The personal dignity of Dutch nursing home residents during COVID-19: a cross-sectional, quantitative pilot study Open Access

Nursing home residents are often confronted with challenges which may impact their personal dignity. The latter is defined as the subjective experience that deserves respect, has value and maintains a sense of self-worth (Jacelon et al., 2004; Chochinov et al., 2006). Personal dignity can be influenced by disease related conditions (Barclay, 2016), including physical and psychological functioning, as well as social interaction and, in the case of nursing home residents, by the quality of care. They have moved to a new, unfamiliar daily living environment without family and with little privacy (Oosterveld-Vlug et al., 2013). In addition, they depend highly on professional caregivers for their personal care, and their social network may shrink (van Tilburg et al., 2021). Next, disease-related conditions induce existential stress and loss of dignity (Barclay, 2016). Besides, understaffing in their nursing home can be an additional threat to their sense of dignity (Chochinov et al., 2006). These challenges should be understood as consequences of structural and health-related circumstances rather than as shortcomings in professional care intentions. Residents whose dignity has been compromised or lost can experience themselves as useless and their lives as meaningless and even unbearable (Chochinov et al., 1998). For some, this can eventually result in a wish to die (Monforte-Royo et al., 2018; Belar et al., 2021).

Up to now, interventions to maintain or improve the feeling of dignity of nursing home residents are mainly based on the ideas and opinions of healthcare professionals and informal caregivers (Naden et al., 2013; Rehnsfeldt et al., 2014). Oosterveld et al. (Oosterveld-Vlug et al., 2015) showed that these views do not always correspond with the opinions of the dignity of nursing home residents. Therefore, based on the Chochinov Dignity Model, (Chochinov et al., 2006; Chochinov et al., 2012; van Gennip et al., 2013), the Patient Dignity Inventory (PDI) self-reporting questionnaire for people with cancer was developed to study their perceived dignity (Chochinov et al., 2008; Chochinov et al., 2012). Oosterveld et al. adapted the PDI for nursing home residents: the Measurement Instrument for Dignity Amsterdam – for Long-Term Care Facilities (MIDAM-LTC) (Oosterveld-Vlug et al., 2014). It measures on multiple domains nursing home residents’ own perceptions related to subjective experiences. Although quantitative, the instrument captures subjective perceptions by asking residents whether dignity-related situations apply to them and to what extent these affect their sense of dignity. This instrument appeared to have good content validity, construct validity and intra-observer reliability.

In 2020, the global COVID-19 crisis greatly impacted on health and well-being, especially for nursing home residents (Verbiest et al., 2022; Palacios-Cena et al., 2021). Infection-control measures such as visitor bans, cohort isolation, use of personal protective-equipment, and cancellation of communal activities limited social and altered care interactions. Residents often experienced loneliness, loss of autonomy and reduced opportunities for meaningful relationships (Noten et al., 2022; Heudorf and Stalla, 2025). We hypothesize that it improved their sense of dignity.

Previous research on dignity focused on topics such as optimism, social connectedness, culture, coping style and existential meaning (Jacelon et al., 2004; Dong et al., 2021; Kisvetrova et al., 2022).

These studies informed the selection of demographic, psychosocial and functional predictors in the present study.

Therefore, we aimed to (1) get insights into the experienced dignity of Dutch nursing home residents during COVID-19, and (2) to explore the personal, social and functional factors that influenced this dignity.

We performed a quantitative cross-sectional pilot study.

In November 2019, we started approaching psychologists working in nursing homes in The Netherlands to participate in a dignity questionnaire survey for their residents. The study was designed before the COVID-19 pandemic. Data collection however, took place during the pandemic. For that reason, we decided to focus on experiences of dignity during the COVID-19 period.

Fifty-three institutions affiliated with the Psycho Geriatric Service (PsychoGeriatrischeDienst, 2023), an organization that supports psychologists in elderly care, were approached. Inclusion started in January 2020 and ended in August 2022.

In each participating Dutch nursing home, a psychologist working in that specific setting was asked to invite their residents who met the following inclusion criteria to participate in an interview:

• residing in a nursing home;

• being 18 years of age or older;

• being cognitively capable of participating (Mini-Mental State Examination MMSE-2 BV, cut-off score T-score ≤ 30); and

• having high care demand and/or nursing needs.

