1. 1 School of Nursing © Jacelon 2012 School of Nursing The Evolution of the Concept of Attributed Dignity Cynthia S. Jacelon, PhD RN-BC CRRN FAAN Associate Professor School of Nursing University of Massachusetts Amherst

2. 2 School of Nursing © Jacelon 2012 This Research was Partially Funded by:  Beta Zeta at Large Chapter of STTI (Grant 1999)  Rehabilitation Nursing Foundation (ARN/STTI Grant 2001)  The Center for Self and Family Management of Chronic Illness ( T32NR008346 ) School of Nursing, Yale University (2004-2006)  Scholar in Residence Fellowship, Jewish Geriatric Services, Longmeadow, MA (2004-present)

3. 3 School of Nursing © Jacelon 2012 Identification of the Phenomena  Grounded theory study of hospitalization of older adults Research Question “What are the social processes elderly people engage in during hospitalization? 5 cases: 3 interviews with hospitalized older adults, interviews with 1 nurse, 1 family member, extensive participant observation, and document review

4. 4 School of Nursing © Jacelon 2012 The Beginning: Personal Integrity (2001)

5. 5 School of Nursing © Jacelon 2012 First Conceptualization of Dignity  A property of Personal Integrity  Defined as an individual’s self-worth Attributes: Self-Dignity Interpersonal Dignity Relationship between attributes mediated by privacy and respect  Particularly important during the middle phase of hospitalization  Insults to dignity can be absorbed until the insults to dignity exceed an older individual’s cache of dignity

6. 6 School of Nursing © Jacelon 2012 Self Dignity and Interpersonal Dignity (2001)

7. 7 School of Nursing © Jacelon 2012 Theoretical Definition of Attributed Dignity  Hybrid Concept Analysis of Dignity Purpose: develop a conceptual definition of dignity based on a review of literature and the ideas of older adults (n=23) who participated in focus groups (n=5)  The word “ Dignity ” was used several ways: Philosophically Cognitively Developmentally Behaviorally Self Others

8. 8 School of Nursing © Jacelon 2012 School of Nursing Dignity is an intrinsic characteristic of being human, it can be subjectively felt as an attribute of the self, and is made manifest through behavior that demonstrates respect for self and others. Dignity must be learned, and is affected by the treatment received from others Definition of Dignity following Concept Analysis

9. 9 School of Nursing © Jacelon 2012 Intrinsic and Attributed Dignity (2004)

10. 10 School of Nursing © Jacelon 2012 Operational Definition of Attributed Dignity  The Attributed Dignity Scale (ADS) Item Development Item generation from Focus Group Data Item Evaluation Review of items by expert (n =17) and lay (n = 7) panels Cognitive Appraisal Interviews (n = 15) Instrument Testing Pilot Testing (n=18)

11. 11 School of Nursing © Jacelon 2012 School of Nursing Dignity is an intrinsic quality of being human that is manifested as an attributed, dynamic sense of self value and behavior that demonstrates respect for self and others Definition Following ADS Pilot (2009)

12. 12 School of Nursing © Jacelon 2012 Exploring Attributed Dignity  Psychometrics (n=289): Four factor solution Self-value (SV) was retained The individual’s self perceived value Behavioral Respect Others (BRO) was retained Behavior that demonstrates respect for others Behavioral Respect self (BRS) not retained Perceived Value from Others (PVO) new factor The value an individual perceives he or she is attributed from other people Self in Relation to Others (SRO) new factor Self reflection on how an individual interacts with others

13. 13 School of Nursing © Jacelon 2012 Four Factor Model of Attributed Dignity (2012)

14. 14 School of Nursing © Jacelon 2012 School of Nursing An attributed, dynamic sense of self value, behavior of self in relation to others, perceived value from others, and behavior that demonstrates respect toward others Attributed dignity is a concept that dependent on the relationship between individuals Current Definition of Attributed Dignity

15. 15 School of Nursing © Jacelon 2012 From Concept to Middle Range Theory  Attributed dignity is:  Stable over time (reliability >.70) Related to the cache of dignity proposed earlier  Distinct from Social Desirability (correlation = 0.25, p = <.001) and Self Esteem (correlation = 0.15, p=<.01)  Managed by older adults (n=19) using Introspective, Interactive, Active strategies in response to an assault on his or her dignity Incidents that affect dignity affect either self value or perceived value from others

16. 16 School of Nursing © Jacelon 2012 Next Steps  Relationships among the factors of Attributed Dignity The factors of the ADS are moderately correlated ( range 0.43 –o.57 p <.oo1) The directions of these relationships is yet to be tested  Relationships among attributed dignity, health, function, and sense of control  Intervention to support older adult’s ability to manage his or her attributed dignity

17. 17 School of Nursing © Jacelon 2012 School of Nursing Over the course of several research studies the concept of attributed dignity has evolved from an idea to a well defined concept that will serve as the root of a middle range theory It has long been said that dignity was important for the health and wellbeing of older adults. Now we have a way to understand and operationalize this concept and to develop interventions to support older adults’ strategies to protect or restore attributed dignity Conclusions

18. 18 School of Nursing © Jacelon 2012 References  Jacelon, CS (2004). Managing personal integrity: The process of hospitalization for elders. Journal of Advanced Nursing, 46(5): 549-557  Jacelon, CS (2003). The dignity of elders in an acute care hospital. Qualitative Health Research, 13(3): 543-556  Jacelon, CS, Connelly, TW, Brown, R, Proulx, K & Vo, T (2004) A concept analysis of dignity for older adults. Journal of Advanced Nursing, 48(1) 76-83  Jacelon, CS; Knafl, K; Dixon, J (2009). Development of the attributed dignity scale. Research in Gerontological Nursing, 2(3): 202-213  Jacelon, CS & Choi, J (in review). Evaluating the psychometric properties of the Attributed Dignity Scale.  Jacelon, CS (in preparation).Older adults managing attributed dignity.