Geriatric Nursing 36 (2015) 394e396
Contents lists available at ScienceDirect
Geriatric Nursing
journal homepage: www.gnjournal.com
Acute Care of the Elderly Column
Elizabeth Capezuti, Sarah Hope Kagan,
PhD, RN, FAAN PhD, RN, FAAN
Dignity, evidence, and empathy
Sarah H. Kagan, PhD, RN, FAAN
School of Nursing, University of Pennsylvania, Clarie M. Fagin Hall, 418 Curie Boulevard, Philadelphia, PA 19104-4217, USA
How do we conceive of the place of dignity in our care of acutely
and critically ill older people? A visit to my friend Joan who was
hospitalized recently when she fractured her pelvis in a fall at home
prompted me to revisit dignity. A retired high school teacher who is
nearing 90, Joan is looking forward to celebrating her milestone
birthday in a few months. While I reassured Joan about the
simplicity of recovering from her injury “it’s all about controlling
your pain so that you can get moving and keep moving”, I could not
prepare her for the indignities she experienced in the hospital. It
wasn’t the dreaded hospital gown, though she hated wearing one.
The chief threat to Joan’s dignity arose not from depersonalizing
hospital systems, indifferent clinical care, or even a lack of
compassion.
“Just go in the diaper, dear!” I heard the stage whisper half way
down the hall. I picked up my pace to Joan’s room, worried that
what I heard was directed at her. I immediately thought of scientific
and clinical evidence on early mobilization with stable pelvic
fractures and effective pain control along with all that indicates we
should not be using so called adult diapers if we can avoid them.
Joan’s dignity was not yet uppermost in my mind but it quickly
became so. I saw the tears in Joan’s eyes from the door and realized
how e as she told me herself a few moments later e “how terribly
undignified and not at all like a lady” she felt being asked to wear a
diaper and then being told to urinate in it. All her nurse Peter
wanted to do in that moment was to help Joan avoid the pain he
knew she would feel if she got out of bed to use the commode.
Nevertheless, he unwittingly threatened her dignity, making her
feel childish and incapable.
The suggestion to use the diaper is the crux of the matter in
Joan’s case, the place in her care where dignity was first neglected.
As nurses, our role in safeguarding dignity differs from that which
E-mail address: skagan@nursing.upenn.edu.
0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2015.08.005
Mary Beth Happ, Lorraine C. Mion,
PhD, RN, FAAN PhD, RN, FAAN
we would see in relationships outside of nursing and health care.
We hold the unique and privileged place of seeing dignity as a
fundamental aspect of personhood, linked to our professional
interpretation of compassion by evidence and empathy. Integration
of scientific ad clinical evidence e as it is integrated into our as-
sessments, judgments, and decision-making e distinguishes our
role in promoting and preserving the dignity of our patients.
Dignity is fundamental to being human. A sense of being worthy
of respect and honored just for being ourselves, dignity is some-
thing we feel when our integrity as a person is expressed, eliciting
affirmation from others. Indignity is a response e action or emotion
e to which we are subjected by others. It results in our feeling
undignified, diminishing our sense of innate value and injuring our
self-respect as a result. Empathy is the emotional fulcrum through
which we feel compassion and the person for whom we have
compassion feels dignity. Empathy, as recognition of the existential
predicament of another, promotes dignity. All of us e as human
beings e feel empathy, compassion, and dignity. Just how we
choose to use those emotions in daily life, however, is the subject of
considerable discussion in lay and professional literature.
Nursing frames dignity within terms of self and personhood
unlike those used in everyday social relationships. We act on
empathy and compassion but must uphold our professional obli-
gation in all actions. In acute care of older people, vulnerability
commonly potentiates threats to personhood. Health, function,
and wellbeing are compromised, perhaps permanently, while both
independence and life are at risk. Our appreciation of personhood
integrates the perspective of normal development e like aging e
with alterations in health and function brought about by illness
and injury e like Joan’s fall-related fracture. With that apprecia-
tion, comes the need for theory and science we use to intervene in
and help manage development and changes in health. We feel
empathy toward people, who as our patients are experiencing
disruption in life and health. We act on our empathy, rendering
 S.H. Kagan / Geriatric Nursing 36 (2015) 394e396
nursing care from our sense of compassion for our patients. While
our feelings of empathy and compassion are shared by others, our
actions are not. Nursing care is the central expression of a so-
phisticated discipline, a practice anchored equally in philosophical
notions of what it is to be human and in the theory and science
required to preserve personhood and mitigate risks to health and
function, and to dignity. While dignity occurs in the context of our
relationships with patients, the act of assuring our patients’ dig-
nity requires that our shared personhood supersedes our roles of
nurse and patient.
