Article Text

How do the older adults in nursing homes live with dignity? A protocol for a meta-synthesis of qualitative research
  1. Kejimu Sunzi1,
  2. Yadi Li2,
  3. Cheng Lei3,
  4. Xin Zhou4
  1. 1Nursing Department, People's Hospital of Deyang City, Deyang, Sichuan, People's Republic of China
  2. 2Traditional Chinese Medicine Department, People's Hospital of Deyang City, Deyang, Sichuan, People's Republic of China
  3. 3School of Public Health, Chongqing Medical University, Chongqing, Chongqing, People's Republic of China
  4. 4Psychosomatic Medicine Department, People's Hospital of Deyang City, Deyang, Sichuan, People's Republic of China
  1. Correspondence to Dr. Cheng Lei; lifecool_lc{at}


Introduction As the population continuous to age and family sizes decrease, residing in nursing homes has emerged as a crucial option for older adults’ care. Ensuring a dignified life for older adults in nursing homes is critical for enhancing their overall quality of life. The primary objective of this study is to synthesise the evidence of qualitative research on the feelings and experiences of dignity among older adults living in nursing homes. This will enable a better understanding of the factors influencing the perception of dignity and its preservation, ultimately assisting older adults in achieving a more comfortable and fulfilling experience in nursing homes.

Methods and analysis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses will guide this meta-synthesis. We conducted an initial search on 1 June 2022, for studies published between the inception of each database and 2022, using the population exposure-outcome nomenclature. We searched the Embase, Web of Science, CINAHL, Cochrane Library and PubMed databases for relevant studies. For data synthesis, we will employ the Ritchie and Spencer framework, and the Supporting the Use of Research Evidence Framework will be used for data analysis. To minimise the risk of bias, we will critically appraise the selected studies using the Qualitative Assessment and Review Instrument.

Ethics and dissemination This review does not involve human participants and, therefore, does not necessitate ethical approval. We plan to disseminate the protocol and findings through relevant channels, including publication in pertinent journals, presentations at conferences and symposia, and engagement with local and international health stakeholders.

PROSPERO registration number CRD42022343983.

Conclusion This study aims to offer comprehensive evidence to guide nursing staff in providing dignity-focused interventions for older adult residents in nursing homes.

  • Old age psychiatry
  • Protocols & guidelines
  • Aged
  • Health policy
  • Health Services for the Aged

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  • A key strength of this meta-synthesis is its novelty, as it is the first to review the understanding and influencing factors of dignity among older adults in nursing homes.

  • This study emphasises the importance of nursing staff providing dignified services to older individuals, which can enhance their enthusiasm for life.

  • One limitation of this study is its focus solely on published qualitative research studies, excluding other sources such as grey literature, unpublished reports and government documents.

  • The systematic review further limits its scope by excluding any qualitative studies published in languages other than English due to constrained financial resources for interpretation costs.

  • To mitigate these limitations, we will collaborate with an experienced librarian to ensure that the meta-synthesis encompasses as many relevant, high-quality studies as possible.


In 2019, the average global life expectancy reached 72.6 years, marking an increase of 8.4 years since 1990. Projections indicate that by 2050, the average life expectancy will rise to 77.1 years.1–4 The proportion of people aged 65 and above constituted 6.2% of the global population in 1990, increasing to 9.1% in 2019. It is anticipated that by 2025, the global population aged 60 and above will reach 1.2 billion.5 According to international standards, a country or region is deemed an ‘ageing society’ when 7%–14% of its population is aged 65 and above. When this figure surpasses 14%, the country or region is classified as a ‘super-ageing society’.6 7

Western societies have experienced more rapid ageing. Many developed countries or regions, such as Japan and Canada, entered the ageing society stage as early as the 1960s and 1970s,8 9 resulting in a significant number of older adults.10 In 2019, the number of Japanese individuals aged over 65 increased by 320 000–35.88 million, representing 28.4% of the total population. By 2025, this figure is expected to reach 30%, and by 2040, it may rise to 39.9%. As of 2013, people aged 57 or older accounted for 12.3% of the total population, with projections suggesting this figure will reach 26.9% by 2060.11 12 In Canada, older individuals are expected to comprise 23% of the population by 2030, with average life expectancy continuing to rise.13 14 The ageing phenomenon is also particularly pronounced in low-income and low/middle-income countries, where population ageing is outpacing the development of eldercare policies and services.15 16

As the number of older adults continues to grow, residing in nursing homes has emerged as a vital option for their care.17 It is crucial to prioritise the quality of life for older adults in these institutions. A high quality of life for older people encompasses not only physical health but also mental well-being and spiritual fulfilment. Maslow’s hierarchy of needs theory posits that esteem and self-actualisation represent higher-level needs for individuals.

