Social Welfare: Interdisciplinary Approach eISSN 2424-3876
2026, vol. 16, pp. 201–228 DOI: https://doi.org/10.15388/SW.2026.16.10

Possibilities for Fostering Independence of Older People: The Dimension of Dignity in Residential Social Care Institutions

Inga Mikalauskienė
Vilius Gaigalaitis Care Home, Lithuania
E-mail: inga.mikalauskiene@gaigalaitisgloba.lt

Ginter Harner
Vilius Gaigalaitis Care Home, Lithuania
E-mail: ginter.harner@gaigalaitisgloba.lt

Kristina Rūdytė
Vilnius University Šiauliai Academy, Lithuania
E-mail: kristina.rudyte@sa.vu.lt
https://orcid.org/0000-0002-8525-1268
https://ror.org/03nadee84

Abstract. Grounding on the applied qualitative research methods based on theories of humanism and social constructivism, employed semi-structured interview and simulation game “Gamlec”, the article presents an analysis of possibilities for fostering independence in residential social care institutions, emphasises a dimension of dignity and reveals how the interaction of staff, residents and relatives leads to support of independence in the institutional environment.

The analysis reveals that respectful communication, assurance of privacy, possibility to participate in the decision-making, acknowledgement of romantic relationships and a positive social climate maintain independence. Several negative factors, such as hyper-care, bullying, lack of privacy and insufficient preparation for palliative care, are pointed out.

The research represents a close connection between independence and dignity as well as supplements earlier studies with new insights on the significance of emotional climate, the role of relatives and organisational culture. The results are relevant to practice, enhancement of competencies of staff of care institutions and building of dignity-based care.

Keywords: independence of older people, dignity, social care institutions, competencies of staff.

Recieved: 2025-09-12. Accepted: 2026-09-04
Copyright © 2026 Inga Mikalauskienė, Ginter Harner, Kristina Rūdytė. Published by Vilnius University Press. This is an Open Access journal distributed under the terms of the Creative Commons Attribution 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Introduction

The fostering of older people’s independence has been acknowledged as an international principle of the policy of ageing. According to demographic trends drawn for the period until 2050, the entire world would be inhabited by 2.1 billion of people aged over 60 (World Health Organization, 2025). With regard to the said, all countries of the world, jointly with the United Nations and the World Health Organization, design the policy programme which includes three dominating and interrelated principles: active ageing, social engagement, and fostering of independence. After comparing the ageing policies in four countries (Australia, Denmark, India, and the United Kingdom), it was found out that promotion of independence is not equally acceptable, its significance in policy is shaped by personal and family values as well as social responsibility (Plath, 2009). Based on the data of research conducted in Romania, independence, individuality and autonomy are important to well-being of older people; it is emphasised that people having more independence in their daily activities value their lives higher (Ghenţa et al., 2022). Having identified the outcomes of the demographic ageing of society in Lithuania, it is obvious that a need for integrated care services increases with every year (Lietuvos Respublikos Vyriausybės kanceliarija, 2022). National documents on the social care field highlight independence as an important aspect of life (Lietuvos Respublikos Socialinės apsaugos ir darbo ministerija, 2007; Lietuvos Respublikos Socialinės apsaugos ir darbo ministerija, 2006; Lietuvos Respublikos Seimas, 2006). They point out the necessity to help an individual to develop and enhance skills to independently solve social problems, to provide a possibility for self-expression, to maintain independence in daily activities; also, there is an emphasis on the principle of enablement including a key statement to promote a person’s initiative in the decision-making and to deliberately assume responsibility for those decisions.

Rabiee (2013) puts an attitude of care specialists who emphasise that older people are treated as passive receivers of services who are not able to independently take care of themselves and perform activities without somebody else’s help, which results in lowered significance of the fostering of independence. However, there is an emphasis on independence defined by older people themselves as an ability to make decisions concerning their own life. Kolbergytė & Indrašienė (2012) declare that it is necessary to encourage, motivate clients to independently solve their social problems and assume responsibility for their own lives. Pinker (2020) notices that, in contemporary world, people perceive the life as improving not only according to the assessment standards set by economists, but also by people’s ability to appreciate the highest forms of progress: aesthetical, cultural, intellectual, social pleasures, and to independently decide on how they want to spend their time. Naujanienė (2008) underlines that institutional services limit older people’s independence the most. Nevertheless, Gečienė and Gudžinskienė (2018) put it that grounding on present-day topicalities, as the society is ageing, it must be admitted that the need for care increases. Orlova & Gruževskis (2014) suggest assessing the benefit and harm of institutional care by observing the situation of a person and finding him/her the most acceptable option to maintain independence as long as possible. Stiehr et al. (2016) emphasise that independently made decisions, independence from others, respect, maintenance of dignity and privacy are important to older people living in residential institutions.

When older people lose their ability to independently perform their activities, this does not mean that their wish to be independent has diminished. Šinkūnienė (2010) puts it that there is prevalence of the paternalistic strategy when a social worker performs actively and an older person remains passive while having a decreased self-esteem. An older person’s independence is diminished, one becomes socially cared for and cannot independently make decisions in one’s daily life. Therefore, it is important to identify how to maintain balance among the provision of care, acceptance of it and independent performance of skills in a holistic approach. Despite an increasing political interest in the fostering of independence of older people, there is more research from theoretical viewpoints rather than from practical experience. Yet there is a lack of empirical insights on how independence is maintained in institutional environment when building dignity-focused care. This research investigates the existing gap related to daily practices in care homes, interventions of staff and application of institutional rules, which make effect on the residents’ independence through experiencing dignity. The research problem can be described by a key question: How do social workers, nurses providing care to residents of care institutions, and relatives of the residents conceptualise possibilities for older people’s independence that manifest in the dimension of a person’s dignity?

Research object: possibilities for fostering independence of older people in residential social care institutions in the context of the dignity dimension.

Research aim: to reveal possibilities for fostering independence of older people in a residential social care institution in the context of the the dignity dimension.

Literature Review

Every ageing person lives one’s modelled life and has accumulated different life experiences. People with higher self-esteem try to remain more independent as long as possible by protecting their autonomy and vice versa: the more a person is independent, the more dignified one feels when maintaining one’s independence from the help of other people. We can assess the process of ageing namely through the individual experience of every person, by identifying it either as independent, active age phase, or as dependent on others and the environment. Indarwati et al. (2023) observe that, due to weakening physical and cognitive skills of older people and their changing social roles, their independence decreases and dependence on others increases. Sherwin and Winsby (2011), while discussing a situation of older people residing in care homes, emphasise that independence is determined not only be one’s health condition but also by preconceived cultural attitudes towards them.

