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. 2022 Jun 5;30(7):2362–2369. doi: 10.1111/jonm.13689

Experiences with dignity among older people confined to beds living in a nursing home: A qualitative descriptive study

Zvonka Fekonja 1, Sergej Kmetec 1, Mateja Lorber 1, Janja Lavrač 2, Wilfred McSherry 3, Nataša Mlinar Reljić 1,✉
PMCID: PMC10084146  PMID: 35593523

Abstract

Aim

The aim of this study is to explore the concept of dignity from the experience of older people with limited mobility and confined to beds while living in a nursing home.

Background

Nursing staff have an important impact on the dignity of those older people confined to beds in nursing homes. Individuals' uniqueness with respecting dignity should be ensured.

Methods

A qualitative descriptive study was conducted. The study was carried out with 19 older people who were immobile and confined to bed and living in nursing homes. The individual in‐depth interviews were conducted between July and October 2021. Inductive thematic analysis was used to synthesize data.

Results

The main theme ‘Dignity of older people confined to bed’ emerged from subthemes ‘Emotions’, ‘Lived experience’ and ‘Failure to maintain care’. The participants expressed their dissatisfaction towards the nursing staff's disrespectful care, which evoked feelings of insignificance and inferiority.

Conclusion

Undignified and disrespectful nursing care can cause feelings of suffering, sadness and anger in older people confined to their beds. Nurses must listen to this group of older people and learn from their experiences. Compassionate, person‐centred care with kindness and empathy should be provided by all those providing and receiving care in nursing homes.

Implications for Nursing Management

To provide dignified care, nursing staff must understand the importance of person‐centred, individually oriented nursing care for older people living with immobility in nursing homes.

Keywords: confined to bed, dignity, experiences, nursing homes, older people

1. BACKGROUND

Many older people living in nursing homes are frail, especially those with restricted mobility and confined to bed. The aetiology of immobility includes physical, psychosocial factors and environmental changes. The effects of these factors result in older people being confined in beds. Older people with limited mobility are defined as being confined to bed for at least 15 days, and 90% of this time is spent in bed, requiring nursing care with all their daily activities (Normala & Lukman, 2020).

Nursing staff working in nursing homes can substantially impact the dignity of older people confined to bed and the quality of their daily interactions (ICN, 2021; Ostaszkiewicz, Dickson‐Swift, et al., 2020). Nursing staff must ensure the whole person's body, mind and spirit are respected and preserved from any violation of their dignity. It is a professional requirement and competence to ensure individuals are treated equally and that their uniqueness and dignity are safeguarded (Clancy et al., 2020). Nursing management must enable and ensure a clinical environment that supports providing dignified care (McSherry et al., 2012).

Dignity is primarily defined as the quality or state of being worthy, honoured or esteemed (Chochinov et al., 2012). Dignity is based on personal values, like holiness, freedom, responsibility, duty and serving one's fellow humanity (Lindwall & Lohne, 2020). Maintaining dignity is closely connected with the feeling of freedom and one's autonomy and independence (Fenton & Mitchell, 2002). Also, the experience of confirmation, faith and hope is crucial to preserving the dignity of older people (Tranvåg et al., 2015). Dignity can also be provided through friendships, social inclusion (Clancy et al., 2020) and nursing staff caring, giving older people confined to bed feelings of self‐worth. Older people, especially those confined to bed, are more exposed to the risk of dignity violation. Lack of respecting dignity is a reason for distrust between nursing staff and older people and causes a sense of humiliation (Elvish et al., 2013). Nursing and caring which do not preserve dignity can lead to psychological and spiritual distress (Mlinar Reljić et al., 2021).

