Week 7

Context

Dignity is a human right and is important to every individual but can become compromised during healthcare. Being treated with dignity and involved in decision-making is associated with positive outcomes, such as high patient satisfaction (Beach et al, 2005). In a review of the World Health Organisation (WHO)’s general population surveys in 41 countries, most participants selected dignity as the second most important domain in care - only ‘promptness of care’ was more highly rated (Valentine et al, 2008). The Amsterdam Declaration recognised dignity as one of the main rights for patients (World Health Organisation [WHO], 1994).

The materials in this section were produced by Professor Lesley Baillie, Florence Nightingale Foundation Chair, School of Health & Social Care, London South Bank University

Introduction

This week runs from 3rd - 9th 2014. You will need to:

Content

Professional, legal, and health policy perspectives on dignity in care

There are professional, legal, and health policy expectations that health care workers will promote dignity in their practice.

Professional

All nurses have a professional duty to promote dignity of those in their care. The International Council of Nurses’ Code of Ethics for Nurses (2012) sets out that ‘inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect’. In the United Kingdom (UK) the Nursing and Midwifery Council's (NMC) Code states that nurses must: Make the care of people your first concern, treating them as individuals and respecting their dignity (NMC, 2008, p.2). Likewise those health care workers registered with the Health and Care Professions Council (HCPC), "must treat service users with respect and dignity" (HCPC, 2012). In the UK medical practitioners must follow the General Medical Council 'Good Medical Practice' guidance, which requires them to "treat patients as individuals and respect their dignity and privacy" (GMC, 2013). Most health care workers, wherever they practice, are bound by similar codes.

Legal

The UK’s Human Rights Act (HRA) (1998) established that all individuals have minimal and fundamental human rights. Two of the articles are particularly relevant to dignity in healthcare:

Article 3 'Prohibition of torture‘: ‘No one should be subjected to torture or to inhuman or degrading treatment or punishment'.
Article 8 ‘Right to respect for private and family life’: ‘Everyone has the right to respect for his private and family life, his home and his correspondence’. Privacy is closely aligned with dignity and provision of privacy in healthcare, including confidentiality, are key principles in professional practice.

Health policy

Health policy documents increasingly emphasise the importance of compassionate and dignified care. The National Health Service (NHS) Constitution (Department of Health 2013) includes ‘Respect and dignity’ as one of the seven NHS values. The quality standard for care of adults in hospital states that all staff involved in providing NHS services should: ‘treat patients with respect, kindness, dignity, compassion, understanding, courtesy and honesty’ (NICE 2012).

The meaning of dignity

Reflect on the following questions: What is dignity? How does it feel to have your dignity? How does it feel to lose your dignity? Now ask someone else for their views and compare these with your own.

In 2008, the Royal College of Nursing (RCN) published a definition of dignity, based on a literature review, to guide nursing practice. The definition emphasises that dignity applies to people whether they have capacity or not. In relation to dignity loss, those most vulnerable to dignity loss may well be people who lack capacity to independently make their own decisions, for example, a person who is unconscious or critically ill.

Definition of dignity

Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals. When dignity is present people feel in control, valued, confident, comfortable and able to make decisions for themselves. When dignity is absent people feel devalued, lacking control and comfort. They may lack confidence and be unable to make decisions for themselves. They may feel humiliated, embarrassed or ashamed. Dignity applies equally to those who have capacity and to those who lack it. Everyone has equal worth as human beings and must be treated as if they are able to feel, think and behave in relation to their own worth or value (RCN 2008, p.8).

Influences on dignity in care

Health conditions can affect people’s identity through impacting on body image or function and people can experience discomfort and a loss of control and confidence (Baillie and Black 2014). Baillie (2009) found that a serious illness, or uncertainty about diagnosis, led to patients feeling out of control, which diminished their dignity. In Berg and Danielson’s (2007) study patients with severe and acute illness talked of feeling ‘so small and so vulnerable’. The care environment is another important influence on dignity as are all the different interactions patients have with both clinical and non-clinical staff and with their families.

Dignity is dynamic and can fluctuate, affected by interactions, events, the person’s own feelings and care environment factors. Patients’ views about what is most important for their dignity might vary and differ from our own views.