Dignity in everyday interaction is supported or damaged by the
extent to which respect and honor for the person are present. The
more fitting and extensive the respect and honor are, the greater
the worth felt. Nursing transforms simple empathies with evi-
dence. While we innately feel that avoiding pain is a good thing,
nursing directs us to carefully evaluate a situation in which pain
might be felt. Best practice and current evidence call for us to assess
Joan’s need to void with a new but stable pelvic fracture carefully.
We must precisely weigh the threat of temporary pain, readily
alleviated with effective analgesia, against the innumerable risks of
immobility and the dual physical and emotional dangers of using
incontinence garments and calling them adult diapers.
Joan’s nurse Peter, I am certain, never intended to make her feel
undignified. Nonetheless, in suggesting that she intentionally lose
continence using a “diaper”, Peter misjudged the balance of pain,
mobility, and function in Joan’s self-perception. He consequently
though inadvertently slighted her, making her feel belittled and
undignified. Joan felt his direction as a comment on her incapacity
to do what she had taken for granted for as long as she could
remember e using the toilet. Anyone could have made this misstep
in trying to protect a frail, vulnerable elder. As nurses, however, we
bear a greater responsibility.
Our analysis of factors in a clinical situation like Joan’s encom-
passes more than merely kind social interaction. Evidence in-
tervenes between our feelings of empathy compassion and care we
provide to an older person like Joan. We must consider relevant
scientific evidence in concert with the philosophical tenets of what
it means to be a person, valued and respected. Though Peter had
tremendous empathy for Joan’s situation, he missed the element of
evidence as he provided nursing care through his compassion for
her. As a result, Peter was unsuccessful both in making Joan feel
better and in fulfilling his obligation of applying best evidence in
light of his empathy and compassion for her. Joan was devastated
by his suggestion as she inferred she could no longer be trusted to
use the toilet and must rely on diapers. I could see Peter, too, felt
terrible as he stood for a moment and watched Joan visibly work to
keep her composure. As nurses, we have all endured that agonizing
realization of “oh dear, that was the very wrong thing to do”. In the
end, Peter and Joan understood each other better. As they found
acknowledgment and respect from the other, they repaired each
other’s dignity.
Providing nursing care to acutely and critically ill elders is a
profoundly intricate process. Cognitive, physical, interpersonal,
emotional, and spiritual dimensions simultaneously twine together
against a pressured institutional background. We negotiate a vast
body of knowledge to assure evidence-based acute care practice. In
parallel with our largely cognitive process of assessment and de-
cision making, we juggle strenuous logistical demands of delivering
and coordinating patient care. On top of all of this work, we
contend with often crushing emotions as we manage manifold
crises and witness life too easily tipped toward death. Add to all for
which we are responsible as nurses the depersonalizing and
sometimes dehumanizing institutional characteristics of hospital-
ization e just call to mind the hospital gown e and we all see that
dignity is under attack in acute care.
395
With all that acute care nursing practice requires, simple human
dignity becomes anything but simple. We slip too lightly into ac-
tions where dignity vanishes. An ill chosen word or a poorly
thought out instruction may leave lasting damage, whether in
beneficently intended intervention or in less acceptable exertion of
our professional power when we are tired or, worse yet, insensible
to the plights of our patients and their families. As nurses in the
high-stakes acute care environment, we often feel pressured by
power misapplied by colleagues. Our response may be to transmit
the disrespect we feel into half-hearted care or inappropriate use of
our power over others. Indignities are incurred by patients and
their families as well as our coworkers as we suppress our feelings
and fail to use appropriate evidence to guide our care.
Typically, our response to failures in health care like the loss of
dignity is to study them. Like compassion, dignity is a hot topic in
current research. Dignity is being examined for relationships to
perceived health status, quality of life, and similar concepts.1,2 It’s
being studied as in therapeutic intervention.3,4 There are in-
struments to measure it, protocols to assure it, and interventions to
preserve it.5,6 But might all of this science pose peril to truly sup-
porting our patients’ dignity in actual practice?
