from interventions that increase SV

• Influence of behavior on others

Physical health influences mental health


Conclusions

• Interventions to support/ enhance attributed dignity

Great potential to improve health

Most likely to enhance both social and physical role function

• Although not assessed

Potential to increase overall well being

• Future directions

Validate on more diverse population


Thank you!

Questions?


Cassity-Caywood, W. and R. Huber, Rural older adults at home. Journal of

Gerontological Social Work, 2003. 41(3/4): p. 229-245.

Erikson, E.H., J.M. Erikson, and H.Q. Kivnick, Vital involvement in old age. 1986, New

York: W. W. Norton & Co.

George, L.K., Dignity and quality of life in old age. Journal of Gerontological Social

Work, 1998. 29(2/3): p. 39-52.

Jacelon, CS., Managing personal integrity: A grounded theory of elderly people surviving

hospitalization, in Division of Nursing. 2001, NYU: New York.

Jacelon, CS., (2003). The dignity of elders in an acute care hospital. Qualitative Health

Research, 13(4): p. 543-556.

Jacelon, CS & Chiodo, L. (2014). (Poster) Testing a theoretical model of attributed

dignity. Gerontological Society of America 67th Annual Scientific Meeting,

Washington, DC (abstract published)

Jacelon, CS & Choi, J. (2014). Evaluating the Psychometric Properties of the Attributed

Dignity Scale. Journal of Advanced Nursing: 70(9): 2149-61

Jacelon, CS (2012). (Paper). The evolution of the concept of attributed dignity. Council

for the Advancement of Nursing Science 2012 State of the Science Congress on

Nursing Research. Washington, DC.

Jacelon, CS; Knafl, K; Dixon, J (2009). Development of the attributed dignity scale.

Research in Gerontological Nursing, 2(3): 202-213.

Tadd, W., T. Bayer, and P. Dieppe, Dignity in health care: reality or rhetoric. Reviews in

Clinical Gerontology, 2002. 12: p. 1-4.

Walsh, K. and I. Kowanko, Nurses' and patients' perceptions of dignity. International Journal of

Nursing Practice, 2002. 8: p. 143-151.


Cynthia S. Jacelon

PhD RN-BC CRRN FAAN

Personal Strategies for Managing Dignity

in the Course of Human Interaction

This work was partially funded by: Scholar in Residence Fellowship, Jewish Geriatric Services, Inc.,

Longmeadow, MA


Purpose & Background

Purpose: To discover how older adults manage their attributed dignity

Many aspects of dignity have been studied

• Experience of Care and hospitalization(Bridges & Nugus2010; Matiti & Trorey 2008; Baillie 2009; Jacelon, 2003)

• End of Life (Brown et al. 2011; Chochinov et al. 2006)

• Community (Tadd 2004; Calnan et al. 2006; Jacelon et al., 2009 )

Little is known about the management of dignity by older individuals


Research Questions

1. What are the characteristics of situations in which the dignity of older adults is threatened?

2.What strategies are employed by older adults to protect, restore, or maintain their dignity when it is threatened?

3.How do the strategies vary according to the characteristics of the older adult?

4.What are the similarities between strategies used by community dwelling and hospitalized older adults?


Methods

Grounded theory (Corbin & Strauss, 2008)

Constant comparative method using NVivo• Open coding, Axial Coding, Theoretical Coding

Comparing findings to previous work

Trustworthiness• Interviews audio recorded and transcribed verbatim• Researcher logs, Audit trail, Participant checking

Data Collection• Interviews: In person, audio recorded interviews in elder’s

home or place of choice • Elders were asked to talk about a situation in which he or she felt

that his or her dignity was threatened


Participants

• 19 participants: 8 black women, 9 white women, 2 white men

• Age: average 76.68 (68-90)

• Martial status: 2 women and 1 man were married

• Living in the community in western Massachusetts, urban, suburban, and rural

• Income range: < $10,000 - >$59,000

• Education: Some High School – PhD

• Living situation included: alone, with children, with spouse

• Housing: single family homes, multi family homes, HUD housing


Findings: Question 1

• What are the characteristics of situations that adversely affected elder’s dignity?

• All situations affected the elder’s perceived value from others or their self value

• All situations demonstrated, racism, classism, or ageism

• Perceived value from others:

• “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. And that makes me mad.”


Findings: Question 1 (con’t)

• Situations affecting self value:

“Being in that environment [senior center] with the very poor and doing what I would call doing a kind of menial work -- it feels to me undignified, but I’m doing it.

