Recently there has been an increase in dignity in care campaigns but do they improve patient experience or detract from serious debate about cultural change?
Dr Wilfred McSherry, PhD, MPhil, BSc, PGCE, PGCRM, RGN, NT, FHA, is professor in Dignity of Care for Older People, Centre for Practice and Service Improvement, Faculty of Health, Staffordshire University.
McSherry W (2010) Dignity in care: meanings, myths and the reality of making it work in practice. Nursing Times; 106: early online publication
In recent years, dignity in care has become a catch-all phrase in nursing and healthcare. This article looks at different definitions of the concept and at the origins of dignity in care campaigns and champions. It questions whether dignity in care campaign is a genuine attempt to improve the patient experience or a political and professional ploy to delude the public that something is being done, and which detract from serious debate about the nature and structure of nursing and healthcare.
Keywords Dignity champion, Holistic care, Public expectations
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- Nurses becoming more aware of the diverse needs of people within society and this has encouraged them to explore the idea of dignity.
- Any practice that devalues and does not respect the dignity of the individual should be confronted.
- Dignity in care is not the sole responsibility of one professional group: all health and social care professionals need to be dignity champions.
I write this article not as an expert in “dignity” but as someone struggling to find a reason and explanation as to why we have dignity in care campaigns. It is a sad indictment that we have a world-class health service that is at the leading edge of scientific and technological advancements, but growing evidence that there has been an erosion of the core or primary values associated with care and caring (Health Care Commission, 2009; The Patients Association, 2009; Alzheimer’s society, 2009; The Mid Staffordshire NHS Foundation Trust Inquiry, 2010; The Prime Minister’s Commission on the Future of Nursing and Midwifery in England, 2010.)
It may seem a little trite to say that healthcare has lost its primary values without acknowledging a broad range of factors that may have contributed to this erosion, such as the introduction of extended roles, new technologies, and a dramatic increase in the throughput of patients. These factors have all contributed to a number of significant changes in the systems and resources associated with the delivery of healthcare.
In August 2008, I was appointed as professor in Dignity of Care for Older People; a joint appointment between the Faculty of Health, Staffordshire University and Shrewsbury and Telford Hospital NHS Trust.
I understand it is the first post of its kind and while I am delighted and feel privileged to have been appointed to this role, I also feel a sense of sadness and unease. To appoint professors in dignity of care means something has gone fundamentally wrong in the health and social care system.
When I was studying to become a registered nurse, dignity was never mentioned in my training - it was assumed to be an integral part of the caring process, something innate and intuitive, a fundamental principle of care and caring.
One explanation why dignity in care has emerged now as a topic for study is that nursing’s own understanding of people and the nature of the profession have evolved. Over the last twenty years, nursing and healthcare have changed dramatically in terms of education and practice. Some of these changes have been welcomed, and offer new opportunities and challenges.
Nurses are more aware and informed of the different dimensions of people’s lives. They operate more autonomously, facing challenging caring situations and responding sensitively to the people from diverse cultures with diverse needs. They are working in a more complicated healthcare system where people are better informed of their rights and expectations regarding care. The appearance of dignity in care campaigns is not therefore a simple case of “Paradise Lost”, but a reflection of nurses being more aware of the needs of people within society.
Emergence of dignity campaigns
The current drives for dignity in care and subsequent campaigns appear to have emerged from within older people services (Health Advisory Service, 1997; 1998) and have permeated the entire health and social care sectors (Cardiff University, 2004; Department of Health, 2006 a, b, c: HCC, 2007; Royal College of Nursing, 2008.) However, it could be argued that these campaigns are a mask for the consumerist, bureaucratic and managerial systems that have infiltrated healthcare, deflecting from the government’s struggle to provide a cost-effective and efficient health care system for all.
Reviewing the emergence of these campaigns, there is clear justification for challenging and modernising the way that older people have been cared for. Any practice that devalues and does not respect individuals’ dignity should be confronted; there can be no room for complacency, age discrimination and any unfair practice (DH, 2001).