A traditional thinking of common society treating the older age as a life phase of losing independence and receiving social services is being substituted by more positive assessment criteria: the life of older people can be active, dynamic, autonomous and dignified (Tanner, 2005). Bimou et al. (2021) have it that the main goal in geriatric practice is to postpone dependence. Based on the conducted research, scholars declare a fact that there is a probability to retain a high level of independence at an older age if it was being maintained throughout life; and they also state that a higher risk to lose independence is caused by a poor health condition. Due to natural outcomes of ageing, it becomes more difficult to live independently, like it was possible to do earlier. However, this does not mean that a wish to be independent decreases when the ability to perform activities independently disappears. Rabiee (2013) holds it that an understanding about independence is multidimensional: to some, it associates with an ability to do everything by himself/herself, and yet to others it is important to control the life by making decisions by himself/herself, yet some others suppose that independence is related to self-confidence, an ability to be oneself; moreover, there are people who believe that it is a possibility to live at one’s own home.

It is noted that independence is not defined as living without the help of others; however, this does not mean that people around must perform activities, make decisions instead of the older people who still are able to take care of themselves. By emphasising the strengths of older people, through self-reliance, a level of independence is increased, and independent living is explained as self-control and possibility to make choices, which is highly important in retaining a person’s dignity. Orlova and Gruževskis (2014) provide research results on the life quality of socially fostered older people for the period between 2011 and 2013; they observe the following major factors: independent decision-making, maintenance of relationships, re-creation of memories, maintenance of vitality, and participation in the course of provided support. The scholars state that causes of older people’s happiness lie in the words “I’m able”, i.e., in the ability to accept care and fostering of independence.

In the contemporary world, there is a strife for making older people be not passive receivers of social services, but rather active and independent solvers of their own problems. It is an important social competence in daily life; to enhance it, one must understand subjective well-being of older people, foster their independence. Residential social care institutions pay substantial attention to older people’s possibility to independently decide about daily activities, which is related to a person’s dignity, human rights, social relationships, practice of care provided by specialists as well as the environment of a care institution.

Even though it is impossible to avoid some obstacles in one’s pursuit to maintain independence, we can allocate some time to understand the importance of independence of an older person, one’s dignity, and to search for potential to increase and extend possibilities for independent living in a residential social care institution. Referring to the research data obtained by Groenvynck et al. (2022), a care home as a care institution is associated with “an imprisonment site” and “a place where people die”. A more recent investigation by Groenvynck et al. (2023) reveals that older people’s attitude focuses on retention of a personality in terms of being independent and maintaining relationships with other people. Therefore, the interview participants in this investigation expressed their wish to live at home as long as possible, and confessed that they were even afraid of a thought about settling in a care institution. Hoof et al. (2016) give a different definition of institutionalised care home based on their research, by emphasising that this is a residential environment and place where people are provided with dignified multiple support and care. Wada et al. (2020) identified four main features that create a sense of cosiness in residential social care institutions: these are characteristics of physical environment, privacy and individualisation, independence, choice and flexibility, relationship and commonness. Hoof et al. (2016) suggest that the creation of the homely feeling, environment where people can stay in dignity and feel safe without losing a sense of privacy, autonomy, control, self-esteem and independence is highly important to service receivers. The researchers have it that dignity at an older age may also be assessed by people’s dear memories, emotions evoked by personal belongings, ability to use technologies, and even the very outlook of a person, etc.

Orlova and Gruževskis (2014) note that the attention of residential care institutions is focused on a person’s dignity, and that it is ensured by providing palliative nursing in the final phase of life, when a person has already lost his/her independence. Nevertheless, Dong et al. (2021) express a contradicting idea underlining that older people’s dignity is negatively affected when staying in residential institutions, and this is impacted by one’s physical health condition, as well as loss of independence and control. Clancy et al. (2021) declare that the absence of recognition and the presence of social invisibility cause a real threat to an older person’s dignity.

Orlova (2014) compares her research results to the conclusions obtained by a group of scholars (Falk et al., 2012) and states that a person’s privacy in Lithuanian care institutions is not a prioritised indicator because people are still being accommodated in shared rooms. Whereas, peer scholars emphasise the importance of ‘attachment’ to the institution, i.e., a possibility to spend their free time in a personal space, to carry out minor domestic tasks, etc. Another important area where a person can feel dignified is his/her financial situation. Those who think that they are able to independently control this feel happier and more valuable. Žalimienė and Dunajevas (2015) put it that care providers have doubts about the service receivers’ capability to independently choose the necessity of services. They are considered as those unable and too weak to make decisions themselves. Therefore, a paternalistic attitude prevails in institutions; service receivers are stigmatised, i.e., they “are labelled as socially weak, nursed, cared of, socially supported, belonging to social risk groups, dependants etc.” (Žalimienė & Dunajevas, 2015, p. 281). Thus, the staff consider the issues of person’s independent choice, autonomy and dignity as insignificant.

To sum up, independence when ageing is not only an ability to perform activities without others’ assistance, but, first of all, it is the right to choose, to retain dignity, to be respected and enabled to live according to one’s needs. This requires not only a good health condition or physical strength, but also a supporting environment, adjusted services, and understanding society. This is joint, long-term and mutual trust-based process that allows living a full-fledged life phase. Older people can feel dignified when they feel safe in the environment around them, when they socialise with other people and materialise themselves; this is the time when they fell being more valuable and valued. To retain dignity, it is important to maintain a sense of independence in financial, social and psychological areas as long as possible. It should be noted that the aspect of dignity is also important in the last phase of life, when independence has been lost.

Research Methodology

Theoretical and methodological provisions. A methodological fundamental of the research aiming to reveal possibilities for fostering older people’s independence in residential social care institutions comprises the humanistic provision. Goroff (1981) declares that social institutions are not humanistic because vertical hierarchical relations are subordinate, and a person’s needs, wishes, as well as desires are not motivating. Therefore, social workers aiming to be humane find themselves in dilemma-based situations. Structured relationships reflect power; thus, it can be assumed that paternalism prevails in social institutions. An older person living in a care home should not be dehumanised, but rather, they must be respected and valued for who he/she is. Representatives of the humanist field focus on strivings of people to be independent and materialise their opportunities. This methodological theory is inseparable from such concepts as empathy, favour, and sincerity. All this is called respect for a human, which is closely related to a person’s dignity and self-esteem and leads to the concept of independence.