Some research has been conducted exploring the dignity of older people in nursing homes (Oosterveld‐Vlug et al., 2014). However, this focus has been disease related (Torossian, 2021) or end of life oriented (Caspari et al., 2014). In Slovenia, nursing care for older people is organized as a community nursing care, home care, home care assistance, personal assistant care, day‐care in nursing homes, long‐term care and nursing care in nursing homes (Črnak Meglič et al., 2014). Registered nurses lead nursing care teams in Slovenian nursing homes, but most nursing interventions provide nurse assistants and professional caregivers. The educational level of nursing staff has a significant impact on the quality of care (Aiken et al., 2017), and dignified care is one of the quality indicators. This research emphasizes essential themes related to dignities, such as fragility, dependency and illness‐related aspects of care. Since many older people in nursing homes are confined to their beds, nursing staff needs to understand the concept of dignity from their perspective.

Therefore, this paper describes the experience of older people confined to their beds and receiving nursing care in nursing homes in Slovenia. The paper addressed the following research question: ‘What kind of experiences have older people confined to bed living in nursing homes about their dignity?’

2. METHODS

2.1. Study design

A qualitative descriptive approach was used based on phenomenology (Lindseth & Norberg, 2004). Such research design enables authors to illuminate lived experiences (Lindseth & Norberg, 2004) with dignity among older people confined to beds in a nursing home. This approach is useful as this study describes a phenomenon and comprehensively details how older people confined to bed experience the concept of dignity. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used (Tong et al., 2007).

2.2. Settings and participants

Purposive sampling (Polit & Beck, 2021) was used to collect data. Purposive sampling is commonly used to identify the in‐depth experiences of a typical representative of the target population. The suggestion that the required sample size in qualitative studies is between 5 and 25 participants was followed (Creswell & Creswell, 2018). The study was carried out in four nursing homes in Slovenia. The inclusion criteria were (1) people of both genders with a non‐cognitive impairment aged above 65 years, (2) the ability to verbal communicate and (3) having lived experiences of being confined to bed for at least 1 year. The exclusion criteria were (1) people with cognitive and/or behavioural impairment, (2) inability for verbal communication and (3) people receiving end‐of‐life care. Based on eligibility criteria, 19 participants were included in the study. No one refused to participate or withdrew from the study.

2.3. Data collection and analysis

Individual in‐depth interviews with older people confined to bed living in the nursing home were conducted. Based on the eligibility criteria, the head nurse of each nursing home recruited the participants. Data collection was conducted between July and October 2021. All participants were interviewed two times. Before the first interview, the confidence between participant and researcher was created. Discussion about dignity started in the first interview. In the second interview, we gained in‐depth meanings and captured the experience dignity of older people confined to bed. All the interviews were digitally recorded and lasted approximately 35–40 min. Data collection ended after 35 interviews when data saturation was reached (Polit & Beck, 2021). Additionally, three more interviews were conducted to ensure that no new themes emerged. The researcher used an interview guide containing the question: ‘What does dignity mean to you?’ and ‘What experiences do you have about your dignity here in the nursing home?’ Interviews were held in a participant's room, ensuring privacy and the absence of interruption. The interviews were transcribed verbatim and imported into the MAXQDA program for organizing data and systematic coding. The inductive thematic analysis based on Braun and Clarke (2021) was used. Any discrepancies were discussed until a consensus was reached.

2.4. Rigour and trustworthiness

To ensure the rigour and reliability of this qualitative study, we followed the criteria from Lincoln and Guba (1985). The four researchers independently read the transcripts repeatedly to ensure credibility. After the transcripts were created, the participants were revisited to confirm the transcripts of the interviews. Also, the designed themes and subthemes were discussed with participants. The translated transcripts were reviewed by a nursing expert fluent in English and Slovene and experienced in qualitative research to ensure dependability. To provide confirmability, the authors adhered to the original interviews of participants and added quotations to present the originality of the discussions. The audio‐digital recordings and transcribed interviews were securely stored with passwords in the computer and anonymized. The findings of this study are transferable and may be helpful for management, nurses and caregivers of those older people, confined to bed in nursing or residential homes and long‐term care facilities.