Today, “dignity in care” has become a catchall phrase within nursing and healthcare (Smith, 2008). It puts a positive spin on the issue, disguising all that has gone wrong within an ailing healthcare system. The net effect has been the introduction of a number of high profile public (DH, 2006, a, b, c, HCC, 2007) and professional campaigns (RCN, 2008) rallying nurses and other interested parties to sign up and be counted as dignity champions.
The aim of such campaigns is to restore dignity at the heart of nursing, health and social care. These campaigns imply that nursing and health care professionals may have taken their eye off the essentials and the solution is to refocus attention back on the importance of care. However, this refocusing should also encourage campaigners to discuss and explore the changing context in which dignity needs to be reinstated. The Department of Health has already begun reviews into the effectiveness of the dignity in care campaign and the role of the dignity champion (Department of Health, 2009).
The utmost care and attention should be taken to prevent the violation of any patient, service user or indeed any health care professional’s dignity. However, by exploring the premises of dignity outlined in Box 1 we can try to explain the origins of these campaigns and why calls for restoring or reintroducing dignity in care have arisen.
Box 1. Dignity in healthcare
- Founding principle of healthcare
- Historically care and caring were better
- Models of care delivery
- Public expectations
- Reflection of wider society
Before exploring the premise of dignity it is important to define it. Dignity is a subjective, complex and difficult concept to pin down. Nordenfelt and Edgar (2005) present a theoretical model of dignity created within the Dignity and Older Europeans project. This suggests that there are four types of dignity, outlined in Box 2.
Box 2 Types of dignity
- Menschenwürde: refers to the dignity inherent within every human being.
- Dignity as merit: either formal or informal – this kind of dignity is conferred upon someone either as a result of merit or rank. Some people may inherit titles. However, in this classification dignity is usually earned or conferred by others because of deeds or actions.
- The dignity of moral stature: refers to one’s own moral identity and stature and how an individual may lose this if they fail to act according to their guiding principles and values.
- The dignity of personal identity:concerns a person’s identity. An individual can be robbed or violated by physical assault or humiliation. The notion of integrity and physical identity, autonomy and inclusion are all important aspects of the person’s identity.
Fenton and Mitchell’s (2002) definition seems to capture the four types of dignity and offers a way of understanding and engaging with the concept within nursing and healthcare. They state: “Dignity is a state of physical, emotional and spiritual comfort, with each individual valued for his or her uniqueness and his or her individuality celebrated. Dignity is promoted when individuals are enabled to do the best within their capabilities, exercise control, make choices and feel involved in the decision-making that underpins their care.”
These definitions imply that nursing and healthcare professionals can undertake activities that promote and preserve dignity. However, they also suggest that these practitioners have the potential to rob or violate a person’s sense of identity and dignity. The latter is certainly referred to in a number of recent reports asserting that healthcare does not always preserve and uphold patient dignity but actually leads to violations (Alzheimer’s Society, 2009; Health Care Commission, 2009; The Patient Association, 2009).
Premises on which dignity in care is based
One premise is that dignity in care has never been a central or founding principle of our healthcare system. Therefore historically, dignity in care has not been a reality. Many nurses talk about the “olden days”, seeing them through a nostalgic set of lenses that have perhaps become distorted over time.
Was nursing or healthcare any better then, than it is today? Were patients treated with more dignity then than they are today? My first instinct is to say “no”. I can recall many incidents from my clinical practice working as an auxiliary nurse in a psycho-geriatric hospital where patients were subject to many indecencies: queuing up in toilets before mealtimes; wearing outdated ill-fitting hospital clothes and being restrained by a number of means, both chemical and physical.
These widespread practices seemed to be the norm and in hindsight would now constitute institutional and personal abuse. Thankfully, they are no longer tolerated in the healthcare system because they represent a violation of dignity. These examples of poor practice bring into question the relationship between dignity in care and caring values. Campaigns for dignity in care may not necessarily result in the change of values, attitudes and beliefs that are perceived lacking in nursing (Maben and Griffiths, 2008).