Another methodological theory which is important to the investigation is social constructivism whose one of the principles declares a person’s active participation in knowledge building through one’s own experience (Burr, 1995; Berger & Luckmann, 1999). An individual subjectively perceives this as an activity and not as an objective reality. Aiming at independence, older people must be provided with a built environment where they can be able to construct processes for maintaining their independence and feel dignified and mature. In social work, it is important to construct an entire process so that a person would perceive that he/she is able to help himself/herself in daily living. There is a belief that it is achieved when one’s independence will grow in the dimensions of dignity as well as autonomy and participation. In the research, the concept of older people’s independence is analysed through independence from other people, and it is being constructed through a person’s activeness, relation to others, as well as physical or mental ability. Studies show that the independence of an older person is a dynamic process which cannot be assessed only by grounding on a person’s abilities or self-assessment (Rabiee, 2013; Molenaar et al., 2020). Independence is significantly impacted by environment and the people around oneself: this is both the physical and social environment, interaction of the staff, family members and other residents of the care home, which enables making decisions, meeting the needs and maintaining dignity (Jack et al., 2019; Plath, 2008). A socially engaging model of fostering independence is based on both individual and group, community interventions, where active participation of the staff and family members is highly important (Lukamskienė & Budėjienė, 2013; GAMLEC Consortium, n.d.).

The qualitative research was chosen to analyse the object under investigation in a holistic way (through the dimensions of independence, participation, person’s dignity), by grounding on the theories of constructivism and humanism. The latter suppose that the research participants construct their knowledge about an older person’s independence through the principles of humanism, and the researcher constructs and interprets the obtained insights on the concept of independence.

Research methods, instrument and procedures. Aiming to reveal the concept of possibilities for fostering older people’s independence in the dimension of dignity, the qualitative research method of a focus group was chosen. It included semi-structured questions and additional questions to be asked in the process. This method is explained as “an interaction of participants that proceeds when discussing a research question” (Morgan, 1997, as cited in Rupšienė, 2007, p. 87). Seeking to perceive the concept of possibilities for the fostering of independence in a holistic way, the group triangulation was applied as a possibility to collect comprehensive data, observe more different insights and to better understand the phenomenon under investigation (Caillaud & Flick, 2017). The time and place of the research were coordinated with each participant of the research group and agreed separately with all groups. The research instrument included semi-structured questions grounded on the partial operationalisation of the research object. Based on the person-focused strategy, the structure of the operationalisation pointed out three dimensions of fostering independence: autonomy, participation, person’s dignity (Stiehr, 2020; GAMLEC Consortium, n.d.). The present article focuses on possibilities for fostering independence in the context of the dignity dimension.

During the data collection process, the simulation game “Gamlec” (GAMLEC Consortium, n.d.) was used as a stimulating tool to evoke reflection. In the research, the game was used as a tool of facilitation. In the course of the focus group discussion, when playing the simulation game, cards with described situations (depicting the life in a care home) prepared in advance according to three dimensions fostering independence (autonomy, participation, a person’s dignity) were presented, and questions prepared in advance were asked. The duration of discussions in the focus groups was from 2 hrs to 2 hrs and 38 mins. The content of focus group discussions was transcribed, translating it from oral into written language.

The data analysis employed qualitative content analysis which allowed systematic investigation of the textual data and identification of their meanings, thematic relations in the context of the research. “One of main advantages of the qualitative content analysis is that the data analysis procedures allow a researcher contract a large amount of information (i), merge research data into sub-categories and categories according to their content and meaning (ii), formulate conclusions based on empirical data (iii) (Cavanagh, 1997; Cohen et al., 2007)” (Žydžiūnaitė & Sabaliauskas, 2017). The analysis of the textual data was carried out on the basis of the sequence suggested by Elo and Kyngäs (2008): the selection of a notional unit, multiple reading of a text, open coding, data grouping based on the content, categorisation and abstraction. A decision was made to analyse the latent aspects of the data, aiming to reveal not only direct (manifesting), but also deeper meanings of the participants’ experiences. When coding, topics rather than linguistic units (usually in quantitative content analysis) were considered as notional units (Zhang & Wildemuth, 2009). The analysis was based on the inductive logic, where concepts emerge from the very data and help answer the research questions.

Research sample. The sampling of the research participants was purposeful. Therefore, aiming to answer the research question (how social workers, nurses providing support to residents of care homes as well as relatives of these residents conceptualise possibilities for independence of older people manifesting in the dimension of person’s dignity) and reveal the research object (possibilities to foster independence of older people at an institution of stationary social care in the context of the dimension of dignity), three groups were formed: one group comprising social workers, one group of nurses, and one group of relatives of the residents. Each group included six informants (thus, N=18 in total). The research participants are united by the same goal as they all have connections to older people residing in the care institution, i.e., social workers and nurses work in the care institution where participants of the group of residents’ relatives who took part in the research are living.

Research ethics. Complying with the principles of ethics, when asking for a permission to carry out the research, the consent was signed by the head of the social care home who did not object to, and allowed carrying out the research. The research participants voluntarily agreed to take part in the research; the research aim, methods, and rules of the simulation game were introduced to them. After receiving explicit oral consent of the research participants, the audio technology (a voice recorder) was used. The audio materials were deleted after describing the content of the discussion with the focus groups. Anonymity and confidentiality were ensured. The data of the research participants were depersonalised by coding. When presenting the research results, the names of the participants are not mentioned, and only codes are used (e.g., SD3 – social worker number three, S5 – nurse number five, GA2 – resident’s relative number two). Three pieces of minutes were drawn up. They included information of the categories of participants of the target focus groups, dates of meetings, their time (duration), and place; also, schemes of the participants’ seating arrangement were depicted.

Analysis of the Research Results

The qualitative research is based on the concepts of independence, by emphasising the dimension of a person. When implementing the semi-structured interview of the qualitative research in the field of dignity, five main open-ended questions were asked, and qualitative content analysis was carried out.

Five categories in the content of the interview were pointed out in relation to the dimension of a person’s dignity: retention of dignity in relationships with others, possibilities for ensuring privacy of the residents, possibilities for creating a private space in the care home, assessment of independence as a changing process, challenges in maintaining a person’s dignity. The tables demonstrating categorisation display examples of statements substantiating the (sub-)categories. The tables that visualise the research results present authentic statements of the research participants; their language was not edited.

