Warmth and kindness to bring dignity in care

People feel their dignity is respected when the care they receive is delivered with human warmth and empathy. They are not: objects, burdens, numbers or aliens. They are us – cared for with kindness.

Other sections in this guide have looked at communication, relationships, rights, privacy and involvement – all important to social care which supports dignity. This section is concerned with feelings.

The undercurrent of grief and loss

Nurses and nursing staff treat everyone in their care with dignity and humanity – they understand their individual needs, show compassion and sensitivity, and provide care in a way that respects all people equally.

Royal College of Nursing, 2018 Principles of Nursing Practice

Over to you

Think about the following situations. Try to imagine how you would feel.

• JaneOpen

  Jane has early stage dementia, she also has type 2 diabetes and arthritis. Jane had lived very happily with her husband of 50 years but he died eight months ago. Jane is grieving and finding life alone very difficult. Jane has two daughters who both think she needs to consider moving to a care home.

  What does Jane need to consider about this suggestion? What questions might she have?

• NigelOpen

  Nigel is 92, never complains – in fact, he hardly speaks at all to the staff in the nursing home where he lives. He walks with great difficulty, often gasps when he gets up and frowns all the time. The staff say it’s just old age. But perhaps it’s pain that makes him behave this way?

You can think of many more possible situations like the ones above. One writer has described them as the, ‘undercurrent of grief and loss’ in care homes and other settings, which may be unnoticed by care workers. Pain – physical or emotional – may go unrecognised and untreated. What’s missing here?

The report of Sir Robert Francis on the inquiry into Mid-Staffordshire NHS Foundation Trust was published in 2013. Among many other things, it emphasised the need for compassionate care. He said that patients ‘must receive effective services from caring, compassionate and committed staff working within a common culture’.

Qualities of compassionate care

Here are some definitions of compassion in care, taken from Compassion, dignity and respect in health care (Health Foundation, 2014).

• ‘Compassion comes from that moment when we can see the world through somebody else’s eyes.'
• ‘Compassion is about treating patients with dignity, respect and empathy.'
• ‘I think it’s particularly powerful when we are feeling vulnerable, in physical or psychological pain, or when we are afraid.'
• ‘The consistent theme is that it’s always the smallest things that make the greatest differences.’
• ‘You hear so many stories nowadays of people being treated as a number.'
• ‘Compassion isn’t just about talking to the patients – it’s making them feel safe in a nice clean environment, where they can feel at home.'
• ‘I think that the most valuable gift that we can give each other, and give the patients, is the gift of time.'

The need for compassionate care was reflected in the personalisation debate, and in the discussion of the full implications of the Care Act 2014. The ‘wellbeing principle’ set out in the Act covered not just the practical elements of a good life, but also the feelings of the individual – their need for personal respect and emotional wellbeing.

Research has shown that people appreciate the qualities care staff bring to their work. For example, use of humour, respectful attitude and committed (What do older people want from their care services)

What would matter more is a wee bit of attention, not to be in such a rush. Now they do everything, and everything is done, but ... well he wouldn’t feel that he was just a vegetable, that he wasn’t a person. It’s all about personality ... the friendly touch.

Family carer (SPRU 2005, University of York)

Quality conversations and relationships

In Commissioning home care for older people, Scie found that most people being cared for at home want a warm relationship with their paid carers and place a lot of value on conversation.

A friendly and sociable carer is regarded by people who use services to be a marker for whether they are a good carer or a poor one. Paid carers themselves complain that they often don’t have time to talk to their clients, and that this part of their role is not recognised as important.

The following SCIE video looks at domiciliary care with a particular focus on relationships. Getting the right relationship between staff members and the people they support is fundamental to excellent care.

 View the full video

A team from the University of Leeds has looked at the ways in which ‘good’ relationships develop in extra care communities, from the perspectives of residents, families and service providers. People participating in the study were asked to rank a series of statements that represented the elements of good quality relationships. They were organised under the headings:

1. Integrity
2. Respect
3. Fairness
4. Compassion
5. Trust

Allowing time to listen has been shown to be crucial to the development of real relationships repeatedly, as well as a way of expressing empathy.

Over to you

Look at the examples below.

• AssumptionsOpen

  It’s really important that you get to know me. Take time to find out what I like, need and want. Don’t assume. If I can’t tell you myself, ask the people close to me.

  I am a man with Down’s syndrome and dementia, I was brought to England as a young boy from India. I can’t tell you what I like to eat.

  What will you do?

• In the gardenOpen

  The staff talk, but they don’t talk much, they don’t talk to you … I was put in the garden, I didn’t want to go in the garden…

  How can you find out what people want to do?

What are the possible effects for the person who uses the service, in relation to:

• self-respect
• safety
• inclusion
• autonomy
• resilience
• emotional wellbeing?

What qualities do you need as a worker in these situations?