One positive aspect of being a nurse years ago was that there seemed to be time to care. Nurses had less paperwork, patient throughput and dependency were lower than today, and there were also some excellent role models in delivering total patient care. Nurses were visible and at the bedside. While there was still good and bad practice, dignity in care was not really a word used in the vocabulary of nurses or patients, since nursing care seemed to encompass all of this in an integral and intuitive way.
My second premise stems from the first. If dignity in care did exist historically, then where and why has it gone from caring in contemporary nursing? One of the reasons could be the perceived erosion or loss in care and caring (Corbin, 2008) caused in part by the delegation of fundamental caring skills to unqualified staff, while qualified practitioners undertake roles and duties once performed primarily by medical staff. Maben and Griffiths (2008) write: “Some of the enduring qualities of nursing such as care and compassion are thought to have been lost and not demonstrated by some nurses.”
This seems to have been compounded by a bureaucratic agenda in terms of undertaking risk assessments and form filling - meaning nurses do not have the time to care. It is not that bureaucracy is unnecessary - on the contrary, inspections, satisfaction surveys and documentation are all important and valuable. But the emphasis on the importance of bureaucratic tasks seems to be detracting from the provision of fundamental nursing care.
Another position is that dignity is a social construct; one that is constantly evolving reflecting the values and norms of the society in which it is located. Roman history tells us that dignity or dignitas was not conferred to all members of society in equal measures. Dignity then, was associated with rank and merit and the authority and command a person held over others, either through wealth, power or status.
Similarly, a review of some of the Victorian novelists reveals that not all sections within society were treated with dignity. The concept of dignity has changed and evolved across time and human history. This is certainly reflected in the four types of dignity noted in Box 2, where the emphasis in modern society is not so much on status and power but on integrity, values and the practice of actions and attitudes that preserve and uphold the identity and uniqueness of each person.
The point is that dignity campaigns reflect the time and social context. Their emergence mirrors the values and discomforts that nurses and healthcare professionals are experiencing, such as a reduction in the amount of time available to spend with patients.
The desire to restore dignity to the heart of nursing is an attempt to challenge and redress some of the delegation and over specialisation that has occurred over the last decade, which have perpetuated the perceived erosion of care (Scott, 2000). Nursing and healthcare must learn from its past. However, nostalgia alone will not reinstate care and caring at the heart of our healthcare system, since nostalgia can be just as destructive as over specialisation.
Too much bureaucracy prevents innovation and development. We all need to be vigilant and prepared to challenge bad practice in whatever form it takes, rather than just going with the flow or blending in with the status quo. Socialisation and “wanting to fit in” are powerful suppressers, which can silence the best and most well intentioned nurse.
Organisation of care
Premise three explores the organisational and operational models of care delivery. The phrase “holistic” care has been a popular mantra for the nursing profession, which challenged the apparent domination of the medical model of care (Thorne, 2001; Paley, 2002). This means providing individualised person-centred care addressing all dimensions of the individual: physical, social, psychological and spiritual.
However, nurses have not always provided holistic care. For example, my own work reveals that the holistic revolution within nursing has not really succeeded and lip service is paid to only some of the dimensions - for example spirituality and spiritual care (McSherry, 2006, 2007). Fenton and Mitchell’s (2002) definition underlines that we cannot provide dignified care to patients unless we attend to the spiritual dimension.
It would appear that the language and rhetoric associated with holistic care has been replaced by dignity in care. While holistic care was an attempt to remove some of the dehumanising, medicalisation and fragmentation of care, dignity in care could be interpreted as an attempt to challenge the managerial and bureaucratic influences that prevent nurses from caring for patients.
There have been many drives to ensure that the voice of the public inform and direct developments within our health and social care systems. One just needs to look on the DH website to identify the weight and importance placed on public consultation in the development of policies and strategies. This inclusive partnership working is to be applauded and strengthened but it is impossible to ignore a political agenda that seeks to deflect or divert attention from some of the fundamental issues that have led to the perceived erosion in care such as the over emphasis on targets and bureaucracy at the expense of quality of care and ultimately the patient experience.
The result of this inclusive approach is that the public’s awareness and expectations have dramatically increased in terms of how they believe they should be treated within health and social care. Perhaps so much so, that public demand and expectation now far outweigh what can actually be delivered within current economic constraints imposed on the NHS.