The exclusion criteria were:

• not being able to speak or read Dutch;

• not being able to communicate with the interviewer who administered the questionnaire;

• being too vulnerable to participate as indicated by an involved healthcare professional (nurse or physician). Residents were considered “too vulnerable” if participation could cause excessive burden due to acute illness, terminal phase of illness, severe psychological distress or inability to take part in an interview;

• not understanding the instructions and questions; and

• not being able to decide independently about participation.

Interested residents received a written and oral information document about the survey via their psychologist. After at least two days for consideration, each willing resident signed an informed consent form after a detailed reading.

The study was performed according to the Dutch law and Good Clinical Practice guidelines. The Medical Review Ethics Committee region Arnhem-Nijmegen concluded that this study was not subject to the Medical Research Involving Human Subject Act (case number CMO:2022–13739). All participants provided informed consent before starting to participate in the research.

Two questionnaires were used; one was completed by the psychologist and the other by the participating resident. Each questionnaire consisted of several questions and scales.

The questionnaire for the psychologists consisted of three parts. Firstly, in case of any ambiguity concerning the participating resident’s cognitive capability, the Dutch version of the Mini-Mental State Examine 2 Brief Version (MMSE-2BV) was used. The MMSE-2BV scale contains 16 questions, each granting one point if answered correctly. The raw total score (0–16) is standardized based on norm values for age and education. If the residents had a t-score ≤ 30 (2 or more standard deviations below the mean), they were excluded from the study. In the second part of the questionnaire, nursing home data were documented, i.e. the religious signature of the nursing home, location of the nursing home, number of employees working within the nursing home as indicated by an involved healthcare professional (psychologist, nurse, physician) and the number of residents staying within the nursing home, as provided by the manager. The third part of the first questionnaire contained resident-specific information, i.e. date of admission, type of health care package, primary and secondary diagnosis and country of origin. The degree of dependency was noted using the Barthel Index, a measure of limitations in daily activities (de Haan et al., 1993). The scale contains 11 questions, which are granted 0, 1, 2 or 3 points. The total Barthel Index score can range from 0 to 20, and a higher score indicates that the patient experiences fewer limitations in daily activities.

The questionnaire for the nursing home residents contained several questions and one scale. Firstly, resident characteristics were asked which might influence dignity, i.e. gender, age, religion and the level of importance of religion on a five-point scale (very important – not important at all), degree of optimism on a five-point scale (very optimistic – very pessimistic), highest completed education and number of completed school years, and the number of times per week that family or acquaintances visit the nursing home. The second part of the questionnaire consisted of the MIDAM-LTC (Measurement Instrument for Dignity Amsterdam – for Long-Term Care facilities); (Oosterveld-Vlug et al., 2014). This scale consists of 31 symptoms/negative experiences which can play a role in the experience of dignity impairment. The 31 symptoms are divided into five dignity impairment domains, namely, evaluation of self in relation to others, functional status, mental state, care and situational aspects and long-term care. For each symptom/negative experience, two questions were asked. Firstly, the respondents were asked whether the symptom/negative experience had been applied to them (question a). If the answer was no, then the respondent was invited to continue to the next symptom/negative experience into the list. If the answer was yes, the resident was asked to indicate the level to which the symptom/negative experience influenced their sense of dignity on a five-point scale from 0 = not to 4 = to a very high degree (question b). To calculate domain scores, if question a was answered with no, question b was given the value of 0, as it can be assumed that the respondent did not perceive any dignity impairment for that symptom/negative experience. Then, dignity impairment domain scores were calculated by summing the scores of question b of the respective symptoms. The raw domain scores were converted from a 0 (no dignity impairment) to a 100 (maximal dignity impairment) score based on their theoretical range. After completing the MIDAM-LTC, respondents were asked to indicate on a scale of 1 (feeling of dignity completely lost) to 10 (feeling of dignity completely intact) how they experienced their general sense of dignity over the last two days. Finally, on a scale from 1 (very poor) to 10 (optimal), they were asked how they generally experience the quality of their life.

Spss version 29 was used for the data analyses. Spearman’s rank correlations were computed to determine bivariate relationships between the dignity impairment domain scores and the potential predictors of gender, age, religion, optimism, number of school years, family visits, length of stay, country of origin and Barthel index.

Next, six multiple regression analyses were performed, each with a dignity impairment domain score as the dependent variable. The predictors were gender (female = 1), age, religion (yes = 1), optimism, education (number of years), family visits (per week), length of stay (in months), country of origin (Dutch = 1) and Barthel index. Given the limited sample size, a stepwise backward approach was used, with the predictor with the highest p-value removed at each step. After each step, the adjusted R² was used to determine whether the model improved by removing the predictor. The model with the highest adjusted R² was used as the final model. Bootstrapping (2000 samples) was used to estimate standard errors.