Reflect on what is most important for your own dignity. If you were seriously unwell in hospital ( like Gary), what would be the top three factors that would help preserve your dignity in this situation? What would be the top three factors that would diminish your dignity in this situation? Ask a friend or family member these questions and compare them to your own. Are your views the same or different?

Attitudes, behaviour and interactions with others

There are three key aspects of staff behaviour that affect dignity in care: interactions and communication; providing privacy; and essential care. The attitudes of staff affect how the behaviour is carried out and how it is perceived. Baillie and Gallagher (2011) found that treating people as valued individuals was the core factor that promoted dignity.

Interactions and communication

A key aspect of promoting dignity is about getting to know the person and developing a relationship with them, through your interactions. Even in an acute care situation, you can quickly build a rapport, make people feel respected and inspire their confidence. Non-verbal communication is as important as verbal in interactions that influence dignity. In Baillie’s (2009) study interactions that diminished dignity were being curt (brusque or off-hand) and being authoritarian. Communication that promotes dignity helps people to feel comfortable, in control and valued; here are examples:

Interactions that make patients feel comfortable, in control and valued (Adapted from Baillie 2009; RCN 2008)

Interactions which help people to feel comfortable

Sensitivity
Empathy
Developing relationships
Conversation
Professionalism
Family involvement (if desired by the patient)
Friendliness and reassurance.
Humour (if used sensitively and appropriately)

Communication which helps people to feel in control

Explanations and information giving
Informed consent
Offering choices and negotiating
Enabling independence

Communication which helps people to feel valued

Listening
Giving time
Showing concern for patients as individuals
Being kind, considerate and helpful.
Courteousness: addressing people by their preferred name, introducing self, being polite and respectful, including respect for culture and religious beliefs

Privacy and Confidentiality

Valid consent must be obtained from people in your care before any physical examination, treatment or provision of personal care reflecting the right of people to determine what happens to their body (DH 2009). There are three key areas of privacy for people accessing healthcare: privacy of personal space, privacy of their bodies and privacy of personal information: confidentiality. Whilst the care environment influences privacy, staff behaviour strongly affects experiences of privacy.

Personal space: Patients may feel that their personal space has been breached when staff move patients’ belongings around without discussion or when staff enter closed curtains or doors without asking. In a hospital setting, health care workers should close doors or fully draw bedside curtains when privacy is needed.

Privacy of the body: People undergoing healthcare are at risk of bodily exposure as they often need to undress for procedures or examinations and need help with personal care. Examples of privacy breaches are: bedside curtains which are not fully closed when patients are exposed, removal of clothing without discussion or consent, or providing clothing that does not cover patients’ bodies adequately, e.g. hospital gowns that do not close fully at the back (Baillie 2009). When a patient’s body is exposed for a procedure or examination, only the minimum clothing should be removed, ensuring that the rest of their body is covered, by bed linen or clothing. Some patients will not wish to expose their bodies to staff of the opposite sex; religious beliefs may influence individual views about modesty. Health care workers should behave sensitively and respect people’s wishes.

Privacy of information: confidentiality: Respecting confidentiality relates to you as an individual and to all NHS organisations. Information provided by those in your care is given in confidence; people in your care should be able to trust that you will keep their information safe and confidential, sharing it only with those involved in their care as necessary (Baillie and Black 2014). Any sharing of information must be legitimate; the DH (2013) states: "For the purposes of direct care, relevant personal confidential data should be shared among the registered and regulated health and social care professionals who have a legitimate relationship with the individual" (DH 2013, p. 14).

The Department of Health (2003) developed a Confidentiality Model to outline the areas that must be met to comply with the requirements of confidentiality:

PROTECT – look after the patient’s information
INFORM – ensure that patients are aware of how their information is used
PROVIDE CHOICE – allow patients to decide whether their information can be disclosed or used in particular ways
IMPROVE – always look for better ways to protect, inform, and provide choice

Examples of lack of confidentiality occur when personal information, for example, about incontinence, medical diagnosis or home circumstances, is overheard or displayed in public areas. In curtained areas in hospital, curtains provide a visual barrier but auditory privacy is more difficult. If exposing or intimate procedures (e.g. urinary catheterisation) have to be carried out at the bedside, staff should communicate discreetly, by keeping voices low and using non-verbal communication.