2.5. Ethical considerations

Ethical approval was obtained from the Ethical Committee University of Maribor, Faculty of Health Sciences (No. 038/2018/2733‐5/504). Also, approval for the study was obtained from the participating institutions. All the participants were informed about the aim and objectives of the study, and informed consent was obtained. They were also informed that they could withdraw at any time without consequences. All the interviewees' identities were hidden and changed into pseudonym names.

3. RESULTS

Older people confined to bed (n = 19; 12 female and 7 male) while living in a nursing home participated in the study. The minimum period of living in a nursing home was 14 months, and the longest was 37 months. Thirteen participants were dependent on nine daily physically living activities, according to Henderson (1997). The data analysis resulted in the main theme ‘Dignity of older people confined to bed’ emerged from three secondary subthemes themes: (1) Emotions, (2) Lived Experience, (3) Failure to Maintain Care and seven primary subthemes as displayed in Figure 1. Emotions, like anger and sadness with failure to maintain care, substantially impact experiencing dignity. When people do not have the autonomy of their lives, they experience this as disrespect and dehumanized care.

FIGURE 1.

FIGURE 1

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Main theme and relations between subthemes

3.1. Emotions

Secondary theme Emotions were comprised of three primary subthemes: (1) Anger, (2) Sadness and (3) Hope and Faith.

The results show that older people are confronted with a sense of selflessness. All participants identified states or situations that indicate limited mobility, inferiority, lack of independence and inability to take care of themselves. They experience such feelings as losing control of their own lives. They found it very difficult to cope with the loss of their mobility and the need to depend on others to maintain their daily living activities. This sense of frustration and anger is reflected in the following:

No, it is tough for me to accept that I cannot stand on my own feet and that I cannot walk anymore. If I could walk again, I would not be here, but I would rather live at my home. It is hard for my wife because she cannot take care of me anymore while immobile. (Charles)

I feel angry because you always have to call someone for something you need. (Brian)

Participants described how they sometimes felt inferior. They expressed a sense of dependence on the nursing staff. Feelings of lack of independence are consequences of involuntary adjusting to the current life situations in the nursing home. This often led to feeling sad, as evident in the following:

I feel like I am just one thing for them. If you were incontinent of faeces, they change the diapers, and that's it. (Amanda)

Participants spoke about how they had lived in their own house with loving family members and hospitable environments, for example, animals, domesticity and things that made sense of life and made them happy. The loss of this was a cause of sadness:

I am so sad because I cannot have my dear dog here with me. I feel very attached to my dog. At home, it always lying at my feet. (Gary)

The participants felt sad when they remembered their past life and were independent and could take care of themselves. Being independent at home gave them a sense of worth and personal satisfaction.

Some participants indicated how they still strived to maintain hope, faith:

Yeah, it would be great if I could walk without help. I hope it will come a time when I can walk without help again. (Linda)

3.2. Lived experience

The subtheme “Lived Experience” was comprised of three primary subthemes: (1) Disrespect, (2) Dehumanization and (3) Live Day Today, which are explained below.

Feelings of inferiority are the worst when changing underwear, as it reminded them of early childhood, which they experience as infantile. Comparison with other, healthy older people further deepens, reinforcing feelings of powerlessness as expressed:

I'm like a little child who needs to be rewound. […] I am like a baby. You depend on everyone, you just watch how others can walk and you cannot. (Carol)

The immobility also represents the feeling of being forgotten. They receive very few but essential visits as outlined below:

It is nice when someone visits you and caresses you a little. Do you know how much this is worth? (Betty)

The participants suffered distress if they had to ask the nursing staff for help for every little thing. This causes sadness and emotional distress as participants were taken off the opportunity to decide for themselves, thus affecting their dignity.

