Caring for Older People Improving Healthcare Quality to Ensure Well-Being and Dignity

The aim of caring is to promote health. The global trend is that people are living longer, but in many cases, there is no support system for the care of older people, leading to major challenges in ensuring their health and well-being. The proportion of older people is expected to increase globally, and skilled healthcare professionals will be required to care for them. There is a risk that older people as suffering and vulnerable human beings will be forgotten due to the increasingly effective and technical care worldwide. A caring culture and relationship should be prioritised and developed to promote participation, well-being and dignity for older people in order to fulfil their care needs and ensure quality healthcare. It is important that research focusing on universal health coverage identifies the benefits of increased investment in service quality. To contribute to the improvement of this output, we propose the application of Eriksson’s caritative theory. The aim of this theoretical chapter is to provide examples of how the dignity and well-being of older people can be promoted, at no additional cost to the person, by means of Eriksson’s caritative theory, which can strengthen healthcare for universal health coverage.


Introduction
Human beings' becoming in health and suffering can be both promoted and inhibited. Human becoming is characterised by life in a movement and to live means being in a constant movement of change and feeling of existence [1]. Nursing is of importance for improving and maintaining older people health [2]. As suffering human beings older people need to meet healthcare professionals who see and take responsibility for their suffering [3].
Ethical care for older people concerns being aware of their vulnerability and respecting them as human beings. In caring it is important to promote participation and focus on the older people's resources [4]. One study compared nursing home residents with community-dwelling older adults and found that older people in nursing homes were more depressed and that their well-being was impaired [5].
Professional care involves caring for a human being where the relationship differs according to the specific context. There is a risk that empathy and compassion can be lacking if the circumstances under which patients are cared for are continuously deprived of the necessary resources for high quality and safe care.
Relationships are of importance when caring for human beings. However, an ethics of care with a relational ontology is preferable [6]. When meeting other people, it is important to respect the dignity of the individual, especially in meetings with people who depend on others on a daily basis to cope with everyday life [7]. Nurses have a responsibility to treat all people with dignity and respect [2]. When caring for older people it is important that healthcare professionals confirm the older people's dignity as a human being and promote an experience of well-being in her/his complex healthcare situation. One way of promoting the older people's dignity and well-being is to use Eriksson's theory of caritative caring [8]. The aim of this theoretical chapter is to highlight Eriksson's theory for promoting older people dignity and well-being in the perspective of service quality of universal health coverage.

Older people care from a global perspective
The number of older people aged over 60 years is steadily increasing all over the world, thus their care and care needs will become an increasingly important part of healthcare. Improving the health and functional capacity of older people, as well as their social participation and security, is challenging for society [9]. The need for healthcare is universal and in the nature of care lies respect for human rights, including cultural rights, dignity, well-being and to be treated with respect [10,11].
Older people want quality care. Despite this, the care they receive is not always perceived as respectful and dignified. In healthcare today, violations of the dignity of older people are common [12,13]. A British study revealed that older people with a high sense of well-being live longer than their peers who are less satisfied. The study highlights the feeling of having a reason for existence as an independent factor with a strong connection to health. Care should not be focused solely on curing diseases but also on giving people the prerequisites for a meaningful life [14]. Health is a fundamental prerequisite for people's ability to achieve their full potential. For that reason, we need to invest in health by devoting resources to quality-assured healthcare systems, which implies that we are reinvesting in the development of society as a whole [15]. Caring for older people means providing qualified care and many do not receive the care they need [16]. Older people feel safe and secure with the healthcare they receive but believe that they are a low priority group [17]. There are no clear strategies for developing the care of older people in terms of how dignified and continuous care can be ensured [11]. Every person should have access to quality healthcare without risking financial difficulties. The challenge for many countries lies in determining how to expand healthcare to meet existing needs with limited resources. A cost-effective part of the solution is having motivated health workers [18], whose demeanour enhances the patient's sense of self-dignity and well-being.

