SCIE Practice guide 09: Dignity in care

Respect

Key points from research and policy
Practice points
Ideas from practice
Other resources

'Respect is the objective, unbiased consideration and regard for the rights, values, beliefs and property of all people.' (Wikipedia, 2006)

The Dignity in Older Europeans study (Tadd, 2005) found that: 'Respect for personal identity is the critical aspect of dignity that has to be addressed in health and social care.’ A number of issues relating to respect were highlighted in the Department of Health (DH) online survey (DH, 2006d). People expressed concerns that they were not treated as an adult or as an individual, that they were not seen as a whole person but viewed in terms of their illness or disability and that they were not listened to or given time to talk. These findings are supported by further DH evidence in Now I feel tall (522kb PDF file) (DH, 2005b) in which NHS patients reported feeling 'isolated, overwhelmed by the experience and treated like a number instead of an individual’.

The research overview highlights a number of issues relating to respect: staff and family attitudes, patronising and disrespectful ways of addressing older people, being treated as an equal and issues relating to death and dying, such as control of suffering and maintaining a respectable appearance. The DH End of Life Care Programme (DH, 2006e) aims to improve the quality of care at the end of life for all patients and enable more patients to live and die in the place of their choice.

The research also associates ageism and other forms of discrimination with the lack of respect for older people and, clearly, there are implications here for wider society. Intergenerational community work has been suggested as one way of tackling ageism.

Respect has been summarised in terms of courtesy, good communication and taking time (Davies et al., 1997, Woolhead et al., 2004, Woogara, 2005, Calnan et al., 2005, Birrell et al., 2006, Bayer et al., 2005). In a Swedish study (Randers and Mattiasson, 2004), the identification of 'authentic autonomy’ was found to be dependent on 'full documentation of a patient’s previous history, preferences and habits’. Patients in a US study (Jacelon, 2004) found that 'consciously reviewing their previous lives and achievements’ was a strategy that helped them to maintain a positive attitude and to 'resist the demoralising effects of their situation’. My Home Life: Quality of life in care homes (Owen, 2006) asserts that maintaining a sense of identity is key to retaining self-esteem. For people with dementia, reminiscence activity has been used for many years to reaffirm the identity of individuals based on their own personal history.

A small study into residential care (460kb PDF file) (PG Professional and the English Community Care Association, 2006) found that: 'Residents’ primary desire … is to be cared for with respect and dignity as an individual and to hold onto their independence’. Residents emphasised the importance of staff spending time to chat with them and felt that frequent staff changes made it difficult to build positive relationships; they were concerned that care was task-oriented rather than person-centred. Another study into staff views (Calnan et al., 2005) reiterates this point: '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.’ The research overview found evidence from a range of surveys which showed that the qualities most valued by older people in home-care services were reliability, continuity and the quality of the relationship with the care worker.

It is clear from the evidence above that people value respectful delivery of services over task-oriented care and, getting to know people for what they are is, therefore, an essential aspect of person-centred health and social care practice.

Key points from research and policy

Being respected as an individual is very important to older people receiving health and social care services.
Older people want a workforce that is patient and takes the time to listen to individuals and does not rush care (DH, 2006d).
Getting to know service users as individuals, people with a history, is key to providing person-centred care (Randers and Mattiasson, 2004, Jacelon, 2004, Owen, 2006, PG Professional and the English Community Care Association, 2006).
Staff respect for service users and their carers and relatives is enshrined in Standards for Better Health (78kb PDF file); this also encompasses respect for people’s diversity (DH, 2004e).
The Essence of Care benchmarks for privacy and dignity are based on the need for respect for the individual (DH, 2003c). National minimum standards for domiciliary care (249kb PDF file) require that: 'The service should be managed and provided at all times in a way which meets the individual needs of the person receiving care, as specified in their care plan, and respects the rights, privacy and dignity of the individual (DH, 2003b).
National minimum standards for care homes (340kb PDF file) states that: 'The principles on which the home’s philosophy of care is based must be ones which ensure the residents are treated with respect, that their dignity is preserved at all times, and that their right to privacy is always observed’ (DH, 2003a).
The NHS core standards require that healthcare organisations have systems in place to ensure that 'staff treat patients, their relatives and carers with dignity and respect’ (DH, 2004e).
The National Service Framework next steps (692kb PDF file) aims to ensure that, within five years, all older people receiving care services will be treated with respect and dignity (DH, 2006h). The report acknowledges the need for wide-reaching culture change and zero tolerance of negative attitudes towards older people.
Barriers to providing person-centred care have been identified as: increasing bureaucracy, tighter budgets and restrictive commissioning leading to limited time, poor and inconsistent management and a mixed picture on training (Innes et al., 2006).