The concept of human dignity is a fundamental ideal in the care of older persons. Maintain dignity is essential when caring for older adults, as experiencing dignity allows them to lead fulfilling lives despite various challenges.18 Hence, dignity is a core aspect of nursing practice, and preserving patients’ dignity is an integral component of nursing.19 Over time, dignity has been defined in numerous ways. Cicero believed dignity referred to the respect and recognition of personal value by others, groups and society within social relations, allowing individuals to gain a respectable identity or status in the hearts of others.20 Thomas Aquinas defined as a person’s individuality, with rational nature determines universality.21 The common understanding of dignity is that it is inherent to all human beings, a status we attribute to one another and a quality in which a person exhibits self-respect and/or authenticity.22 23

A dignified life in nursing homes is crucial for improving older adults’ quality of life. Recognising the dignity of older people is an expression of respect. A study based on data from the UK Older People Survey identified the main factors for quality of life as good social relationships, a positive psychological outlook, a happy family life, health and mobility, and personal independence.24 Research has demonstrated that dignity therapy can yield numerous benefits, such as reduced anxiety and depression, enhanced hope and improved overall quality of life among patients with chronic diseases.25 How can the older population experience dignified lives in nursing homes? Various scholars have conducted qualitative studies on the dignity of older adults in nursing homes, but the research themes and results differ due to inconsistencies in research areas and research groups.26–28 This study aims to consolidate relevant qualitative research to help older adults achieve a dignified life in institutional care and provide evidence for pertinent departments to develop policies.

Study aim

This meta-synthesis seeks to consolidate qualitative examining the influencing factors of self-esteem among older people in care institutions.


  1. To identify the perception of the dignity experience of the older people in the nursing home?

  2. To sort out how older people maintain their dignity within care institutions?

Methods and analysis

We will synthesise evidence from published qualitative studies focusing on the experience and perception of dignity among older adults in nursing homes. This protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA) statement guidelines.29–31 The meta-synthesis will be guided by an interpretive paradigm that aims to ensure researchers distance themselves from their views and ideas.32–35 We have chosen this paradigm because it encourages researchers to construct and interpret their understanding of collected data based on participants’ experiences or reported data, without imposing their views or experiences. We will include all relevant qualitative studies regardless of the methodology employed (eg, phenomenology, content analysis, anthropology). We will use Thomas and Hardens’ three-stage thematic synthesis approached to code emerging themes from the extracted data.36 The report of findings for this review will be published following the PRISMA guidelines.31

The research question of our systematic review and meta-synthesis is: What factors affect the dignity of older adults in nursing homes?

Eligibility criteria

Inclusion criteria

We will include the following:

  1. Studies published in the English language due to limited financial resources for translation.

  2. Qualitative studies or mixed-methods studies containing qualitative research components (phenomenology, grounded theory, action research, ethnography and other qualitative research).

  3. Studies published between database’s establishment and 31 December 2022.

  4. Study population: older adults residing in nursing homes without severe mental illness or cognitive impairment.

  5. Phenomena of interest: understanding, cognition, feeling, experience and perceptions of dignity.

Exclusion criteria

  1. All qualitative documents found in grey literature.

  2. Duplicate publications.

  3. Articles with incomplete data.

Search strategy: information sources

We searched the following databases: Embase, Web of Science, CINAHL, PubMed and Cochrane Library, limiting our search to studies published on or before 31 December 2022. The search process will first consist of an initial informal scoping phase to develop a search strategy, followed by a formal main phase to identify and collate eligible research. The scoping stage aims to familiarise the ourselves with the literature, refine search parameters, identify MeSH terms and keywords, and test the preliminary search strategy. The main stage will be informed by the scoping stage and search strategy guidelines from the Cochrane Collaboration.37 38 The database mentioned above were chosen because they are most likely to index studies about older adults' understanding of dignity. Studies have shown that Web of Science, PubMed and CINAHL searches retrieved the highest number of qualitative health studies, while other databases did not list the highest number of qualitative health studies.39 We plan to complete the literature search on 31 December 2022. We used the keywords: old age homes, nursing homes, long-term care, aged, old, older adults, older people, respect and dignity.

Screening of articles

Two independent reviewers (KS and CL) will screen the articles for this systematic review to increase trustworthiness and eliminate bias. The reviewers will use the inclusion and exclusion criteria to select relevant studies. The screening of studies will be done in three stages using EndNote V.X20 as a reference manager.30 In cases of disagreement between the reviewers, particularly during the final screening stage (for full-text studies), we will consult another reviewer (YL) to help resolve the dispute.

