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Views on dignity in providing health care for older people

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VOL: 101, ISSUE: 33, PAGE NO: 38

Michael Calnan, PhD, MSc, is professor of medical sociology;

Gillian Woolhead, PhD, is research associate; Win Tadd, PhD, is senior research fellow, Department of Geriatric Medicine, College of Medicine, Cardiff University

Michael Calnan, PhD, MSc, is professor of medical sociology;

Aim: The aim of this study was to explore the salience and meaning of dignity and dignified care for care providers and the implications for the proviosion of care. The project forms part of an international study being undertaken in different European countries comparing health and social care workers' views on dignity.

Method: Focus groups were chosen as the primary method of data collection. Twelve focus groups were carried out involving a total of 52 participants representing a range of occupational groups.

Results: All participants stated that dignity and respect were important for people of all age groups. The evidence that emerged from these focus groups showed that, in spite of the appropriate intentions of providers, older people were not consistently provided with dignified care.

Conclusion: In order to ensure dignity in providing care for older people, tasks need to be organised around older people's needs and time frames. Without such changes there is a danger that 'institutional ageism' will persist in the health service.

The need to provide dignified care is increasingly emphasised in government policy for older people (Department of Health, 2001) and is embedded in many health and social care practitioners' codes of conduct (College of Occupational Therapists, 2001; NMC, 2002; Chartered Society of Physiotherapy, 2002). There is also evidence that treating people with dignity and providing dignified care can have a positive effect on treatment and social outcomes and health and well-being (Tadd et al, 2002; Walsh and Kowanko, 2002; Ranzkjn et al, 1998). Studies of the views of older people have also shown that being treated with dignity and respect is important (Woolhead et al, 2004).

However, despite these professional requirement and research findings there continue to be many examples of undignified or inappropriate treatment and care in social and health care institutions. This is especially prevalent in relation to the care of older people (Baggott et al, 2004; Tadd and Bayer, 2001).

There has been some analysis of the concept of dignity and its importance for nursing (Shotton and Seedhouse,1998; Gallagher and Seedhouse, 2002; Haddock, 1996), but limited systematic evidence is available (Seedhouse and Gallagher, 2002) about how those providing care for older people perceive dignity, or about the ways in which they promote dignified care. This paper aims to fill this gap by examining a range of providers' perspectives on dignity and the influences that affect their ability to provide dignified care.

Methods
Focus groups were chosen as the primary method of data collection in this study (Calnan and Tadd, 2005). Their strengths and weaknesses as a qualitative methodology have been well documented (Webb and Kevern, 2001; Bloor et al, 2000). The aim of this study was to explore the salience and meaning of dignity for care providers and the implications for the provision of care. It is suggested that focus groups are particularly appropriate for this type of date collection (Kitzinger and Barbour, 1999).

This project forms part of an international study comparing views on dignity of health and social workers from different European countries. Focus groups are believed to be a particularly valuable tool for gaining insight into different cultural perspectives (Kitzinger and Barbour, 1999).

Participants were purposively selected to represent different occupational groups, different levels of experience and seniority and care provision in different settings in one city in England. Overall 12 focus groups were carried out in 12 different locations. A total of 86 individuals were contacted for participation and 52 attended the focus groups. The principle reason given for non-attendance was lack of time. Participants consisted of:

- Care assistants (11);

- Nurses (8);

- Physiotherapy assistants (8);

- Occupational therapists (5);

- Care home managers (3);

- Fourth-year medical students (4);

- Members of a multidisciplinary rheumatology team (4);

- Physiotherapists (4);

- Social workers (3);

- Geriatricians (2).

All participants worked with older people, (on average they spent 73 per cent of their time caring for people aged over 65 years) and came from various clinical settings such as clinical research, rheumatology, hospital rehabilitation units, acute hospitals, community hospitals and private residential/nursing homes.

They were predominantly women (44) and their ages ranged from 18 to 60 (average 38 years). The majority were based in hospitals (42) with the remaining working either in residential homes (7), or in the community (3).

A schedule with specific themes was used to direct the focus group discussions but the emphasis, at least in the initial stages of the discussion, was on spontaneous talk where informants discussed their work. Prompted questions were introduced, if necessary, on:

- The salience of dignity and its meaning to focus group participants;

- The implications for the provision of care;

- The factors that enable or obstruct the provision of dignified care.