Nursing staff in nursing homes are very rigid in adapting and organizing nursing interventions, which participants in the study describe as limiting their desires, needs and freedom, as indicated in the following:

Yes, but I cannot. Now I'm in bed, I cannot go anywhere. Today, for example, I cannot go anywhere. The nurse cannot transfer me into the wheelchair anymore. I'm not going anywhere today. (Roger)

The loss of freedom, weakness and helplessness evoke a sense of inferiority, which is exacerbated by the feeling that the person is superfluous, dependent on the help of others, which the participants understand as a burden to another person. The notion of burden was manifest in the following:

I felt like one heap of misfortune. Someone else has to take care of me for once. (Jane)

The participants highlighted the fear of the nursing staff's disrespectful care, which aroused insignificance and inferiority. For participants, dignified nursing care should be individualized, with an emphasis on conversation as conveyed below:

Some nurses come, they do not even talk to me, they do their job and then leave the room. It means a lot to me if they take some time and talk to me. (Debra)

The loss of dignity was experienced in many ways but especially associated with sudden and unexpected immobility that was a source of severe distress due to loss of pride and self‐worth. This was explicit in the response by Lily:

When I realised that I would never walk again …. I cried. (Lily)

Participants stated that the loss of dignity was caused by distress due to devaluation while performing personal hygiene. Feelings of embarrassment, shame and worthlessness were expressed:

… when they take me to the bathroom with that big recumbent bathing trolley, I feel like a corpse. (Mary)

Well, I feel fine in a clean diaper, but it is very uncomfortable in a full diaper, I'm ashamed …. (Paul)

Some participants expressed that they live just day today. They lost their faith and hope for a better future. Their dignity is affected because they must ask the nursing staff for help in every activity. They feel hampered (restricted) and unable to control their daily activities. Saly described this living day by day:

We meet and sing down there at the table. We have singing lessons every Thursday, which I like to go to. We have a raffle on Tuesdays, and so time goes by. (Saly)

3.3. Failure to maintain care

Failure to maintain care as the main theme consisted of two subthemes: (1) Authonomy and (2) Relationship.

The participants mostly expressed losing a sense of control and autonomy over their lives. Such losing control and independence causes feelings and emotions like anger and sadness. Furthermore, failure to maintain care with frailty and confining to bed contribute to losing dignity among older people:

… since I am confined to the bed, I have to ring the bell for every little thing and wait for someone to take care of me …. (John)

Some participants articulated the importance of positive and respectful relationships by nursing staff. Participants spoke about how negative attitudes and relationships held by the nursing staff made them feel inferior to the nursing staff. They highlighted the sense of dependence upon the nursing staff. Some of them also referred to the rudeness of the nursing staff and the powerlessness they experienced having to wait for care. The participants experienced distress while waiting for incontinence aids to be changed. This had a severe impact on their sense of dignity, especially when they had to wait for long periods:

Only three times a day, they came and changed the ‘diaper’. At half‐past four in the afternoon, I get a diaper for the night. That is a long time for me to wait for changing if the diaper is full. (Roy)

The participants highlighted how these activities and attitudes affected their dignity due to the disrespectful caring by the nursing staff. It was evident that such care evokes unworthy, unimportance and inferiority. Participants wished to have individual, personal care, which preserves their dignity.

4. DISCUSSION

This study presents older people's confined‐to‐bed experience of dignity while living in nursing homes. The results from this study were derived from individual interviews with older people confined to bed resulting in the identification of one main theme: ‘Dignity of older people confined to bed’ and three secondary subthemes themes: (1) Emotions, (2) Lived Experience and (3) Failure to Maintain Care and seven primary subthemes.

This study found that sadness relates to suffering because of loneliness and dull days in the nursing home. Older people living in nursing homes experience intensifying physical pain caused by psychological suffering factors like loneliness, vulnerability, loss, fear, helplessness and hopelessness (Naik & Ueland, 2020). The helplessness and anger of older people are also evident because of being confined to be and dependence on nursing staff. Anger and sadness are also problems in other nursing homes in different countries (Amzat & Jayawardena, 2016), while researchers identify loneliness, boredom and anger of people living in nursing homes. Causes can be found in the lack of involvement of older people in daily activities and social life in nursing homes. Therefore, nursing staff needs to be aware of the effects of being confined to bed on older people's well‐being, dignity and self‐worth.