Dignity in caring for older people
Dignity is related to human beings' body, soul and spirit. Absolute dignity means that each human being has inner freedom and responsibility for both her/ his own life and that of others [3,19]. The absolute dignity of the human being, i.e. the inner dimension, is free from values. Relative dignity, i.e. the external dimension, is influenced by the culture and context in which the human being is present. The human being has an absolute dignity that contains the spiritual dimension. Absolute dignity cannot be violated or taken away from the human being due to its indestructible holiness. The human being's duty consists of being in communion in reciprocity, love and service [19].
Relative dignity contains an inner ethical dignity that belongs to the spiritual dimension and an aesthetic dignity that belongs to the bodily dimension. Relative dignity depends on the human being's cultural values and is unique for each individual as it is based on her/his culture and situation [19]. Individualised care can confirm the human being's dignity [20].
Preserving dignity when caring for older people means individualised care, good treatment, listening, showing respect [21] and being well treated [22]. Autonomy, respect and dignity are important for enabling older people to live a dignified life in nursing homes [23,24]. Dignity and self-esteem are promoted through respectful treatment, listening, giving choices and respecting privacy [25]. Safeguarding dignity also means taking the older people's perspective into account, i.e. personality, identity and self-determination. Being a unique person of value is important for human health and well-being [26]. An investigation conducted in Sweden revealed deficiencies in care because older people have to adapt to the care instead of the other way around. Having to adapt to the healthcare offered can be perceived as unworthy by the older person. The experience of dignity is crucial for the feeling of well-being [27].
Personal commitment on the part of healthcare professionals is required to get to know and confirm older patients [28]. The healthcare professional can confirm the older people's dignity by being present, showing pity and respect. In elder care, the older people's well-being can be strengthened by healthcare professionals enhancing her/his sense of meaningfulness in life. This achieved by creating different forums for connectedness that can strengthen the older people's self-esteem. In this way, the healthcare professional is involved in the older people's life situation [29]. To provide good care it is necessary to ensure that healthcare professionals receive sufficient education and support in understanding the concept of dignity, as well as the necessary resources to translate dignity into their everyday work [30].

Well-being in caring for older people
The concept of well-being is central in healthcare science and related to health, quality of life and life satisfaction [31]. Well-being describes how a person feels at a certain time and be a measure of happiness or misfortune [32]. Well-being and health are interlinked, and health is defined as a: "state of complete physical, mental, and social well-being and not merely the absence of disease" [33]. This means that health is not only a goal, but also a resource in daily life, and that well-being may contribute to health or to the maintenance of health [33]. From a healthcare science perspective, the body can be understood as being in a movement between health and disease, a habitation of well-being and suffering in the pursuit of dignity [34]. Health is thus achieved through a combination of physical, mental, emotional and social well-being. In this way, health involves well-being and physical, mental and social dimensions. Well-being is important for the individual's self-assessment, degree of autonomy, control and ability to manage the everyday environment [31]. The feeling of well-being is a condition where human beings experience their own health, regardless of illness or disability, which is an important human experience [7].
Well-being is a feeling, thus cannot be observed by others, while health is defined as a wholeness with soundness, freshness and well-being [35]. The use of a computer and the Internet can contribute to enhancing an older people's well-being, as factors such as learning, social benefits, participation and positive feelings have been identified [36]. The quality of life and well-being of older people are not only affected by health, but also influenced by other factors such as social and family relationships, social roles and activities [37].
In elder care, the older people's well-being can be strengthened by the healthcare professionals facilitating the rebuilding of her/his sense of meaningfulness in life. This can be done by creating different forums for connectedness, which can strengthen the older people's self-esteem.