Using G*Power version 3.1 (Faul et al., 2007) it was estimated that, to detect a medium effect size (f2 = 0.15) using a linear multiple regression, taking into account an α = 0.05, 1-β = 0.8, and nine potential predictors, 114 participants were needed. As the available population consisted of 79 residents who met the inclusion and exclusion criteria, a stepwise backward approach was used, with the predictor with the highest p-value removed at each step. After each step, the adjusted R² was used to determine whether the model improved as a result of removing the predictor. The model with the highest adjusted R² was used as the final model. Bootstrapping (2000 samples) was used to estimate standard errors.

A cut-off significance value of p = 0.05 (95% confidence interval) was used in all analyses.

At the start of the study, 79 residents were approached to participate, of whom 66 residents participated. The reasons the remaining residents did not participate included cognitive inability to participate, or because of increasing illness or death that occurred between recruitment and data gathering. The participants’ characteristics are listed in Table 1. The majority of residents were Dutch (90%), female (58%) and religious (67%).

Descriptive statistics of the dignity impairment scores (Table 2) show that, on average, dignity impairment varies between 8.70 (SD = 12.98) for care situational symptoms/negative experiences to 23.06 (SD = 22.82) for symptoms/negative experiences in functional status.

We found significant positive correlations between the number of visits per week and dignity impairment (r_s = 0.25, p = 0.044) and the subdimensions of mental state (r_s = 0.25, p = 0.040), evaluation (r_s = 0.25, p = 0.042) and functional status (r_s = 0.31, p = 0.013) (Table 3). Also, a positive correlation between optimism and mental state dignity impairment was found (r_s = 0.32, p = 0.009). As a higher optimism score indicates less optimism, less optimistic people, in general, experience more mental state dignity impairment. The Barthel Index is negatively correlated with functional status dignity impairment (r_s = −0.39, p =   0.001). The experience of dignity impairment of long-term care symptoms/experiences decreases with age (r_s = −0.27, p =   0.034), Dutch residents report in general higher levels of dignity impairment concerning long-term care than residents with other cultural backgrounds (r_s = 0.29, p =   0.017).

The results of the regression analyses are reported in Table 4. Of the predictors in the model, only the regression coefficient of the level of optimism was significant (β = 0.28, p = 0.010), indicating that less optimistic people report higher levels of dignity impairment. Regarding the subdomains of dignity impairment, optimism appeared to be also the only significant predictor of dignity impairment of evaluation of self in relation to others (β = 0.24, p = 0.045). Gender (female: β = 0.38, p =   0.001) and Barthel index (β = −0.33, p = 0.006) were significant when it comes to dignity impairment concerning functional status, and dignity impairment in mental state was significantly explained by the level of optimism (β = 0.31, p = 0.005) and number of visits per week (β = 0.36, p = 0.039). The domain concerning long-term care symptoms/experiences was significantly explained by age (β = − 0.35, p = 0.002) and cultural background (β = 0.30, p < 0.001). None of the predictors that were used in this study was significantly associated with dignity impairment of care and situational aspects.

We studied the dignity experiences of Dutch nursing home residents during the COVID-19 period and which factors influenced their dignity, while social contact, routines and care interactions were substantially altered. An optimistic attitude towards life and higher age appeared to be associated with higher levels of personal dignity. However, more family visits, having a Dutch background, being female and having a greater degree of care dependency were associated with lower levels of personal dignity in certain domains. The resident’s education level, being religious and the length of stay in the nursing home did not appear to influence the dignity. Of the results mentioned, having an optimistic attitude towards life seems the best safeguard for maintaining personal dignity for individuals in nursing homes.

Our findings that an optimistic attitude is positively associated with personal dignity is consist with dignity research in patients with advanced cancer, which has shown that psychological distress-particularly depression and hopelessness- is negatively associated with dignity. Patients reporting more positive attitudes tend to have higher dignity scores, whereas those with higher levels of depression and anxiety show lower dignity levels (Obispo et al., 2022).

Besides, our finding that a greater degree of care dependency relates to a lower dignity level is also in line with findings in studies on patients with advanced cancer (Rodriguez-Prat et al., 2016).