The first stage involves searching the relevant databases to screen for titles (online supplemental appendices 1, 2). We will save all appropriate titles in the reference manager. In the second stage, the reviewers will screen the abstracts of the selected titles using the Abstract Selection Form (online supplemental appendix 3). The reviewers will choose abstracts, meet to discuss their selections and resolve any disagreements. The final selected abstracts will proceed to the third stage, which involves full-text screening of the studies using a full-text screening form (online supplemental appendix 4). If not publicly available, the reviewers will obtain full articles from relevant sources, including authors. The final studies included after the third stage will constitute the set of studies for the meta-synthesis.

We do not anticipate bias due to missing information on the selected studies, as all the chosen studies would have met our inclusion criteria. However, if there is any missing information on the desired final full-text articles, we will contact the authors for clarification and provide a 1-month time frame for feedback. If the authors do not respond within a month, we will exclude those studies from this review to prevent bias. A memorandum will be used to note the reasons for excluding references from the final synthesis stage.

The conclusive included qualitative studies will each receive a unique ID number. We will use the PRISMA 202040 flow diagram to report the screening results.40

Risk of bias: assessing the quality of selected studies

Critical appraisal in meta-synthesis assesses the rigour of the selected qualitative studies and ensures they are free from methodological issues that may affect the meta-synthesis findings.41 42 We will use the 10-item Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research to guide the evaluation of the quality of the included articles.43 44 Two researchers (KS and CL) will independently evaluate each article (online supplemental appendix 5). If there is disagreement between the scoring results, a third independent reviewer (YL) will be consulted for arbitration.

Data extraction

We will use a data extraction form to collect information about the selected studies, including the author and year, aim, study setting; study population, exposure and outcome (online supplemental appendix 6). Two reviewers (KS and CL) will independently complete this step. For each study, a standardised data collection form will be used to capture the following information:

  1. General information on the study (author names, research location and year of publication).

  2. Participants: sample size, demographic characteristics, methods of participant recruitment and selection.

  3. Setting: type of healthcare, conditions and countries where the research was conducted.

  4. Method of data collection (such as interview or survey).

  5. Outcome themes.

Data synthesis

The data analysis will consist of three main stages using Thomas and Hardens’ three-stage thematic synthesis approach.45 46

  1. Line-by-line coding of relevant texts: The authors will familiarise themselves with the data. KS will inductively generate initial codes for ideas in the data, coding over several iterations until no new codes are needed to capture ideas. Single data fragments can be assigned multiple codes. For coding accuracy, a second author (CL) will check a randomly selected sample of 10% of coded data. A disagreement score will be calculated, and disagreements will be discussed and resolved, involving another author if necessary.

  2. Organisation of codes into descriptive themes. KS and CL will independently organise individual codes into broader themes. The two authors will then collaborate in developing one common descriptive theme, discussing it with the broader author group. Themes will be revised until their fit with data is optimised.

  3. Development of analytical themes: This stage will be interpretative and will seek to generate new ideas. KS and CL will independently re-examine the data organised into descriptive themes to infer dignity-related insights. This phase will rely on the authors’ subjectivities, and the authors will take a reflexive approach to minimise problems in interpretation and improve transparency in analysis. KS and CL will meet to compare their analytical themes.

Descriptive and analytical themes will be tabulated and paired with exemplary data fragments. A separate table will display how the data from each study is represented in the coding. NVivo (V.12) will be used to assist in processing and analysing text to generate codes and topics in a more standardised and convenient manner.

Assessment of confidence in findings

The Grading of Recommendations Assessment, Development and Evaluation-Confidence in Evidence from Reviews of Qualitative research (GRADE-CERQual) approach will be used to assess confidence in the analytical synthesis results. GRADE-CERQual is used to consider four factors about studies contributing to review findings: (1) Methodological limitations: This involves evaluating the quality and rigour of the studies included in the review. (2) Relevance: It considers the extent to which the studies are applicable to the review question and context. (3) Adequacy of supporting data: This takes into account the richness, quantity and depth of the data presented in the studies. (4) Coherence. It assesses the consistency and clarity of the findings across the studies included in the review.

The overall confidence in each review finding (ie, for each theme generated) will be graded as high, moderate, low or very low. GRADE-CERQual assessments will be undertaken independently by two authors (KS and CL). Any disagreements will be discussed until consensus is achieved.