Disrespectful and undignified nursing care for older people being confined to bed can make them feel worthless and lose self‐value. Moreover, it causes distrust between the patient and the nurse, leading to feelings of humiliation and inferiority among patients (Clancy et al., 2020). Our results show that intimate personal care with changing underwear causes the most disrespectful feelings expressed by older people confined to bed. Intimate personal care with changing incontinence aids is one of the nursing staff activities that affect older people's dignity and self‐worth. Similar results were also highlighted by Šaňáková and Čáp (2019), who called these feelings the sense of fractured dignity. Participants in this study also encountered rudeness by the nursing staff. This type of behaviour is unacceptable and unprofessional. It highlights the importance of Chochinov's A, B, C, D model of dignity conserving care (Chochinov, 2007). This model reinforces the importance of positive attitudes and behaviours and should always be based on compassion and dialogue.

Caring in nursing homes should be person‐centred, dignified, and provided with a great sense of compassion and caring (Fekonja et al., 2021). One of the nurses responsibilities is promoting and sensitivity for persons dignity (Barclay, 2016; Caldeira et al., 2017). It is crucial to protect the dignity of older people living in nursing homes, especially when they need assistance in managing intimate personal care (Ostaszkiewicz, Dunning, et al., 2020). Establishing a compassionate relationship between older people confined to bed while living in a nursing home and nursing staff is very important for them both (Roberts, 2018). Some of them express terrible relationships and carelessness. On the other hand, good experiences were reported, such as nursing staff showing empathy; kindness and responsiveness were also described. Nursing staff need to understand that dignity can also be promoted through relationships between older people and staff, friendships and social interactions (Clancy et al., 2020). King (2014) also highlighted the importance of building relationships and providing connectedness to better understand and deliver compassionate care based on individual needs, values and beliefs. This approach affirms recognizing the four notions of dignity (dignity of the human being, dignity of merit, dignity of moral stature and dignity of the individual) developed by Nordenfelt and Edgar (2005) because these four notions encourage a person‐centred approach to care. When nursing care is provided without professional relationships and disrespect, older people confined to bed can experience suffering (Lindwall & Lohne, 2020).

Suffering is mainly understood as undignified care (de Vries, 2021). Our findings should encourage and motivate nursing staff to provide individual, person‐centred care based on dignified, compassionate and caring nursing. Such an approach allows the maintenance of self‐respect and coping with immobility and dependence in people living in a nursing home.

Vaismoradi et al. (2016) report that older people may have a sense of helplessness feel ignored when they are dependent and unable to plan or perform their care and participate in daily living activities. We found that dependency on nursing staff and constantly begging for assistance also gives older people confined to bed a sense of diminished dignity and self‐worth. The feeling of uselessness contributes to a sense of unworthiness that can violate their dignity (Šaňáková & Čáp, 2019).

Šaňáková and Čáp (2019) suggest that good quality nursing care depends on an individual approach and satisfying older people's wishes, expectations and nursing care needs. Nursing management must ensure that nursing staff in nursing homes have the appropriate educational level. Research shows (Aiken et al., 2017) that education level significantly impacts upon patient safety and quality of care, including ensuring dignified care is provided. Furthermore, we found nursing care is mainly provided routinely, as the daily pre‐planned schedule of nursing activities like making beds, bathing, meals and changing underwear. When nursing care is provided routinely, under time pressure and staff shortages (Dierckx de Casterlé et al., 2020) and less compassionate care (Nathoo et al., 2021), the dignity of older people confined to bed is severely impaired. Routine care and unmet needs can result in depersonalized care experiences (Torossian, 2021). Furthermore, nursing management must prevent paternalistic nursing practices that foster a sense of dependence, lack of decision‐making control and involvement in daily activities. Nurse management must provide a person‐centred culture that enhances equality, shares decision‐making that promotes the older person's active role and considers the older person's wishes (Kmetec et al., 2022). Therefore, a person‐centred management style leads to higher nursing care staff satisfaction, which improves care in nursing homes (Kmetec et al., 2022).