With the consent of participants, the discussions they had were audiotaped, the tapes were then transcribed verbatim and the analysis of the data was carried out using the method of constant comparison aided by the software package Atlas/ti (4.1).

Findings
All of the focus group participants stated that dignity and respect were important for people of all age groups:

- Participant 12 (physiotherapy assistant): 'Very important, if I were a patient I would certainly want to be treated with dignity.'

- Participant 10 (physiotherapy assistant): 'I think it is very important.'

- Participant 8 (physiotherapy assistant): 'It can affect the way your patients cooperate as well, if they feel they are given time'.

The participants identified a range of different meanings for dignity (Table 1).

These could be divided into those concerned with the identity of the individual, such as respect for privacy and maintaining self-respect; those reflecting notions of human rights, such as the right to be treated equally and to confidentiality; and those emphasising independence and autonomy.

There were similarities and differences between the various occupations. For example, every group regardless of occupation highlighted privacy and respect as common meanings of dignity.

However, care assistants tended to discuss dignity in terms of functional tasks, such as maintaining personal appearance, whereas other occupations offered a wider range of dimensions such as concerns with independence, equality and exclusion, consent and generally more 'holistic' aspects of care.

The picture portrayed so far is one of providers being aware of and committed to providing care with dignity for older people. However, sometimes the reality is different:

- Participant 8: 'I know that if my nan were being treated the way some of the patients do I would go up the wall.'

- Participant 12 (physiotherapy assistant): 'Well if someone treated me the way we treat some of the patients sometimes I would as well ... If you really did it properly, like really dignified, to get people out of bed and get them washed, it can take up to an hour. I think that is why it does get pushed to the bottom of the list.'

These comments demonstrate an acknowledgement that what should be provided is not always provided and that there is a marked difference between the rhetoric and reality of dignity in care.

Why is this? The focus group participants offered a range of possible factors and explanations that might influence or account for this (Table 2).

These might be categorised into those associated with the specific occupational groups, those concerned with the specific organisation and those related to resources. A number of these are closely interrelated, as will be shown.

The first set of obstacles includes factors such as staff being unaware, or not making the effort as it was quicker to treat without dignity:

- Participant 37 (rheumatology team): 'Sometimes it is quicker to treat a patient - or anyone - with a lack of dignity, to take that extra effort to actually spend a few more moments perhaps explaining something or going a bit slower, a lot of people think about their jobs, and 'I have to do this job and I have got to do it now' and forget that you are dealing with a person.'

This approach reflects, at least in part, the variation in levels of training of the different occupations and the different priority and scope given to dignity and care.

For example, care assistants received no official training about dignity. They were taught basics aspects of care, such as bathing and dressing a patient, and issues related to privacy but for them the priority was often about completing the tasks they were given, such as keeping a patient clean and fed.

In contrast, other occupations such as physiotherapists said dignity was prominent in their training:

- Participant 13 (physiotherapist): 'We were instantly failed on practical exams if you forgot to cover someone up.'

In terms of resources, staff shortages in hospitals and residential homes were cited as an important influence as they led to a lack of time available to care for patients and to 'burnt-out' staff, who were worn out trying to provide a decent service. However, problems with night staff and the reliance on agency staff were also reported. The problems associated with agency staff included expense, a lack of continuity of care, and a lack of interest in and personal involvement with patients:

- Participant 21: 'Some of them are not committed. Some wonder why they are doing the job. It's probably lack of training because they get taken on by agencies and they may get training in how to make beds, how to wash somebody, I don't think they do that actually.'

- Participant 24: 'They have got no idea about dignity.'

These problems with staff shortages are closely linked with organisational constraints. One constraint was associated with the task-oriented approach to the work that many people adopted. This was also linked with the current emphasis on NHS performance targets:

- Participant 37 (rheumatology team): 'People are very task oriented, I think so. 'We have to get this clinic through on time'; 'We have got to get all these patients through on time'; and one thing that often bugs me is that no one will go and tell the patients, well they do it sometimes but they often forget to turn around and say, 'Look we are really sorry but the clinic is running half an hour late, and there is nothing we can do about it but just bear with us', just explain to people but they often forget to do that.'