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 ‘ok Jack you’re going to do the filing and the vegetable counting and the whatever.’ My dignity might be insulted”



What strategies are employed to protect, restore, or maintain dignity when it is threatened?• Strategies were aimed at improving the elder’s self

value and included:• Introspective Strategies aimed at restoring self

value:• Considering the source• Taking it to God

• Interactive strategies:• Getting mad• Maintaining one’s position

• Active strategies• Removing one’s self from the situation• Reporting the behavior


Findings: Introspective Strategies

Considering the Source

• I don’t usually speak back. My mother taught us to consider the source and consider what you want to fight for and what you want back off of. I kind of think about – 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 ok.

Taking it to God

• “I take it to God in prayer”


Findings: Interactive Strategies

Getting mad:

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.’


Findings: Interactive Strategies

Maintaining One’s position:

Depending on the seriousness of the situation, I try to refrain from ugly outbursts, but I speak up. If I’m among strangers or something, 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.


Findings: Taking Action

• Removing oneself from the situation

I might walk away, I might say something and then walk away. You know, or 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. Because that’s not being respectable to me or to the person.

• Reporting the behavior

I think I would go to the head of…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 talk with him.



• How do the strategies vary according to the characteristics of the elder?

• Most participants had a usual style of maintaining dignity

• No obvious relationship to

demographic characteristics

• Only black participants mentioned

“taking it to God”



Comparing the findings to previous work

• The three types of responses (introspective, interactive, and active) were similar to earlier work (Jacelon, 2003)

• Individual strategies varied

Strategies identified earlier:

• Introspective: Life reviewing, Adjusting attitude

• Interactive: Making meaning out of interactions with others, Managing image, Managing information

• Active: No active strategies to maintain dignity were identified in this population


Process of Managing Attributed Dignity

Interactions that Enhance Attributed Dignity

Jacelon, 2014


Process of Managing Attributed Dignity

Interactions that Diminish Attributed Dignity

Jacelon, 2014


Discussion, Next Steps & Conclusions

• Developing an intervention• Based on the participant’s responses, an intervention focused on teaching

and encouraging introspective, interactive, and active strategies to maintain dignity can be developed

• The efficacy of the intervention can be evaluated by using the JADS pre & post intervention

• In conclusion

• There is evidence that attributed dignity is important for health andwellbeing of elders as indicated by Jordon’s presentation

• Many situations, particularly interactions with healthcare professionals threaten

elder’s dignity

• Vulnerable elders, like those with chronic health problems, are more at risk for

alterations in their dignity than healthier counterparts

• Have a repertoire of strategies to protect or restore attributed dignity may enhance

the health and well being of community dwelling elders


Baillie, L. (2009) Patient dignity in an acute hospital setting: A case study.

International Journal of Nursing Studies, 46, 23-37.

Bridges, J. & Nugus, P. (2010) Dignity and significance in urgent care: older people's

experiences. Journal of Research in Nursing, 15(1), 43-45.

Brown, H., Johnston, B. & Ostlind, U. (2011) Identifying care actions to conserve

dignity in end-of-life care. British Journal of Community Nursing, 16(5), 238-245.

Calnan, M., Badcott, D. & Woolhead, G. (2006) Dignity under threat? A study of the

experiences of older people in the United Kingdom. International Journal of Health

Services, 26(2), 355-375.

Chochinov, H., Kristjanson, L., Hack, T., Hassard, T., McClement, S. & Harlos, M.

(2006) Dignity in the Terminally Ill: Revisited. Journal of Palliative Medicine, 9(3),

666-672.

Corbin, J. & Strauss, A. (2008) Basics of Qualitative Research, Sage, Thousand

Oaks, CA.

Jacelon, C. (2003) The dignity of elders in an acute care hospital. Qualitative Health

Research, 13(4), 543-556.

Jacelon, CS (2014). Strategies Used by Older Adults to Maintain or Restore

Attributed Dignity. Research in Gerontological Nursing: 7(6): 273-283.

Matiti, M. & Trorey, G. (2008) Patients' expectations of the maintenance of their

dignity. Journal of Clinical Nursing, 17, 2709-2717.

Tadd, W. (2004) Dignity and older Europeans: Comparative analysis of data from

older people’s focus groups from all Centres. University of Wales, Cardiff, Wales,

pp. 33.


Symposium Conclusion

In all of the models presented in this symposium, dignity is a product of the interaction between humans and their social and ecological environment

• Dr. Walker demonstrated how dignity is a form of resilience and how the concept fits into an ecological model spanning the distance from cellular to societal levels

• Mr. Bosse used path analysis to explore relationships among attribute dignity as measured by the JADS, sex, age, health, and living status

• I demonstrated how older adults appraise threats to dignity and respond to restore their dignity

There is increasing evidence that dignity does matter for wellbeing in older adults


Thank you!

Questions?

Documents

Managing Dignity in Later Life: Global Influences ... · Life: Global Influences, Personal Strategies, Cellular ... Discuss the role of dignity as a form of resilience 2. ... environment