Table 1.
Retention of older people’s dignity in relation to others

Category	Sub-category	Examples of evidence statements	Number of statements
			SD	S	GA
Retention of dignity in relation to others	Value-based aspect of respect for residents	We <...> knew from earlier times that we must accept our client, resident the way one is (SD5); We must respect one. <...> if <...> it occurred <...> to have a quarrel and something, maybe a bad moon, a bad sun, maybe something was wrong from one’s side or perhaps you have a headache <...> you must go and communicate, talk to one as if nothing has happened <...> not remind <...> about doing something wrong last time and now I will revenge on you. Such things can’t happen <...> it also depends on a staff member’s values and character <...> (SD5).	4	2	0
	Need for respectful daily communication	<...> a raised voice against a resident is the lowest level of a staff member ever (SD2); <...> sometimes, a raised voice doesn’t mean that it’s bad, for instance, if a person has hearing impaired, this might look unacceptable (SD5); It’s not a complaint but a cleaner shouted at me when I came in; perhaps it shouldn’t be like this? Doesn’t she know what the disease is diagnosed to her?	5	0	1
Retention of dignity in relation to others		If <...> she were smart, thoughtful, she wouldn’t be here... <...> to put it nicely (GA5). <...> it was thrown at the resident in an ill manner. Totally useless <...> whoever he might be <...> quite loudly though, so that other residents <...> could hear (SD2).
	Features of bullying residents in care institutions	Sometimes it happens when some person <...> approaches crying <...> because someone said something unpleasant. A disturbed person is in tears (SD4); <...> called bad words because of the disability (SD4); Earlier, there were more ill names used <...> ‘a crooked one’, and the like. Now, a little bit less, I think <...> (SD5); But how much this tall one really suffers. Yes, the entire care home suffers. She is the walking negative (S1). To those newcomers, perhaps <...>. Now, I don’t see anything to be present (GA3); It is more complicated in this situation. <...> people also forget quite often because of their age, because of various diseases. <...> you would sit them round and tell them that it is not allowed to bully; there won’t be <...> any result (GA2); Here the population is different. Both age and diseases (GA4).	6	7	9
	Manifestation of residents who bully staff	The residents <...> consume alcohol, isn’t it bullying of staff <...> (S6); <...> girls take me outside and don’t give me sunshine to enjoy. <...> like to take it away <...>? They don’t locate me in the sunny spot, but rather in a shadow, I smoke there and then they bring me back in. They spare the sun for me. And accept as everything was done to him on purpose (S2); Nevertheless, there is an understanding, despite being ill with dementia. <...> does wrong. She knows that she does wrong, that she is also able to hide <...> somewhere where nobody would find her (S6).	2	5	0
	Risks of non-formal communication in the context of providing care	<...> a person brought me a stick <...> I decided to joke <...> I took that stick and said I would shoot you now <...>. And the person, it seemed, understood that joke, but next morning the director of the institution called me up for a meeting (S6); <...> I was measuring the blood pressure but she was talking. I said don’t babble. I said	0	4	0
Retention of dignity in relation to others		and she became insulted. So, our vocabulary <...> I can use words like ‘to babble’ in my close circle of people but, when talking to the residents..., we cannot say that (S1); <...> she says to me, ‘aaaa, it’s you who came’ <...> came up, pulled my ear. You understand, how it is, she pulled my ear <...>. Perhaps she made a joke <...> ‘I will wake you up’ (S1).
	Aspects of disagreement of different opinions	Also, with the staff members. There is disagreement very often. And when one gets stuck, when no solution is found <...>, focus on opinions of nurses and usually <...> completely disagree with those of a social worker <...> (S6); Quality differs very much. <...> whom I liked, I know that if that person is working today, I will be having like a day off. Later I figured out when the shifts were changing (GA6); <...> it happens that nurses only when it is their time to be on duty in the evening <...> find out that a resident was transferred <...> (S6); <...> understanding each other (S1); <...> a problem would occur <...> I don’t want to say anything wrong but the staff members differ very much (GA6); <...> people are really different, you simply need to learn to trust them all, they will still do it, they still do it (GA2).	0	4	4
	Independent ability to take care of oneself	<...> they do exercises, sit around <...> always leading. She wants to be that leader. It’s her personality <...>(S1); There is a tendency in our care home: the worse you behave, the better conditions you get <...> (S6); Because you are hated, that is dignity (S1); <...> I live here for a long time, since olden times and I will go nowhere. Those who are capable can demand (S1).	0	6	0
	Persisting public disapproval of the care about relatives in a care institution	<...> because of society, I suppose, something <...> still is wrong with us. <...> earlier, society was <...> somewhat more tolerant, there were more friends who visited, somehow communicated. <...> such alienation and no one cares, neither about you nor about others (GA4); I was beaten with a switch. <...> by those aunties there. Total alienation of relatives (GA2); To change his <...> point of view (SD3); <...> very rarely <...>	2	0	18
		someone arrives <...> oh, I will visit. Still, a public worker. And a television cameraman <...> a folk crafts artist <...> no longer visits (GA4); <...> I have accepted and now no longer pay attention and no longer hear anything. For five years now <...> (GA2); People of that generation still view these homes like something evil <...> (GA3); The generation will change, will change <...> automatically (GA3); If you took there, it means one is no longer needed to you. From olden times it is called beggars’ home (GA6); <...> who asks <...> what, still didn’t bring back home, how is it so? <...> think what a trauma (GA4).
	A sense of guilt and helplessness felt by relatives	<...> if the mother stood at the table, I would have... I have conditions, I am a pensioner, I could look after. But I was unable physically. <...> not only physically, but also morally, psychologically. <...> everybody said I needed a psychologist (GA6); My son said, ‘mum, it’s better if our grandmother and grandfather would be placed in the care home rather than you found yourself in a mental home.’ <...> after hearing those words, I started thinking what to do. To search for help because I was no longer living (GA2); I cannot work, I have no work experience. I was absolutely in such despair. <...> it calmed me down. I have no idea what I looked like that day. I was there like cast away from a ship (GA6); We brought her here, it was also very hard to leave her here. I was in tears <...> she didn’t want GA1); <...> everything was explained, told, shown and all. That day was very painful. When you leave your own person and still get some kind words (GA5).	0	0	13

To conceptualise the research data, retention of dignity in relation to others is observed (see Table 1). The qualitative research data reveals aspects of attitudes of the staff and relatives of the residents. Statements expressed by social workers and nurses reveal respectful behaviour of the staff towards residents, and this results from the staff’s value attitudes, including their culture of communication and individual personality traits. Social workers represent a clear insight concerning an obligation for the staff who have to build the culture that does not accept intolerance, bullying and other negative aspects at the institution; they must also avoid excuses for misbehaviour of other staff members. Moreover, a conflict of assessment of communication with the staff is observed, e.g., an ambivalent attitude of social workers towards the service providers’ raised voice at the residents has been revealed; they say that it may be treated as a low level of the staff member’s communication or as assistance to a person with hearing impairment. Whereas relatives of residents emphasise the facts of impolite behaviour of the staff that hurt them, even though it is a very rare occurrence; the highlighted cases of dissatisfaction shape the institution’s negative image in terms of the aspect of dignity. The analysis of statements by social workers, nurses and relatives of residents reveals that residents of care institutions experience bullying caused by disability; there is also bullying of the staff (negative statements and actions of dependent residents). The causal relationship of the bullying occurs due to age, disability, education differences, and/or personality traits of the residents of care institutions. However, there is no manifestation of discrimination based on attribution to a specific national group. The experiences of nurses show that the boundaries of humour in professional relationship are sensitive, as some statements said or actions performed in a joking manner may be perceived by a resident literally, in a direct sense, and this reveals vulnerability of the relationship while also posing a risk of triggering a conflict in terms of interpretation of dignity. Aspects of disagreement based on different opinions were observed when there was disagreement of opinions of the staff in teams as well as between relatives of the residents and the staff, and this disagreement led to reducing the independence of the residents. Večkienė et al. (2013) analysed the research data and presented results displaying different value-based attitudes of health care specialists and social workers towards the services provided. Complicated communication manifested by them affects the dissemination of information on the support necessary to older people. Miscommunication in teams occurs when providing services; it is reflected in the work quality which is necessary in order to ensure dignity in the years of sunset.