It is not surprising that optimism is an important factor in maintaining dignity. Optimism is defined as: “hopefulness and confidence about the future or the successful outcome of something; a tendency to take a favourable or hopeful view” (Oxford English Dictionary, consulted on March 12, 2025). Jacelon et al. (2004) stated in a concept analysis of dignity for older adults, that ‘dignity is an inherent characteristic of being human, it can be subjectively felt as an attribute of the self and is made manifest through behaviour that demonstrates respect for self and others’ (Jacelon et al., 2004). Dignity must be learned, and an individual’s dignity is affected by the treatment received from others. Optimism and dignity appear to be strongly connected. Optimism can influence dignity because positive expectations about the future can help maintain dignity in the face of setbacks. Chopik et al. (2015) found that optimism was associated with improved self-rated health and fewer chronic illnesses. Bhattacharyya et al. (2025) also found that optimism and satisfaction have potentially positive impacts on achieving successful ageing. Conversely, maintaining dignity can promote a sense of control over one’s life and future (locus of control), which increases optimism (Guarnera and Williams, 1987).

We also found higher age to be positively related to dignity. This confirms the findings from Pergolizzi et al. (2021). They showed that in patients with advanced cancer, older age could be a protective factor against the perception of perceived dignity-related distress compared to younger patients, as they have a seemingly adaptive resilience to dignity-related threats, especially in the domains of psychological and existential distress. However, some studies report other outcomes. For example, in an article by Higgs and Gilleard (2022), ageism is seen as a means of oppression. A cross-sectional study of older adults (Kisvetrova et al., 2022) showed that patients with a low dignity rating and women have more negative attitudes towards ageing. Henry et al. (2024) came up with solutions to break through ageism.

In this study, there appeared to be a connection between increased family visits and a decrease in dignity. This contradicts most of the studies that have been conducted on the relationship between family visits and dignity. Wang et al. (2024) studied the effects of family dignity interventions and concluded that they improve the mental health of adults with advanced cancer. Research by Leontjevas et al. (2021) showed that during the COVID-19 period, challenging behaviour increased and decreased after a visit ban or changes in organized activities. Research into family visits and loss of dignity has not been extensively studied, but it is conceivable that factors such as loss of autonomy, manner of treatment, lack of respect, loss of health and physical appearance can contribute to a sense of loss of dignity among individuals who live in nursing homes.

In our study, women experienced a greater loss of dignity concerning their functional status than men. This outcome is in line with research conducted by Martin-Abreu et al. (2022), among others, which concluded that being a woman and limited functionality are associated with less dignity in older advanced cancer patients. Research by Kisvetrova et al. (2022) also showed that women experienced a greater loss of dignity.

Finally, we found that the degree of care dependency negatively influenced the perception of dignity. This corresponds with the results of multiple studies. Moradoghli et al. (2022) investigated the relationship between frailty and dignity and concluded that higher levels of frailty in older people were associated with decreased dignity. Research by Dong et al. (2021) into dignity and its related factors among older adults in long-term care facilities showed that older adults with more chronic diseases, among other things, experienced low-level dignity.

This study is one of the first to examine how nursing home residents experienced their dignity and factors that can influence dignity during the COVID-19 period.

However, conducting a study during the COVID-19 period also had its challenges. The original plan was to conduct research throughout The Netherlands, but it had to be scaled back due to reduced participation from nursing homes. The limited sample size reduced statistical power and restricted the number of predictors that could be reliably tested. Regression analyses were exploratory and intended to generate hypotheses for future studies. Besides, the study mainly took place in nursing homes in the western part of The Netherlands. Furthermore, care workers actively approached the participants, which may also have led to selection bias. Given the above, it is therefore not clear to what extent these results can be generalized to the entire Dutch population of nursing home residents.

The perceived personal dignity of the elderly in nursing homes is influenced by psychological, social and cultural factors. Optimism plays an important protective role, whereas more family visits, having a Dutch background, being female and a greater degree of dependency appeared to lead to a feeling of reduced dignity. These findings underline the importance of a person-centred, culture-sensitive and value-oriented approach to care in nursing homes. It may be relevant to investigate further whether interventions focused on improving optimism levels could improve dignity levels among nursing home residents. Screening for depressive symptoms or low optimism may help to identify residents at risk for dignity impairment.

The authors thank the nursing home residents and psychologists of Laurens, Careyn, WZH, Evean, Inovum, Amaris, Vivium and Wijdezorg for giving their time and Drs Judy Nijman-van Erven for her statistical support.