Research that deconstructs dignity to better understand it risks
a reductionist perspective that makes translating any findings into
actual practice nearly impossible. The almost incalculable
complexity of acute and critical care, coupled with the monumental
demands of nursing practice in the hospital context, begets a
phenomenon akin to the proverbial straw that broke the camel’s
back. More evidence about dignity is unlikely to help us preserve it
as we care for acutely and critically ill older people. Reducing dig-
nity to targeted interventions or sequenced protocols likely only
adds straws to that camel’s swayed back, at least in the fraught
acute care setting. I do not dispute that dignity is imperiled in acute
care; however, I question how best to preserve and protect it.
Adding to the list of the dimensions of care for which nurses are
responsible is a viable solution. What then are we to do to insure
the place of dignity in our practice, sidestepping the sort of situa-
tion in which Peter found himself and defending ourselves against
emotional disengagement?
I advocate reframing rather than adding to the span of our
nursing practice as we care for older patients. Dignity begets dig-
nity. People who feel dignified empathize with others, treating
them with compassion, and making those people feel dignified too.
As a result, personal habits of reflection and care for the self may
foster self-worth and respect for ourselves, promoting our dignity.
As we honor our own dignity through reflection on it, we are able to
expand our capacity to promote and protect it in others.
Reflective practice enhances our embodiment of nursing, of-
fering a means to know dignity as a whole and to trace its re-
lationships to empathy and compassion in nursing. Sharing
reflective practice with our colleagues strengthens common un-
derstandings of dignity and its intersection with both evidence-
based and best practices. Building a culture in which reflective
practice is central engages all nurses practicing together to recog-
nize the place of dignity as they care for older patients, realizing
patients’ personhood as arching over the process and tasks of
nursing practice. Such cultures of care for the person elevate dig-
nity and compassion from “taken for granted” to treasured touch-
stones for “how we do it here.”
Dignity, like compassion, is less likely to be disregarded when
explicitly acknowledged as central to the philosophy of care,
modeled by leaders and celebrated by all. The instability and ten-
sion inherent in acute care, along with episodic relationships and
high stakes clinical problems make cultures of care harder to
achieve. Making dignity a priority in care requires clearly expressed
commitment to connecting it with empathy and compassion and in
396 S.H. Kagan / Geriatric Nursing 36 (2015) 394e396
underscoring how it is reflected through evidence-based and best
practices. Reflective practice avoids reducing these intersections
and instead highlights interrelationships as these essential ele-
ments come together in care.7 Elevating dignity as a cornerstone
for our nursing practice provides cultural context for more tech-
nical care as well as mechanisms like checklists and protocols that
assure the safety of that care. Placing dignity at the heart of nursing
care for older people recalls why we are nurses and enables to us to
better makes sense of the chaos we find as we strive to preserve
the dignity of those older people we are privileged to call our
patients.
Sarah H. Kagan, PhD, RN, is Lucy Walker Term Professor of
Gerontological Nursing, University of Pennsylvania, Philadelphia, PA.
She gratefully acknowledges the comments of Angela Iorianni-Cimbak
MSN, RN, G. J. Melendez-Torres DPhil, RN, and Kristen W. Maloney
MSN, RN, AOCNS in preparing this column.
References
1. Albers G, Pasman HRW, Deliens L, de Vet HCW, Onwuteaka-Philipsen BD. Does
health status affect perceptions of factors influencing dignity at the end of life?
J Pain Symptom Manage. 2013;45(6):1030e1038.
2. Chochinov HM, Kristjanson LJ, Breitbart W, et al. Effect of dignity therapy on
distress and end-of-life experience in terminally ill patients: a randomised
controlled trial. Lancet Oncol. 2011;12(8):753e762.
3. Goddard C, Speck P, Martin P, Hall S. Dignity therapy for older people in care
homes: a qualitative study of the views of residents and recipients of ‘gen-
erativity’ documents. J Adv Nurs. 2013;69(1):122e132.
4. Chochinov HM, Cann B, Cullihall K, et al. Dignity therapy: a feasibility study of
elders in long-term care. Palliat Support Care. 2012;10(01):3e15.
5. Albers G, Pasman H, Rurup M, de Vet H, Onwuteaka-Philipsen B. Analysis of the
construct of dignity and content validity of the patient dignity inventory. Health
Qual Life Outcomes. 2011;9(1):1e9.
6. Jacelon CS, Choi J. Evaluating the psychometric properties of the Jacelon
Attributed Dignity Scale. J Adv Nurs. 2014;70(9):2149e2161.
7. Bulman C, Schutz Sue, eds. Reflective Practice in Nursing. Oxford UK: John Wiley &
Sons; 2013.