But has the bar been falsely raised in terms of the public’s awareness and expectations? This premise may be at the heart of the problem of dignity - not that nurses are less caring.
While the issue may be that dignity is valued by nurses, it is the economic and political constraints imposed on the delivery of healthcare that prevent dignified care from being provided. This phenomenon is evident in recent investigations and inquiries (HCC, 2009; The Mid Staffordshire NHS Foundation Trust Inquiry, 2010).
The introduction of the dignity campaigns can be viewed from different perspectives. The optimist within me sees them as a genuine attempt to improve care and the caring experience. The cynic views them as a political and professional ploy to delude the public that something is being done, and deflect from some serious debate about the nature and structure of nursing and healthcare.
Ultimately, are these campaigns attempting to restore fundamental elements of care that have been eroded? My reason for asking this is that one drawback of these campaigns is dignity champions tend to adopt an “opt in” mentality, where people sign up or register their interest. This approach places sole responsibility on the shoulders of interested parties, asking them to challenge bad practice and instigate change without providing an infrastructure or support.
It is my belief that although these campaigns generate awareness of the importance of dignity in care, they will not result in the cultural change that is necessary within the health and social care sectors. The difficulty with campaigns is they are short lived, have a limited shelf life and, once the immediate interest and enthusiasm has dwindled they fade out.
Campaigns are also aimed at engaging particular groups within the health and social care sectors - primarily nursing - and will not resolve some of the issues that seem to be operating around respect and dignity within the wider society.
Reflection of wider society
The fifth premise develops the point about the perceived erosion or loss of respect and dignity within society at large. I feel that what happens within our healthcare system is a reflection of what is happening within society and we cannot look at dignity in care without looking at the wider context.
While one must treat with caution the way that the media captures and presents news there does appear to be a devaluing of the person. Perhaps a solution would be to define what is meant by dignity within society, and crucially how to capture and clarify this so that its place, relevance and meaning within the social order are known. There is certainly, an increased awareness within nursing and healthcare of the importance of preserving patient dignity. However, the challenge for all is to ensure dignified care happens (Magee et al, 2008).
Perhaps a starting point for those working within health and social care is to ask themselves some pertinent questions. What do I value? Why did I enter the caring profession? A useful exercise is to look at the 10 point dignity challenge (DH, 2006c) outlined in Box 3 and ask: “How do I measure up?” My simple and perhaps naive philosophy is that if we start challenging our own prejudices, attitudes and behaviours this will have an impact on our practice and interaction with patients and our colleagues. Jacelon et al (2004) support this process of self-reflection and introspection when they write: “We concluded that learning about dignity was an antecedent to behaving with dignity.”
Not everything in nursing and healthcare is bad - on the contrary. Dignity in care is a matter of perspective and for some it may be the reality they seek, while for others it may always remain a myth - something from a bygone age now unattainable. Regardless of which perspective we adopt, dignity in care campaigns and dignity champions will only go a little way towards restoring some of the fundamental principles associated with the perceived erosion of care and caring.
While I support and have registered as a dignity champion, I feel a more strategic approach is required to bring about the desired effect. The “opt in” mentality and registering to be a dignity champion alone will not bring about the sustained cultural shift that is required within the whole health and social care system. All health and social care professionals need to be working as dignity champions, dignity in care is not the sole responsibility of one professional group – namely nurses - but everyone working and employed within the health and social care sectors.
Box 3. The Department of Health (2006 c) 10 point Dignity Challenge
High quality care services that respect people’s dignity should:
- Have a zero tolerance of all forms of abuse.
- Support people with the same respect you would want for yourself or a member of your family.
- Treat each person as an individual by offering a personalised service.
- Enable people to maintain the maximum possible level of independence, choice and control.
- Listen and support people to express their needs and wants.
- Respect people’s right to privacy.
- Ensure people feel able to complain without fear of retribution.
- Engage with family members and carers as care partners.
- Assist people to maintain confidence and a positive self-esteem.
- Act to alleviate people’s loneliness and isolation.
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