Practice points

Ensure that treating older people with respect is fundamental to training and induction for all staff (including domestic and support staff) and followed up by supervision and zero tolerance of negative attitudes towards older people.
Ensure that the service is person-centred and not service- or task-oriented.
Ensure that service users are asked how they would like to be addressed and that staff respect this.
For people with dementia, reminiscence activities may support the maintenance of a person’s identity.

Include 'time to talk’ in care plans. In residential care this may be time spent with the keyworker to discuss any concerns or plan activities. In home care this can be a vital resource for very isolated people. Voluntary organisations and befriending services may be able to provide some support in this area but the importance of staff taking time to talk cannot be underestimated.
Involve older people in service planning and respect the views of individuals by ensuring their ideas and suggestions are acted upon.
Support intergenerational community activities to tackle preconceived ideas and discrimination against older people.

Ideas from practice

Practice examples are self-reported and have not been evaluated.

Other resources

'Let’s respect’ resource box (Department of Health) - Launched in October 2006 as part of the Let’s Respect campaign commissioned by the Department of Health, the box contains powerful images and uses case studies to provide information and practical suggestions on how to better meet the mental health needs of older people, focusing particularly on acute care. There is also a pocket guide published by the 'Nursing Standard'. A number of boxes have been made available for acute hospital trusts, and boxes can be purchased from the social enterprise group, BlueSci.

Link: BlueSci

For further information contact Deborah Sturdy, Senior Nurse Adviser (older people). Email Deborah.sturdy@dh.gsi.gov.uk or Nadine Schofield, National Lead for Older People’s Mental Health, CSIP. Email nadine.schofield@csip.org.uk

Now I feel tall (Department of Health) - offers practice examples on 'being talked to and listened to as an equal’ and 'being treated with honesty, respect and dignity’. End of life care information and tools are available at the:

Link: Now I feel tall (522kb PDF file)

Link: NHS End of Life Care Programme (DH website)

Link: NHS End of Life Care Programme (NHS website)

Link: SCIE research briefing 10: Terminal care in care homes

The Greater London Forum for Older People released a 10-minute training film, 'What Do You See?' directed by Amanda Waring and starring Virginia McKenna. The film, which promotes seeing older people in a fresh light, is a powerful and evocative story and perfectly illustrates the key message that we must see older people as individuals rather than as part of a category. This is not a free resource (funds raised go to Macmillan Cancer Relief and Help the Aged).

Link: 'What Do You See?'.

Positive Steps is new, web-based guidance that sets out some of the key mental health issues and cultural needs for different black and minority ethnic (BME) groups, and includes lists of useful contacts and resources. It also describes some of the excellent work done for others to draw on. The Positive Steps online Supporting race equality in mental healthcare guide was produced with the help of mental health care staff and community workers and offers advice and support for better responding to the needs of BME patients. This web-based guidance sets out some of the key mental health issues and cultural needs for different BME groups.

My Home Life website - new website aimed at care home owners, managers, staff members, education facilitators, residents, relatives, commissioners and inspectors. The website provides:

evidence-based briefings to help you deliver quality outcomes for your residents.
a shared space to exchange ideas and communicate with other care homes.
educational resources linked to a vision for best practice.
an opportunity to join a movement for change - promoting and
sharing best practice in care homes.

Link: www.myhomelife.org.uk

Building on firm foundations - offers a range of practice examples for improving end of life care in care homes. Produced by the National Council for Palliative Care and the NHS End of Life Care Programme.

Link: Building on firm foundations (PDF file)

Not on their way out (DVD) - People from Hertfordshire give their views on dignity and respect in the final section of the DVD. Supporting material is available in the Discussion Points document.

Link: Not on their way out
Link: Discussion Points

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