Nurses declare that a person can feel being dignified when taking part in activities, being able to defend one’s opinion, but not losing good manners in behaviour. Social workers believe and notice that the attitude towards the care institution and the residents has been changing; however, relatives of the residents express the still-persisting hurting public assessment, saddening experiences and say that there is no transformation in societal attitude towards care institutions. Relatives, friends, acquaintances and others are still spreading negative thoughts about and disdain towards those who leave their relatives in professional care institutions. Relatives of residents find consolation and support in those people who have earlier experienced the path of nursing their relatives. A negative connotation of care institutions still exists, and these institutions are still carrying the name “a poor house of beggars”. Relatives of residents have heavy feelings, and the analysis of the results reflects moments of excuse and guilt; however, they are calmed down by support of the staff of care institutions, by the comprehensive information they provide.

Table 2.
Possibility for ensuring privacy of individuals staying at residential care institutions

Category	Sub-category	Examples of evidence statements	Number of statements
			SD	S	GA
Possibilities for ensuring privacy of residents	Ensuring confidentiality and physical privacy in care institutions	<...> from administration <...> for that person, one’s well-being, independence. <...> that staff <...> would change for better <...> (SD3); <...> I notice that not always staff put partitions when draining (SD1); <...> the residents don’t give much significance to this thing, they simply got used to it <...> come to drain and <...> they drain (SD1); <...> I always enter after knocking on the door, I don’t know what I will see when I enter (S3); <...> if I care as a social worker and I suspect something <...> I must bring this letter myself and, if he agrees, to ask <...> to read (SD5); <...> if it is addressed to the resident, nobody has the right <...> (SD5); <...> I leave, but sometimes the door is left open <...>. Perhaps because of this rapidness <...> (S1); <...> staff members come in, rarely someone doesn’t knock on the door (GA2); <...> today <...> while I was downstairs, there were three people who came in. All were different, all knocked (SD3).	19	7	11
	Efforts to maintain a person’s privacy in the practice of hygiene	<...> assistants are called mothers <...> they are really not ashamed (SD1); <...> he almost with his eyes full of tears asked to be washed by another staff member because he couldn’t do otherwise (SD1); <...> the majority of our residents are being washed, so how they can lock their doors (SD5); <...> you respect <...> the wishes <...>, but if a person exceeds everything and can be unwashed for months and you allow him/her be like this <...> such is the attitude. <...> she doesn’t see herself, doesn’t recognise that this is a disease (SD3); <...> she tries to prove others that she is super clever <...> that her memory is good. <...> and still it comes up to compulsory washing, simply a forced intrusion. Against a person’s will (SD3).	7	0	0

The results on the investigated dimension of a person’s dignity highlight the aspect of privacy (see Table 2). The privacy of the residents of the care homes is ensured through a physical space (doors, partitions, knocking on the door before entering) and confidentiality of information (letters, personal documents). Awareness and responsibility of the staff allow maintaining a resident’s dignity and independence in the daily practice. Even though Orlova and Gruževskis (2014) write that privacy in care institutions is ‘hushed up’ and it is not worth considering, this particular research presents social workers’ insight about the administrative staff of care institutions paying special attention to the issues of privacy and seeking to ensure the privacy of the residents. This shows that aspects of ensuring privacy are not concealed or not thought about. The staff seriously consider aspects of the residents’ privacy, confidentiality, as well as provision of information; therefore, the residents feel free and trust the staff. The participants of the groups representing social workers, nurses, relatives of the residents declare that staff members always knock on the door before entering rooms of the residents. Nevertheless, social workers and nurses criticise improper actions of the staff when providing hygienic services and state that there is no strict control of partitions being used when providing services to the residents being nursed. Relatives of the residents are content with the procedures of administering services; however, they notice that there is a lack of promises for private communication with relatives inside institutions. Independence of the residents in the daily hygiene care faces a dilemma of inevitable intrusion. Aiming to ensure safety and health of the residents, the staff sometimes need to intrude against the resident’s will, and this requires constant searching for the right balance between dignity, independence, and necessary care.

Table 3.
Possibilities for creating private spaces in residential care institutions

Category	Sub-category	Examples of evidence statements	Number of statements
			SD	S	GA
Possibilities for creating private spaces in care institutions	Dilemma-based arrangement of residents’ personal belongings	<...> here’s their home. They should have a possibility to create that space. <...>. If two, three people live in one room, they all cannot bring their pianos (SD1); <...> a resident’s daughter brought a blanket decorated with family photos <...> it hangs as a carpet on the wall <...> what a feeling when embracing oneself with the family. <...> she was very happy (SD4); Where are heading to <...> so that it would be appropriate to us or <...> to him. <...> perhaps it will be to him <...> useful <...> a dear item (SD3); <...> to look inside a human <...> we are between two fires. We are between a human who <...> wants to feel like being at home and a governing power <...>. To make one obey some requirements <...> (SD5); One is always angry that belongings are arranged in a wrong order <...> that they were here and are no longer present (GA4).	11	0	7
	Unassured need for residents’ intimacy	We don’t provide conditions <...> behind a closed door, hiding <...> who needed [it], they did what they wanted <...> and as if nobody noticed it, nobody knows it (SD5); To spend some time just two of them is one thing, to intimately spend some time just two of them <...> (SD5); <...> you should respect <...> their wish but, unfortunately, if they live in separate rooms <...> (SD5); There is no room in the care home. Couples form, we condemn them, almost like bullying, but we do nothing ourselves to improve this (S6).	6	2	0
	Caring attitude towards assessment of residents’ intimacy	Where on my storey they live together <...> a couple, this really exists, and both staff members and other residents respect their privacy (SD6); Beautiful friendship, but some space, some corner <...> to find <...> some tiny space. For two <...> (SD6); The age has no significance. Absolutely none (S6); <...> physiology is just the same. They are the same, hormone activity increasing like in us (S1); It is their business and nobody has the right to interfere and enquire <...> what are you doing <...> (S6); <...> somehow does not demand. He hasn’t even mentioned he would like to stay together. Dating meetings are enough, it is even more interesting to him <...>. On Saturday, Sunday, they try to not meet each other somehow <...> dating starts from Monday (GA2); <...> he hasn’t mentioned he would like or would there be a possibility, he even hasn’t asked. He only wants to allow his meeting <...>. To live together, no, he hasn’t mentioned about it (GA2).	5	6	5
	Good emotional impact of love on residents’ health	<...> those people revive immediately (SD4); <...> now there is an example, all those flying ladies are in my section. Who flies high in the sky, with their hands joined (SD5); <...> let’s take that <...> couple <...> they both are shining. They don’t need any urging to participate in physical exercising <...> (S2); The need for friendship <...>. The need for socialising (GA4); They come twosome. <...> would be	2	2	5
		lying in bed. But yesterday she walked three times together, the mood was elevated (S2); Socialising. <...> doesn’t matter what or had no arm but be thoughtful, he would walk back. They would lean onto each other (GA3).

