SCIE Practice guide 09: Dignity in care
The guide: a summary
This guide has been designed for people who want to make a difference and improve standards of dignity in care. It has been compiled to support the Department of Health’s wider Dignity in Care initiative and includes the Dignity Challenge.
The guide provides information for service users on what they can expect from health and social care services, and a wealth of resources and practical guidance to help service providers and practitioners in developing their practice, with the aim of ensuring that all people who receive health and social care services are treated with dignity and respect.
Overview of selected research
This describes evidence from selected research, inspection, policy and practice literature about the idea of dignity and its application in health and social care services for older people. Throughout, the focus is on what older people themselves have said about why dignity is important and - often more easily described - what it is that threatens dignity.
There is one very clear message from these documents: 'dignity in care’ obviously has meaning for older people. Recognising and respecting what it means to them in terms of autonomy, privacy, respect, identity and sense of self-worth, and designing practice to support it, contributes to older people’s well-being, and - ultimately - to what makes their lives worth living. Dignity is never simple, but always important.
The first part of the report looks at some of the public policy background to dignity in care, and attempts to clarify the range of ways in which the term 'dignity’ is understood.
The meanings of dignity
Research with older people, their carers and care workers has identified dignity with four overlapping ideas:
- Respect, shown to you as a human being and as an individual, by others, and demonstrated by courtesy, good communication and taking time
- Privacy, in terms of personal space; modesty and privacy in personal care; and confidentiality of treatment and personal information
- Self-esteem, self-worth, identity and a sense of oneself, promoted by all the elements of dignity, but also by 'all the little things’ - a clean and respectable appearance, pleasant environments - and by choice, and being listened to
- Autonomy, including freedom to act and freedom to decide, based on opportunities to participate, and clear, comprehensive information.
Factors which protect, support and promote the dignity of older people in health or social care contexts are grouped under three headings:
- Resilience describes the inner strength which, research has found, enables older people to bear difficult situations. A sense of self-worth and meaning was maintained by many, by reference to their families and previous life experiences and achievements, and a focus on everyday pleasures. Resilience could be reinforced or undermined by care workers.
- The rights of older people receiving care at home, in hospital or care homes are outlined here. Some analysts see the enforcement of these rights, and increasing awareness of them among service users as the best way to overcome outdated attitudes and systems. Inspection and research have found that the framework of rights is gradually affecting standards of care.
- Person-centred care puts the needs and aspirations of the individual service user at the centre of planning. Embedding the principles of person-centred care is still in progress, and evidence is mixed about how successfully this is being done. Barriers to achieving this kind of care in some settings include bureaucracy, tight budgets and restrictive commissioning which, reduce staff time for flexible, personal care.
The overview identifies threats to dignity with fundamental ways in which society is organised:
- Ageism - prejudice against people purely on grounds of age - has been challenged by legal and policy changes which have successfully combated overt discrimination against older people - for example, in some areas of the NHS. But ageist attitudes and practice remain a serious issue, demanding much further effort.
- The effects of ageism are compounded for many older people by other forms of inequality, disadvantage and discrimination. These include poverty, social class, gender, ethnicity, physical and learning disabilities and sexual preference.
- The abuse of older people has been increasingly recognised as a serious issue in health and social care. Despite legislation to protect vulnerable adults, and detailed guidance for local action, there is evidence that more remains to be done.
The remainder of the overview considers dignity in practice - messages from the literature about dignity in care, in a range of different care settings: at home, in acute hospital, in care homes, in the care of older people with mental health problems, and at the end of life. The fundamental importance of care which respects and supports dignity is the same everywhere, but the implications for practice vary from context to context.
Dignity has proved difficult to define. Researchers have struggled to tackle what is in essence a philosophical idea, and to tie it down with observation, interview and analysis. Everywhere, the literature reflects tensions and questions of balance: between preserving privacy on the one hand, and avoiding silent isolation on the other; between acknowledging autonomy and resilience, while offering close support; between actual frailty and dependence, and the need for usefulness; between setting clear service targets, and leaving room for flexible, personal responses. There are also some gaps in the literature, about the meaning of dignity for some groups of older people, and the specific impact of services on them. But there is one overriding message - that dignity in care matters to older people - and there are consistent themes about what protects or threatens it.
Factors affecting dignity
Ten subject areas relating to dignity were highlighted by older people and their carers in the Department of Health online survey carried out in 2006. The guide takes each of these and covers:
- a brief exploration of the theme
- key points from research and policy
- practice points: what the research highlights, distilled into practical recommendations
- ideas from practice: practical applications from organisations involved in the care of older people, to support and inform those wishing to develop local services
- Other resources: links to related websites, sources of information and tools.
Respect
Respect is summarised in terms of courtesy, good communication and taking time. It covers: staff and family attitudes, treating older people as equals and issues relating to death and dying, such as control of suffering and maintaining a respectable appearance. It is clear that people value respectful delivery of services over task-oriented care, and getting to know people for what they are is an essential aspect of person-centred health and social care practice. Ageism and other forms of discrimination constitute a lack of respect, and intergenerational community work has been suggested as one way of tackling ageism.