Katie Eriksson's theory of caritative caring
One of the pioneers of caring science in the Nordic countries is Katie Eriksson. Her theory of caritative caring is also internationally known [8].
Caring consists of meeting the other with respect, warmth, honesty and closeness in time and space [8]. The fundamental motive for caring is love and healthcare professionals deeply want to do well, even if it is not always visible in their actions. A caritative approach means that care is an ethical act that involves taking responsibility for others. Caring ethics is feeling responsible for the other and a willingness to serve. The ethics of caring is constantly present and cannot be divided into parts. Good technological care is related to how well the art of care is performed [38].
Caring is an act performed in love. To convey love to another person means being generous and involves the people's basic attitude to life [39]. The starting point in caring is that there is something natural in every human being. The ability to nurture is developed in a favourable environment. Caring involves tending, playing and learning and includes the whole human being with body, soul and spirit. To care is to share and heal and has a health promoting purpose. The basic substance is always the same, even if the caring takes different forms [40].
Tending in caring refers to a concrete action of love and means confirming the other as a human being. It is characterised by warmth, closeness and touch. Play is important in caring due to the fact that it is an expression of achieving health, wishes and an art form in caring. Learning means developing as a human being and can open new possibilities [41]. Caring ethics implies seeing the reality as it appears to the patient and recognising her/his right to be confirmed as a unique person with an absolute dignity [38]. Non-ethical situations can, for example, be a slipshod piece of work, being heavy-handed, not respecting the people's right to be involved or not listening or taking account of the patient's integrity [42]. Love can provide possibilities to feel compassion and be involved in a communion with the suffering human being, while for the suffering person, knowing that there is someone who is present and remains close creates trust and makes the suffering less unbearable [43]. To share in caring means being able to participate, for example, share in feelings, experiences or how to distribute concrete work activities [44]. It is therefore important that Eriksson's theory has a clear structure. The structure must ensure visibility and clarity for healthcare professionals. In this way, healthcare professionals can work together with the older person in a social interaction to create a whole.

Eriksson's theory of caritative caring for promoting dignity and well-being in elder care
Eriksson's theory can be used when caring for older people to promote and strengthen their dignity and well-being, thus facilitating the provision of highquality care.
In a caring relationship, caring ethics requires that healthcare professionals have the will to do well and treat the human being with respect and an absolute dignity, in addition to being willing to sacrifice something of themselves [8]. Caring for older people can mean that healthcare professionals are there for them, see and confirm their Caring for Older People -Improving Healthcare Quality to Ensure Well-Being and Dignity DOI: http://dx.doi.org /10.5772/intechopen.85598 suffering and listen to their narratives. This can create trust in the caring relationships, leading to bodily and spiritual well-being. Through tending, playing and learning older people health process can be supported and maintained for a sustainable old age.
A caring relationship means that the human being must be allowed to be a person and confirmed in the care [20]. Caring means relieving a people's suffering through mercy, faith, hope and love. It manifests itself by tending, playing and learning in the caring relationship with the patient [3]. Caritative care is based on ethical decisions made to alleviate human suffering and becomes visible through thought, posture and action [27]. The person who suffers is in the midst of her/his own suffering and therefore needs to meet healthcare professionals who can confirm her/his suffering in nursing [3]. To be able to understand a patient who is suffering, healthcare professionals need to be able to see, confirm and invite the patient to a healthcare communion where there is the possibility to alleviate the suffering [45]. Care should be perceived as meaningful by the patient and what is meaningful should be felt in body, mind and spirit [3]. Dignity includes healthcare professionals' will and ability to see and respect the other's needs and desires. In the caring communion there is warmth and care. Security is created through healthcare professionals' ability to be present. When healthcare professionals protect the patient's privacy, they promote respect, responsibility, self-determination and equality [46].