The conceptualised data reveals that the residents of care institutions are allowed to create their personal spaces – to make their living rooms cosy, to bring belongings that are dear to them or necessary pieces of furniture (see Table 3). These statements reveal that not only physical accommodation but also a possibility to create a space that meets one’s personally meaningful sense of home are important. A possibility to bring dear items, symbols of one’s family or furniture meeting individual needs become an important expression of person’s uniqueness and emotional safety. Nevertheless, this practice takes place between two points of tension: the wish of the staff to create the homey environment versus the institutional requirements regulating the common order in the context of the limitedness of space. Thus, the building of a personal space at a care institution becomes a question of not only comfort but also of maintaining dignity and identity. Social workers and nurses point out that the need for intimacy is not respected in care institutions because couples have no separate room to spend some time of intimacy alone. Social workers, nurses, relatives of residents believe that there is no age limit, and that romantic feelings, intimacy are needed so that a human, having satisfied all physiological needs, would feel dignified. The research participants declare that the effect of love especially revives people’s emotions, they feel happy, and this means the fostering of independence which requires no specific methods to be applied. Relatives of the residents would not object if their relatives found a close friend in the care institution because people by nature want some intimacy and this need does not decrease at an older age. Romantic relationships give a sense of pleasure and improve health.

Table 4.
Assessment of residents’ independence as a changing process in residential care institutions

Cate­gory	Sub-category	Examples of evidence statements	Number of statements
			SD	S	GA
Assessment of independence as a changing process	Decreasing independence when settling in residential care institutions	<...> if arrived at an older age <...> skills perhaps remain, but independence is decreasing (SD6); <...> she used to be very <...> diligent, neat. <...> there’s no <...> such understanding. It’s a pity that she is no longer a woman she used to be. <...> today, everything is so passive, it seems she no longer needs anything (GA5); Much earlier, he was able to walk <...> cross by ferry, could walk to the sea <...> (GA4).	2	0	5
	Independence measures that enhance residents	<...> high motivation, engagement with various activities, choice from a variety of activities, organisation of events (SD1); That staff would pay more attention (S1); Motivation, motivation of staff (S6); not to spoil too much (GA6); But also to not go too far (GA4); <...> first, that everything would be adjusted, <...> and it is so. For example, all these small tables adjusted for eating, so that they could eat independently (SD4); <...> attention to a person by explaining one’s needs (SD5); <...> in fact, the care home is too large. <...> too many residents of various social groups live with us (S6); <...> I tell, you walk round the entire building at least once (GA4); <...> would not walk using a stick, would not go in for sports <...> would not exercise even at home. <...> started going in for sports only here (GA3).
			6	9	5
	Hyper-care as a cause of decreasing independence	Hyper-care (SD3); Everything is included (SD4); I will clean here. I will dress up <...> (SD1); <...> he knows that everything will be done <...> a cleaning woman will come and clean the small room, you won’t need to. An assistant will come, make the bed, clean the cupboard <...> (SD3); <...> they have already used to receiving everything here and for granted. They don’t want anything <...> from their means (S6); <...> our residents are spoilt very much <...>(S6); They become dull if everything is done instead of them, forget. And we call this pampering (S1).	4	3	1
Assessment of independence as a changing process	Reactions of residents towards provided services	They wonder, but later adjust <...> (SD1); <...> it’s very comfortable to him and he’s happy, he’s supplied with everything <...> feels safe <...> warm, with a full stomach (SD3); <...> will never allow a staff member touch him. <...> he makes his bed himself, dresses up himself, everything himself <...> (SD1); <...> it’s simply comfortable. You are spoilt <...> there is no <...> motivation, that stimulus, and it becomes a norm (SD1); <...> a resident once said that this is a five-star all-inclusive hotel (SD6); It seems that no one will master as much as I do. It would hurt my heart <...> when the time goes by and I see that for sure <...> they manage and even better. <...> now I live calmly. I know that I’m not at home, but I cannot change anything <...> (GA2).	9	0	1
	Differences in manifestation of activity in the contexts of home and care institution	Lived in cottages <...> not able to walk <...>. Here everything is brought, taken, cleaned, undressed, dressed up. This automatically is a team of staff working around <...> (SD1); Independence is decreasing. <...> he communicated with doctors himself, consumed medications independently, everything has been taken away now (GA5); I don’t know, she wouldn’t walk using sticks at home (GA4); <...> she wanted to wash the dishes, but still it was necessary to wash again after her <...>, but when you see that she enjoys it, you allow her doing it. You tell her <...> that she did everything well, washed super. <...> later <...> you repeatedly wash again (GA1); He has <...> some poems in his memory, reads by heart very well. <...> but you need to encourage him strongly. <...> at home, I would allow him (GA4); When he lived on the fourth floor, he was afraid that the lift might get stuck <...> he would not go outside <...> he has gotten stuck <...>. Now he doesn’t <...> he goes into the corridor and walks to the front door <...> when it’s warm, he goes outside in the balcony (GA2); <...> it occurs, some kind of phases. If I were at home, it would be different. I say, ‘father, it woulnd’t be different. Wouldn’t be, for sure. Here you have some place to go out and talk to someone.’ It disappears and it’s good again (GA2).	3	0	15