Assessment of methodological limitations

Methodological limitations should be evaluated based on each study’s methodological strengths and weaknesses. CERQual borrows the Critical Appraisal Skills Programme (CASP) framework to assess the methodological limitations of individual studies. CASP is a set of checklist designed to help researchers systematically evaluate the quality of different types of research studies, such as qualitative studies, randomised controlled trials and systematic reviews. By using the CASP checklist, reviewers can identify methodological limitations in the included studies, such as issues related to sampling, data collection or data analysis. These assessments will inform the GRADE-CERQual evaluation of the overall confidence in each review finding, as methodological limitations can affect the credibility and reliability of the synthesised results.

Assessment of relevance

Relevance refers to the degree to which the purpose and objectives of the included research are consistent with the problems to be addressed by the systematic review. Generally, the inclusion criteria of systematic qualitative reviews are designed to align with the research questions, resulting in a high relevance of the included studies. When assessing relevance, reviewers should consider the following aspects: Population, setting, phenomenon of interest, study design and methods. By carefully examining these aspects, reviewers can assess the relevance of each included study and determine how well the study findings contribute to answering the overall research question.

Assessment of adequacy

Adequacy in the context of a systematic qualitative review is the comprehensive evaluation of the richness and quantity of relevant data supporting a specific finding.47 Assessing adequacy is crucial as it helps to determine the reliability and validity of the synthesised results. Data enrichment means that the original research can provide sufficient detailed information to describe the research status and make it easy to understand. Quantity is the number of studies or data fragments supporting a theme. The defects in the quantity and richness of extracted data will reduce the reliability of the system evaluation results. By examining these aspects, reviewers can evaluate the adequacy of the data supporting each review finding.

Assessment of coherence

Coherence in the context of a systematic qualitative review refers to the extent to which the synthesised findings are consistent with the original research findings and whether any differences in the primary research findings are explained. Assessing coherence is crucial as it helps to ensure that the synthesised results accurately represent the data from the included studies. We will use the Kappa consistency test to verify the integrated codes and themes of two independent researchers to improve the credibility of the research results (online supplemental appendix 7). The synthesis topics results are compared with the individual results to check the consistency.48

Patient and public involvement

The involvement of patients and the public is crucial in conducting research that is relevant, meaningful and impactful. In this study, we have sought input from nursing homes managers, who have provided valuable insights that have informed the development of our research protocol. Their input will also be considered when interpreting and integrating our final findings. To further involve patients and the public in the research process, we will engage in the following activities: Collaboration with nursing homes, engagement with older adults and their families, involvement in data interpretation, dissemination of findings to the public.

We will share the results with the public and describe the research topics in various forms (eg, pictures, flow charts, frames, tables), which is done to explain part of an important topic and show which key findings are essential to the public.

Publishing the protocol

The findings from this comprehensive study will be disseminated through publication in peer-reviewed journals. By publishing this comprehensive report, we aim to enhance the transparency of the review methodology and obtain valuable feedback and comments from peer reviews prior to the commencement of the review. This process will further contribute to the overall quality and credibility of the review.


This meta-synthesis highlights the importance of autonomy and the role it plays in maintaining the dignity of older adults living in nursing homes. The loss of autonomy can result in a decline in social status, self-esteem damage and confidence for older adults.49 Furthermore, the attitudes and behaviours of staff in nursing homes are critical in shaping the experiences of older adults and can greatly impact their sense of dignity. As such, it is crucial to continue exploring ways to improve the dignity of older adults in nursing homes.

There has been a growing emphasis on the dignity of older adults in nursing homes in recent research. By conducting this meta-synthesis, we aim to integrate qualitative studies and provide evidence-based recommendations for improving the dignity of older adults in the future. This evidence can inform the development of better policies and practices that cater the unique needs of older adults and uphold their dignity.

However, the exclusion of grey literature and non-English language studies may limit the comprehensiveness of the evidence gathered in this meta-synthesis. Despite this limitation, we aim to collaborate with a librarian to ensure a thorough search of relevant databases and journals to capture as much pertinent evidence as possible.

By understanding the factors that influence the dignity of older adults in nursing homes and identifying strategies to address them, we can contribute to more person-centred care approaches that respect and upload their dignity. This research not only has the potential to improve the quality of older adults in nursing homes but also to guide future research and policy-making in this area.

Ethics statements

Patient consent for publication


Supplementary materials


  • Contributors The study was conceived by contributors KS and CL, who also authored the initial draft of the protocol. KS, CL, XZ and YL played a significant role in refining the protocol design and preparing subsequent drafts. All authors have given their approval for the submitted protocol and are responsible for its content.

  • Funding This work was supported by Sichuan Hospital Management and Development Research Center (grant number: SCYG2022-53).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.