We found that older people confined to bed can lose hope and faith for a better future. On the other hand, some older people maintain their inner power to be as active as possible. Our findings show that older people enjoy chatting, singing in the choir and playing table or parlour games. Daily activities enable older people to deal with their lives in changing circumstances, such as adjusting to living in a nursing home (King, 2014). Being confined to bed has a substantial negative impact on older people's daily living activities and dignity. Vaismoradi et al. (2016) pointed out the importance of social activities and nourishment as tools in taking control of their changed life situations, especially in the case of being confined to bed, which caused dependency and threatened their dignity. Effective management of changed life circumstances can be a source of hopefulness to older people living in nursing homes. Suhonen et al. (2019) noted that practices that increase connections and interaction among people are needed for better resident outcomes.

4.1. Limitations of the study

There are some limitations to the findings of this study. The length of living in the nursing home also contributes to the different dignity experiences in daily living activities. Being confined to bed may influence how older people reflect on their history, personal characteristics, values and beliefs. Also, because of the disease‐orientated focus in this research, the finding may not reflect the lived experience of all older people, especially those who are confined to bed. Older people with no cognitive decline were included in the study. Many people with cognitive impairment live in nusing homes in Slovenia. Therefore, it is imperative to explore how dignity is preserved in the nursing care provided to them.

The inclusion of older people from different cultural backgrounds might influence their feelings about dignity preserving care. The findings cannot be generalized because the study was conducted in one nursing home. The findings might differ if the study was conducted in many nursing homes or other countries.

5. CONCLUSIONS

Older people confined to their beds have diverse experiences of nursing care. Many older people expressed the nursing care as undignified and disrespectful. This can cause feelings of suffering, sadness and anger. Nurses need to listen to older people confined to bed to learn from their experiences. All nursing homes should provide compassionate, person‐centred care with kindness and empathy. This can contribute to dignified care and nursing care practice that preserve and uphold the identity and self‐worth of older people confined to bed while receiving care in nursing home settings.

6. IMPLICATIONS FOR NURSING MANAGEMENT

Our findings have significant practical implications for management and nursing staff. Nursing home managers have a key role in creating resources and environments for ensuring dignified nursing care of older people confined to bed. The results from our study should be used to improve nursing care of older people confined to beds in countries with similar health and social care systems. Management in nursing homes must ensure the technical and organizational resources for providing dignified care. Nursing management is responsible for the employment of nursing staff enabled to provide person‐centred care. Management also must recognize the value and importance of advanced nurse practitioners in caring for older people in nursing homes. Such understanding can lead to preserving the dignity of older people and promoting person‐centred caring in nursing homes. Nursing home management must ensure and provide evidence‐based standards and monitor performance quality according to care standards. Continuous nursing staff training is necessary to promote professional development encouraging interdisciplinary teamwork.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

ETHICS STATEMENT

Ethical approval (No. 038/2018/2733‐5/504) was obtained from the Ethical Committee University of Maribor, Faculty of Health Sciences, prior to beginning the study.

AUTHOR CONTRIBUTIONS

Zvonka Fekonja, Nataša Mlinar Reljić and Sergej Kmetec provide research theme and designed the research. Janja Lavrač and Mateja Lorber collected the data. Zvonka Fekonja, Nataša Mlinar Reljić and Sergej Kmetec analysed the data. Wilfred McSherry, Zvonka Fekonja, Nataša Mlinar Reljić, Mateja Lorber and Sergej Kmetec wrote the manuscript.

ACKNOWLEDGEMENTS

We are grateful to all participants and to the management of the nursing homes where the research was conducted.

Fekonja, Z. , Kmetec, S. , Lorber, M. , Lavrač, J. , McSherry, W. , & Mlinar Reljić, N. (2022). Experiences with dignity among older people confined to beds living in a nursing home: A qualitative descriptive study. Journal of Nursing Management, 30(7), 2362–2369. 10.1111/jonm.13689

Funding information The research received a non‐specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

DATA AVAILABILITY STATEMENT

The data are available from the corresponding author upon request.

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Data Availability Statement

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