When conceptualising the research data, insights on how independence changes at an older age settling in care homes were pointed out (see Table 4). Relatives of the residents say that, at home, the residents were more independent, but the weakening was caused by the passing years, and this is also supported by social workers. Social workers evaluating enhancement of independence say that this is influenced by adjustment of the surrounding environment, use of assistive technologies, engagement in activities, participation in events and comprehensive identification of needs. Relatives of the residents declare that they also try to influence the process of fostering independence by motivating the seniors to act. They notice that residents in care institutions start doing what they did not previously do at home. They believe that the staff of care institutions should not spoil residents, but also that they should not be very strict to them. When assessing tools serving to enhance independence, nurses declare that, in order to ensure dignified senility, it is necessary to reduce the numbers of residential places in care institutions, to create a motivating environment and a system for the assessment of the staff’s performance. Social workers and nurses believe that hyper-care of the residents and performing activities instead of them is the main cause of decreasing independence, leading to demotivation, increasing dependence on the staff, which is encouraged by relatives of the residents, even if not explicitly identifying it. Usually, relatives of the residents stimulate this by posing redundant requirements. The research participants highlighted that it is easy for residents to become accustomed to comfortable service, and they are satisfied with it. However, grounding on occurring reactions to services, there was an insight pointed out about the residents who also want to pamper the staff members and at night, when they do feel unwell, they do their best not to disturb. Whereas, relatives of the residents put it that they feel assured and calm, and they now can do their jobs knowing that professionals will take care of their relatives. When conceptualising the research data, it was observed that, when answering questions, relatives of the residents continuously compare independence of the residents when they were at home and after they settled in care institutions: they washed dishes, read poems, managed their money, attended theatre, cooked food, and assisted family members. Relatives emphasise that they adjusted the surrounding environment to make it easier to go to a toilet. However, they also provide contradicting statements: while at home, a person was not walking while using Nordic walking poles, did not physically exercise, and yet, now they do it. Aspects in the assessment of independence through a prism of dignity reveal a double sense of dignity: first, by reducing the limits of independence and increasing dependence on the staff, a resident in some cases feels decreasing dignity that occurs in a situation of asking for something or performing a role of a disabled person; second, by refusing some housework (e.g., dishwashing, tidying up, cooking food, etc.), residents feel higher satisfaction with being able to do what is acceptable to them, and they do not need to perform the necessary activities, including dignified living when full care is provided.

Table 5.
Challenges in maintaining a person’s dignity in a residential care institution

Category	Sub-category	Examples of evidence statements	Number of statements
			SD	S	GA
Challenges in maintaining a person’s dignity	Lack of measures in ensuring privacy in palliative care	A single on the storey <...> is placed, where female residents don’t wish to see each other (SD4); <...> an effect would be and they would use, they would appear (SD4); There are <...> partitions <...>. It is privacy (S1); <...> while last hours are ticking, let’s say, a person who is still conscious is placed next to that other one.	4	1	5
Challenges in maintaining a person’s dignity		I can’t imagine myself sitting next to a dying person (GA6); Perhaps it could be <...> a separate <...> premise or a room (GA3); <...> environment. Maybe some completely separate one. Not where one lived <...> (GA5).
	Maintenance of resident’s dignity through recognition of one’s will and psychological preparation	<...> sometimes they say she is always grizzling. He has <...> accepted it <...>. <...> I go to the nurses <...> go and see him, he has got enough of this. You measure the pressure and this means attention paid to him <...> (SD4); It’s very important <...> psychological preparation and preparation of that person. Of course, if one is still able, to avoid a situation out of the blue (GA3); Your wish is expressed. In fact, it should be like this. (S6); Will be watching continuously and someone will become sick because of it <...>. I don’t know, I don’t have experience (GA3); <...> we may decide how we would like it to be, but when it happens, completely unpredictable things can happen (GA2).	6	1	8
	Ambivalent attitude towards resident’s demands in the last phase of life	<...> have discussed with relatives <...> such things (SD4); <...> it depends on a person (SD5); <...> if something is wrong with me, in any case don’t call ambulance, don’t revive me, allow me simply pass away (SD5); <...> the female resident’s daughter has expressed a wish, just when it started, health problems occurred <...> to not call for an emergency team, to not take her to a hospital (SD3); <...> a factor of <...> humanity turns on. <...> if that person has expressed one’s will <...> about own choice <...> that one wants to calmly <...> with dignity pass away and die <...>. Why should we tear, pull? <...> to call for emergency and apply various medical measures, revive (S6); If one is not able to express <...> nevertheless, one must do something anyway <...> you will call anyway; <...> if a person said that I <…> would not go anywhere, for sure, and that one’s wish must be obeyed (S6); How to die in dignity, it’s not only this, it doesn’t depend on him and on us <...> (GA3); <...> I imagine maybe he should be moved out of here. Maybe this calm for him, maybe relatives could do this <...> say goodbye <...> (GA5).	5	6	12

The analysis of palliative care while ensuring a person’s dignity reveals that relatives of the residents declare that they have not thought about palliative care, nursing in the final phase of life, about dignified passing away from their relatives. Relatives of the residents have no idea of how the care would proceed, what actions would be taken, but they suppose that a special premise should be allocated for that, and a resident’s dignity should be regarded until the very end of their days. By their research, Holmberg and Godskesen (2022) found out that when aiming to protect the dignity of the residents, it is necessary to provide holistic care encompassing attention to personal, bodily, social, spiritual and psychological needs, and this would enable an increasing well-being of a service receiver while preventing suffering. Relatives suppose that the work of a psychologist is important in providing emotional support to the residents being palliatively nursed. Nurses declare that a wish expressed by a resident is important, we must respect it. Nevertheless, in critical situations, the human factor and a wish to help by continuing medical support services ‘turn on’. Social workers agree that the resident’s wish must be respected; however, they suppose that the staff in care institutions should pay more attention to those people during daily visits.

Discussion

The present research deals with the fostering of independence of older residents in care homes through the dimension of dignity. It aims at revealing how daily care practices, interventions of the staff, and application of institutional rules impact the independence of the residents. The obtained results show that independence of the residents in this environment is a complex phenomenon directly depending not only on the individual needs, but also on decisions made by the staff and relatives, or on organisational restrictions. It is important to note that residents themselves were not directly involved due to several reasons. In the ethical approach, a large fraction of the residents experience cognitive difficulties; therefore, a direct interview might cause additional stress or emotional discomfort to them. At the practical and methodological levels, a perspective of the staff and relatives has been chosen. Such an approach not only protected the daily routine of the residents, but also allowed collecting objective, detailed insights on a real practice of interventions and systematic assurance (or limitation) of the residents’ dignity.