Example of care actions that can promote well-being and dignity progressing towards quality service within universal health coverage
The condition for providing caritative care is that the healthcare professional uses her/his professional knowledge when she/he is part of a communion with the older person [47].
The care activity tending involves the older person being able to experience security in the form of reliability, where proximity and distance are respected by the healthcare professionals in the care relationship [7]. Tending care may involve the healthcare professionals maintaining trust, hope and bodily relief by the love in their hands and the warmth in their voices [34]. To increase the older people's sense of security in an unfamiliar environment, healthcare professionals can invite the older people's relatives to become involved in her/his everyday life. An additional factor in tending is that the older people have their own personal belongings around them, which can give the feeling of a home environment [7].
Through the care activity play, the older people's satisfaction can be enhanced by the fulfilment of needs and desires. The fact that the healthcare professionals employ a playful approach means that they have the ability to reconcile imagination with reality. To find the older people's health resources, healthcare professionals can encourage and support her/him by means of caring play where the activity is adapted to the people's needs and resources [7]. Healthcare professionals can use different symbols and metaphors to access the older people's inner world. Through this approach, they can contribute to the creation of a new reality for the older person in her/his situation, which can contribute to hope and reconciliation of the older person with the outside world [48].
The care activity learning is based on meaningfulness, preserving the older people's everyday habits and strengthening the feeling of a normal environment. Healthcare professionals teach the older person to preserve her/his life story, habits and interests [45]. The purpose of the care activity is to maintain the older people's life experiences and skills. In this care activity new understanding can be created, where strengths, resources and health barriers can be clarified, thus allowing the older person to gain a deeper insight into the self and the/her/his situation [48]. The care should be person-centred in order to create a meaningful everyday life for older Universal Health Coverage 6 people. The care activities of playing and learning can create a bridge between the body's reality and the possibilities of health [34].
The care activities tending, playing and learning can provide a meaningful everyday life for older people and be strengthened when healthcare professionals are educated, supervised and encouraged to reflect on these care activities. Through tending, playing and learning in caring, older people dignity and well-being can be promoted. To share in caring means being able to participate in feelings, experiences or the distribution of concrete work activities [44].

Closing reflections
It is in everyday care that the dignity and well-being of older people can be promoted for a sustainable life. To create a good relationship in the care of the older person, it is important to become aware of her/his suffering. Older people deserve care that is focused on their unique needs for dignity and well-being, and not what is most suitable for the healthcare professionals involved in their care. Understanding the vulnerability of the older person can provide nourishment in the care relationship. Seeing and meeting the older people's face and gaze can confirm her/his dignity and promote health. The nurse's responsibility to develop the care means that knowledge is harnessed to benefit the older person. Critical reflection on the activities together with others can lead to the elimination of inefficient care methods and ways of working. Healthcare professionals have the opportunity to create a high-quality care environment for older people with the help of Eriksson's caritative theory, which is viable in the global healthcare system. Healthcare systems should be concerned not only with disease and illness, but with supporting methods that are sustainable and effective in the long term for improving the health, quality of life, well-being and dignity of older people. In order to strengthen older people' well-being and dignity, at no additional cost, healthcare professionals can use the caring relationship model (see Figure 1). This model is a collaborative © 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Author details
Sandra Pennbrant* and Margareta Karlsson University West, Trollhättan, Sweden *Address all correspondence to: sandra.pennbrant@hv.se process comprising five steps. The steps involve different approaches that healthcare professionals can employ to improve the care relationship activities of tending, playing and learning in the meeting with the older person by: (1) inviting the older person to participate in care activities, (2) communicating with true presence, (3) taking responsibility in the caring relationship, (4) seeing and listening to the older person's life story and (5) confirming the older person as unique with resources, needs and absolute dignity.

Conclusion
In order to improve the caring relationship with older people and to promote their well-being and dignity, it is important that healthcare professionals have the opportunity to use Eriksson's caritative theory combined with a collaborative process model. This theory and model are viable in the global healthcare system and can create national and international research networks to improve the coverage of health services within and between countries, and thereby promote a high-quality care environment for older people at no additional cost.

Conflict of interest
The authors declare that they have no competing interests.