Communication
Good communication begins with addressing a person as they would wish and speaking to them with respect and without condescension - dignity is threatened by treating adults 'like babies’ because of actual or assumed incapacity. Translators, specialised equipment and greater cultural understanding can all help overcome different kinds of communication difficulties. The value of overseas workers in health and social care cannot be underestimated, but it is important that support and training ensure their communication skills are adequate. Good communication is also about providing the right information at the right time, and about building confidence and trust. Older people, especially in residential care, feel more secure by seeing the same faces every day; this presents particular challenges for managers in terms of recruitment, retention and training.
Social inclusion
Age discrimination, sometimes alongside other forms of discrimination, can contribute to the social isolation of older people. The risk is greater for people living alone and the very elderly, and can be increased by bereavement, loss of work or poor health. Such isolation can contribute to the incidence of mental illness, particularly depression. Older people are concerned about lack of social contact with others, lack of meaningful activity and wanting to feel needed. Opportunities to participate, and make a positive contribution to community and society, are integral to dignity. Maintaining contact with family and friends, participating in cultural and community activities and using skills all contribute to social inclusion, and involving older people at all levels of service planning and delivery is an important part of getting it right.
Autonomy
Autonomy is about independence but also control and choice over one’s life. Being supported to continue with routine daily tasks such as shopping, walking a dog or going to a social club can be instrumental in maintaining a person’s autonomy. Autonomy is particularly at risk where a person needs help with their most basic and private needs, as may happen in hospital or residential care, or when impairment affects their ability to communicate. Advice and support with decision-making, advocacy support and schemes such as individual budgets are all key to ensuring that older people can exercise autonomy. Proposed amendments to the Mental Capacity Act and involving older people in staff training are positive moves, but a major culture shift is required to support the autonomy of people within the health and social care systems.
Privacy
Aspects of privacy include: modesty and privacy in personal care, confidentiality of treatment and personal information (particularly when using interpreters), and privacy of personal space and belongings, which extends to personal conversations and mail. The Department of Health has given a clear public commitment to eliminating mixed-sex accommodation for hospital inpatients, and many service providers have improved privacy through small but important changes to facilities, systems and staff training. It is important to achieve a balance so that vulnerable people are not either isolated by privacy policies or put at risk, for example through providing privacy for personal and sexual relationships.
Hygiene and personal appearance
A person's appearance is integral to their self-respect and older people need to receive appropriate support to maintain the standards they are used to. Self-respect can be undermined by neglect of patients' appearance and clothing and, even in death, maintaining a respectable appearance is very important to people. Personal preferences should be respected and care taken with details such as respect for laundry. Appearance and hygiene also affect the living environment: a clean and tidy house and a well-kept garden are important aspects of maintaining dignity in daily living - an overgrown garden alone can give out the message that a person is unable to cope. Older people really value support which enables them to live in their own homes, for example, help with cleaning, DIY, gardening, pets, chiropody, transport and befriending.
Mealtimes
Food and mealtimes are a high priority for older people (a top priority for those from black and ethnic minority groups), and mealtimes are the highlight of the day for many people in residential care. Despite a raft of guidance, there are still serious concerns about meals in the health and social care sectors. Nutritional screening should be a key part of care planning: malnutrition affects over 10 per cent of older people, and is costly in economic terms as well as for individual health. Mealtimes should also be seen for their social opportunities: initiatives include local lunch clubs, and many hospitals have introduced 'protected mealtimes'. While socialising should be encouraged, privacy and discreet support is needed to avoid embarrassment or loss of dignity for those who have difficulties with eating.
Complaints
Complaints should be viewed as a means of ensuring that a service is responsive and not as a threat. Service providers should ensure that there is a fair, open and honest culture around complaints and a simple complaints procedure, so that people feel confident in bringing concerns to their attention. In this way problems are picked up at an early stage, poor practice is highlighted and rectified and the lessons learned lead to service improvements. People, especially older people, often find it difficult to complain - through worries of not being understood, or fear of retribution or being seen as a 'trouble maker'. This section includes advice for complainants, and provides contact details of who to complain to in different circumstances and who can help with making a complaint.
Whistleblowing
It takes a great deal of courage for an individual to raise concerns about poor practice or abuse within an organisation. Attitudes are changing, but a lot still needs to be done to ensure that workers feel safe enough to air concerns. For organisations there are clear advantages to supporting whistleblowers, including the safety of staff and service users as well as the organisation's reputation. If whistleblowers are viewed in a positive rather than negative light, then more people will be willing to come forward; the consequence of this will undoubtedly be better protection for vulnerable people. Organisations should implement a whistleblowing policy and staff need to know they will be offered protection if they make a disclosure in good faith - new staff, in particular, are often in a position to be more objective than existing staff members. The section includes do's and don'ts on whistleblowing and who can provide support.
Abuse
Abuse, which encompasses physical and sexual abuse, threats, harassment, exploitation and neglect, is far wider ranging than the remit of this guide, but this short section outlines immediate action that should be taken if abuse is suspected and provides leads to suitable further resources.
Quick links
This section of the guide provides direct access to practical ideas, resources and information on:
Previous: Quick links
Next: Overview of selected research: Introduction