Having assessed these limitations, the research in the future might purposefully employ the longitudinal design, which would allow observing a person’s independence through the changes in dignity over a longer period of time. Differently from the presently dominating transversal studies that record only a situation at a given moment, the longitudinal observation would help to better understand how daily practices of care and interventions of the staff impact the independence of the residents in a dynamic perspective. Such an approach would allow the identification of the most effective strategies of an institution’s policy which would not only maintain the functional capacity of a resident, but also help to sustainably maintain one’s dignity.

The results of the present research prove that the enhancement of an older person’s independence in residential care institutions is inseparable from the dimension of dignity. Theories of humanism and constructivism highlight importance of a person’s experiences, choices and the social context (Goroff, 1981; Berger & Luckmann, 1999). The humanistic theory allows investigating possibilities for older individuals’ independence from the point of view of social workers, nurses, relatives of the residents, while emphatically understanding a human, without diagnosing, underestimating, crossing the personality’s sensitive borderlines. According to Žydžiūnaitė and Sabaliauskas (2017), insights of qualitative research are substantiated by the research participants’ statements which demonstrate that people construct theories through their experiences. The methodology of the research was based on the theory of constructivism through the application of a simulation game dealing with the construction of a pardigm of older people’s independence through a person’s dignity. The said paradigm was developed by grounding on insights and considerations of social workers, nurses and relatives of the residents.

The research shows that maintaining independence, first of all, manifests through respectful communication, assurance of privacy, possibility to participate in daily decision-making, and dignified mutual relationships. These insights coincide with the research carried out by Rabiee (2013), Orlova and Gruževskis (2014) and Bimou et al. (2021), where an emphasis is made on independence and dignity as closely connected to freedom of choice and the right to be respected.

A stand-out result of the research lies in the identification of bullying being experienced by both the residents and the staff. This reveals that retention of dignity depends not only on physical support, but also on the social climate in that institution. This insight supports the conclusions drawn by Večkienė et al. (2013) stating that value attitudes and styles of communication in teams of staff members (health care specialists and social workers) influence the atmosphere of care institutions as well as the quality of services. Our research supplements these conclusions by showing that bullying reduces the sense of dignity. However, respectful communication and efforts of the staff to creative positive environment may act as a measure of fostering independence. In such a way, the research extends the idea of Bimou et al. (2021) having it that the main goal is to postpone dependence in geriatric practice because it has been demonstrated that the emotional climate is as important as physical support.

In the present research, the importance of privacy became very clear by revealing a two-fold situation. Differently from Orlova and Gruževskis (2014) who put it that Lithuanian care institutions usually do not display privacy, our results demonstrate that staff members understand the importance of privacy: they knock on the door, and they respect private belongings. Still, some drawbacks were observed: a lack of controlled usage of partitions and a lack of private spaces for communication with relatives. This allows declaring that the culture of privacy in care institutions starts forming, though it is still fragmentary and dependent on value-based attitudes of the staff.

In this research, hyper-care has been revealed as a significant obstacle to maintaining independence. Relatives of the residents pointed out that part of daily activities are performed instead of allowing older people to do the chores by themselves, and this reduces their motivation to perform their duties. This conclusion meets the research by Groenvynck et al. (2022; 2023) who demonstrated that institutional care is usually associated with a feeling of ‘imprisonment’ and loss of autonomy. On the other hand, it has been observed that residents of care institutions engage themselves in activities that they did not practice earlier (e.g., physical exercising, walks outside). Therefore, it can be stated that the process of independence is not only purposefully decreasing; it can be enhanced by properly adjusting the environment.

Important results of the research point out to the significance of intimacy and romantic relationships at an older age. The participants of the discussion underline that love and close relationships are not limited by age, and their fostering may become a natural source of emotional well-being and independence. This supports conclusions made by Wada et al. (2020) and Hoof et al. (2016) declaring that a sense of home and dignity in care institutions is created not only by physical environment, but also by the possibility of maintaining personal relationships. Our research newly emphasises the effect of love on emotional well-being, understanding it as a natural source of fostering independence, and not requiring any special methods.

The research data also revealed the aspect of palliative care. Relatives of the residents reveal their unawareness of how the passing away of their relatives should look like; whereas, staff members underline a lack of psychological preparation. This coincides with the insights offered by Holmberg and Godskesen (2022) emphasising that a lack of holistic care limits the retention of dignity in the sunset phase of life. The research shows that nurses and social workers understand the importance of dignified death; nevertheless, in practice, there is a lack of means and spaces to ensure privacy. This shows that care institutions need more means and practical guidelines on how to ensure the dignified death.

It can be assumed that this research allows emphasising theoretical assumptions on correlation between dignity and independence. It also presents new insights on the harm of hyper-care, significance of romantic relationships at an older age as well as social pressure experienced by both residents and their relatives (a sense of guilt, stigmatisation by society). These research results supplement earlier studies, open up practical possibilities for enhancement of care institution staff members’ competencies, and underline the necessity to include relatives and community in the process of maintaining dignity and fostering independence.

Conclusions

The research has revealed that the social workers, nurses and relatives perceive the independence of older people not only through a prism of physical capability, but rather, first of all, as an inseparable part of the dimension of dignity. This manifests through respectful communication, maintenance of personal privacy, and a real possibility of a resident to influence one’s own daily decisions.

It has been identified that a person’s dignity and motivation to remain independent directly depend on the emotional climate at an institution. It has been found out that occurring manifestations of bullying (both involving residents and against the staff) are conceptualised as a key obstacle; whereas positive, empathetic communication is perceived as one of main tools to strengthen autonomy.

A contradiction between the declared values and the real practice has been pointed out: even though the importance of independence is acknowledged, the frequently applied hyper-care (performing instead of allowing a person himself/herself to do things) diminishes the activeness of the residents. Nevertheless, insights of the research participants show that purposeful adjustment of the immediate environment and encouragement to participate in new activities may successfully restore part of the lost independence.

The research newly emphasises the significance of love, romantic relationships and intimacy in an older age. From the point of view of the staff and relatives, a possibility to maintain personal relations in a care institution is a key source of dignity and emotional well-being that helps create authentic homey environment in an institutional space.

It has been found out that although the staff perceive the importance of privacy and dignified death as a value, practical implementation of these attitudes remains fragmentary. This is conceptualised as an infrastructure problem (a lack of specialised spaces) and the staff’s insufficient psychological preparation which limits full-scale assurance of dignity in the last stage of life.

Author contributions

Kristina Rūdytė: conceptualisation, methodology, formal analysis, investigation, writing – original draft, writing – review and editing, visualisation.

Inga Mikalauskienė: conceptualisation, methodology, formal analysis, investigation, writing – original draft, writing – review and editing, visualisation.

Ginter Harner: conceptualisation, methodology, formal analysis, investigation, writing – original draft, writing – review and editing, visualisation.

All authors contributed and approved the final version of the manuscript.

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