As a health care worker, under common law, you are allowed to breach confidentiality in the public interest e.g. the investigation and punishment of a crime, to prevent the abuse of others or to prevent harm (Baillie and Black 2014).

Essential care

Essential care is the personal care that most people can carry out for themselves independently from early childhood, including: personal hygiene, dressing, going to the toilet and eating and drinking. Personal care is essential for health and comfort and impacts on dignity through effects on self-esteem and confidence. We all have our individual standards and preferred ways of carrying out personal care; these are part of our personal identity and therefore our dignity. To promote dignity, essential care must be delivered to a high standard in a timely manner, with privacy and communication that promotes dignity. This includes dealing with incontinence or when a patient has vomited, situations that can often occur when a patient is critically ill.
Care environment.

Consider the healthcare environment Gary is in: What aspects might help dignity? What aspects might threaten dignity?
Think about the whole care environment, not just the physical aspects.

Baillie (2009) identified that the physical environment, organisational culture, leadership and healthcare systems are aspects of the care environment that influence dignity. The physical environment includes privacy e.g. reasonable bedspace size, well-fitting bed curtains, space for private conversations, sufficient bathrooms and toilets. A clean environment with good standards of décor is also important, as it is demeaning (as well as hazardous) for people to be cared for in unclean, neglected environments.

References and Further Reading

References

Baillie, L. (2009) Patient dignity in an acute hospital setting: a case study. International Journal of Nursing Studies 46: 22-36.

Baillie, L. and Black, S. (2014) Professional Values in Nursing. Taylor and Francis.

Baillie, L., Gallagher, A. (2011) Respecting dignity in care in diverse care settings: strategies of UK nurses. International Journal of Nursing Practice 17: 336–341.

Beach, C., Sugarman, J., Johnson, R. et al. (2005) Do patients treated with dignity report higher satisfaction, adherence and receipt of preventive care. Annals of Family Medicine 3(4):331-338.

Berg, L., Danielson, E. (2007) Patients’ and nurses’ experiences of the caring relationship in hospital: an aware striving for trust. Scandinavian Journal of Caring Sciences 21: 500–506.

Department of Health (2003) Confidentiality: NHS Code of Practice. London: Department of Health.

Department of Health (2009) Reference guide to consent for examination or treatment (2nd edn.) London: Department of Health.

Department of Health (2013) The NHS Constitution for England.

General Medical Council (2013) Good Medical Practice. London: GMC

Great Britain 1998. Human Rights Act c. 42. London: HMSO.

Health & Care Professions Council (2012) Standards of conduct, performance and ethics. London: HCPC

International Council of Nurses (2012). The ICN Code of Ethics for Nurses.

Matiti, M.R. and Baillie, L. (Eds) Dignity in Health Care for Nurses and Midwives: a practical approach for nurses and midwives. London: Radcliffe Publishing

National Institute for Health and Clinical Excellence (2012) Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. Clinical Guideline 138. London: NICE.

Nursing and Midwifery Council (NMC) (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. London.

Royal College of Nursing (2008) Defending Dignity – Challenges and Opportunities. London: RCN.

Valentine, N., Darby, C. and Bonsel, G.J. (2008) Which aspects of quality of care are most important? Results from WHO’s general population surveys of ‘health system responsiveness’ in 41 countries. Social Science and Medicine 66: 1939–1950.

World Health Organisation (1994) Declaration on the promotion of patients’ rights in Europe–Amsterdam. Copenhagen: World Health Organisation Office for Europe

Further Reading

There is a ‘Dignity in Care’ network with a website, which provides many resources for health and social care and where you can sign up to be a dignity champion http://www.dignityincare.org.uk

The Social Care Institute for Excellence (SCIE) provides a series of practice guides on Dignity in Care (see http://www.scie.org.uk/topic/people/olderpeople/dignity, which are a useful resource.

In 2008-2009, the Royal College of Nursing ran an extensive campaign ‘Dignity at the heart of everything we do’ and resources remain available; see http://www.rcn.org.uk/newsevents/campaigns/dignity.

For further reading, and a detailed exploration of dignity in different care settings, including acute and critical care, and across the lifespan see ‘Dignity in Healthcare: a practical approach for nurses and midwives’ (Matiti and Baillie 2011).