Furthermore, it was stated that the 'system' (whether an NHS ward or clinic, or a private residential care home) does not value issues such as dignity. Instead they value what gets done in terms of task-oriented jobs:

- Participant 34 (geriatrician): 'There is a great pressure of time getting things done and it is because what the system values, which is getting people off trolleys, getting them sorted out quickly, getting them through quickly and not being delayed, it's a factory.'

- Participant 35 (geriatrician): 'A disease factory.'

- Participant 34 (geriatrician): '... and the system, what gets measured is different, what gets measured is that'.

In addition it was also stated that a high-pressure career, such as being a doctor, make it much easier to depersonalise an individual.

- Participant 35 (geriatrician): '... but I think people operate under huge pressure and when people operate under huge pressure it's very easy to depersonalise the people that you are dealing with. It's very easy to focus on problems rather than people.'

This was compounded by the introduction of the 'managerialism' with its increased regulation, policies and procedures, which are perceived to be restricting:

- Participant 38 (social worker): 'It's an interesting dichotomy because what you have got is a whole group of professionals who are trying their damnedest to give people dignity and support and you have got a number of policies that are actually preventing you using that.'

These policies are seen to lead to increased administrative and clerical work:

- Participant 5 (physiotherapy assistant): 'That (data entry) is the priority as that is where the funding comes in order to get the patients in but the rule or protocol is that the data entry comes first.'

It is hardly surprising given the organisational culture described by these participants, that guidelines for dignity in care, even when available, usually have a low profile:

- Participant 31: 'It's in the ward philosophy. This is how we felt the patients on the ward should be cared for and looked after. I think it is still up in the ... '

- Participant 30: 'Says a lot, no one knows where it is. There is one, but I haven't seen it.'

The final type of barriers were the limitations of resources, which not only limited the care provided because of inadequate facilities such as sufficient space to promote privacy, but also pressurised staff because of the restricted access to home care services and residential care:

- Participant 38 (social worker): 'I think one of the problems, as well, is not just the shortage of places, but because of the shortage I mean the market cost of those places and what the local authority will pay and you are stuck between again trying to provide the support for the individual yet doing it within the framework that is set out and also within the possibilities that exist there physically because so many places are closing all the time.'

Discussion
The evidence from this study shows that while different types of provider in both NHS and social care appreciate the importance of dignity and dignified care there were marked variations in how dignity was defined.

There was also recognition of the gap between what providers would like to deliver and what they were actually able to deliver. Part of the reason for this discrepancy was the limited focus of the service providers, in which those involved in the 'dirty work' of providing frontline care were required to be task-oriented. It also reflected the inadequacies in and lack of emphasis on the training of some of the occupations.

There also appears to be a need for professional groups to take responsibility for prioritising dignified care and ensuring any guidelines are implemented. However, there are clear organisational and resource constraints on service providers, not least the current culture of the NHS with its priority of performance targets and concerns about increasing access to care, the speeding up of the process of care and the patient's journey through the health service.

Conclusion
The evidence from these focus groups demonstrates that, in spite of the intentions of service providers and professionals, older people are not consistently provided with dignified care. The findings, although not complemented by evidence from observational research (Mills et al, 1994), confirm the picture from research carried out with older people (Woolhead et al, 2004) and in other contexts of care for older people (Twigg, 2000; Baldock and Haddow, 2002).

It has been suggested that the difference in the perspectives and realities of users and providers (Baldock and Haddow, 2002) is so marked that it cannot be bridged.

However, one of the keys to this may be time and the different time frames adopted by users and providers. Older users are time-rich but undervalued, while busy care providers are 'time-scarce' and their priority is to complete the tasks required of them.

The problem appears to be compounded by the current culture of 'the new' health service, which is characterised by government initiatives aimed at increasing patient throughput and access. This contrasts with the needs of older people, who require more rather than less time to be spent with them.

To achieve this, organisations providing care for older people need to move towards 'process time' (Twigg, 2000) so tasks can be organised around older people's needs and time frames. Without such changes there is a danger that 'institutional ageism' will persist in the health service.

Acknowledgement
This project is funded by the European Commission Fifth Framework (Quality of Life) Programme - contact no. QLGG-2001-00888.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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