• Practice example: HealthwatchOpen

  One of the homes … told them that – from the following week – 30 minutes was to be set aside each afternoon when care staff would give priority to just spending time with those more socially isolated residents, or those who were harder to engage.

  They were open, cheerful and very relaxed in the way that they communicated together, in an environment that seemed to me a home from home.

  What’s it like to live in a care home? (Healthwatch 2017)

• Practice example: Care Quality CommissionOpen

  They showed us that staff were patient and unhurried while supporting people. Where people needed more time to communicate their wishes we saw that the staff took the time to talk with them.

  They understood how important it was to give people the time and opportunity to express their wishes about their care and their lives in the home.

  Time to Listen in care homes (CQC 2012)

• Practice example: SCIEOpen

  This establishment is viewed as the residents’ home and various organisational practices reflect this philosophy:

  • There is minimal signage throughout. The building with a focus on only posting resident-related information; the assumption is that residents would not have signs at home.
  • There are conveniently located storage areas for equipment to keep the homelike appearance.
  • Doors, for example to the conference room, are intentionally left open so that residents have freedom to move around.
  • Beds are not made until after breakfast so staff can focus on resident dining, which is felt to be more important to resident quality of life.
  • Recreation is geared towards helping ‘the residents to live in the world we all live in’ (manager) by, for example, preparing and enjoying home-cooked meals and going fishing.

  Promising Practices in Long-Term Care (2016)

Meaning of home

The meaning of home varies from person to person, but it’s striking how often the term ‘homely’ is used to describe what’s good about services that are built around people and are based on what they want. ‘Home’, of course, suggests comfort, safety, human company and warmth -it makes you think of human-sized rooms and domestic furnishings. However, it also means the flexible routines and freedoms of ordinary life.

 View the full video

The messages from the SCIE video make it clear how important it is for someone to feel at home.

• Practice example: HealthwatchOpen

  Between January 2016 and April 2017, the Healthwatch network visited 197 care homes in England. Its report (‘What’s it like to live in a care home?’) covers what its volunteers saw and heard from residents, relatives and staff during these visits. It concluded that the best care homes recognise that they are people’s homes.

  The report says that the way individuals interpret ‘homeliness’ are – well – individual. For most, it will mean a pleasant, familiar environment. Perhaps their own furniture, pictures and photos. Most will want to maintain their family and neighbourhood networks, whatever care setting they decide to use. For others, keeping involved with their local club, always making a morning cup of tea, as usual, maintaining their interest in gardening or draughts, etc., will be important.

  They were open, cheerful and very relaxed in the way that they communicated together in an environment that seemed to me to be a home from home.

  Healthwatch volunteer

  The report continues: ’People need care that helps them keep up their interests, stay as active as possible, and maintain the relations they would have in their own home ... Local Healthwatch heard from residents that feeling at home is also important, although the meaning of this can change depending on the setting…Feeling at home is deeply individual.’

• Practice example: The Cinnamon TrustOpen

  A pet may be a lifeline for an individual, particularly if they have lost loved ones. Where people may have lost partners, friends or their home, losing a much-loved pet may seem like the last straw.

  The Cinnamon Trust offers support to pet owners who need help at home, or in residential care.

  We keep them together – for example, we’ll walk a dog every day for a housebound owner, we’ll foster pets when owners need hospital care, we’ll fetch the cat food, or even clean out the bird cage…When staying at home is no longer an option, our Pet Friendly Care Home Register lists care homes and retirement housing happy to accept residents with pets …

In this SCIE video, people with high support needs talk about what they value, and how they want to continue to live their lives.

 View the full video

Understanding the feelings of people who use services depends on the values of staff, the culture of the organisation, and – above all – on leadership.

Tools for commissioners and managers include:

• a human rights-based approach to leadership, (see e.g. Rights in roles: Leadership, brap, 2016)
• values-based recruitment (see Study into the impact of a values based approach to recruitment and retention, Consilium/Skills for Care, 2016)
• compassionate commissioning, using insights from people, carers and frontline staff about what really matters to them in order to commission services that make a difference to the population

Finally

This section has been concerned with the threats to a person’s dignity which arise from feelings that go unnoticed and pain which is not recognised. These may include:

• Grief for the loss of a partner, or a valued way of life. By definition, older people in residential care may experience the loss of friends, including new friends made in the home. There is no evidence that many bereavements make them easier to bear.
• Anger and frustration, which people may feel at their changed circumstances, and the impossibility of making themselves understood to their new carer workers.
• Physical and mental pain, arising from multiple chronic and disabling medical conditions. These may be seen by care workers as ‘normal’ for an older person, instead of crises needing urgent treatment.

People in these situations need care that is based on empathy, sensitivity, warmth, transparency and time. They don’t just need one talented and kind individual – they need an organisation that recognises and rewards compassionate care.