Overview of selected research: Introduction
This overview of selected research, inspection, policy and practice documents draws on British and international literature that relates to dignity in health and social care. It is not a comprehensive review, but aims to offer a window on some of the key issues and debates. Throughout, the principal focus is on what people experiencing care themselves have said about why dignity is important, and - often more easily described - what threatens dignity. Research and practice have identified the special importance of dignity to older people, and their opinions and experience are central to this account.
- Background - fills in some of the public policy background, and describes a growing awareness of the importance of dignity to the wellbeing of people who use services. But what exactly is dignity?
- What 'Dignity' means - considers what dignity means. It outlines some of the many studies that have attempted to define dignity, list its characteristics and refine methods of analysing and evaluating care, which supports it. The section ends with a summary of what appears to be the current state of knowledge about the meaning of dignity.
- What protects Dignity? - outlines what protects dignity. It examines factors identified in the literature that support the dignity of older people in care settings. These include the inner strength and resilience of older people themselves, the range of rights which should protect them and the development of personalised care, which puts the needs and wishes of the service user at the centre of care planning and provision.
- What threatens Dignity?- considers threats to dignity. These are not just the everyday incidents that dent self-esteem, weaken autonomy and remove privacy. They derive from the fundamental ways in which society is organised, and require fundamental remedies. They include ageism and age discrimination, the range of disadvantages and discriminations that can multiply the effects of ageism, and abuse - the violation of an individual's human or civil rights. A number of these ethical issues together influence society's attitudes towards the experience of pain by older people. The management of pain is one important, practical context in which older people's rights can be supported or overridden. Badly managed or unacknowledged pain has emerged from consultation as one of the most powerful threats to older people's dignity.
- Dignity in practice - moves on to dignity in practice, and considers the messages from the literature about a range of contexts - at the end of life, at home, in hospital, in care homes, and in settings which care for older people with mental health problems. There are issues common to all settings, but also some clear differences, which have important implications for practice.
- Gaps in the research - a brief final section summarises some of the apparent gaps in the current literature.
There are three conclusions that can be drawn from this selected overview of the literature. First, there are some themes which occur again and again, many of which coincide with the findings of the Department of Health's online survey of people's views and experiences of care (Department of Health, 2006d).
Secondly, dignity itself has proved very difficult to define. For more than a decade, researchers have struggled to pin down what is in essence an ethical concept that varies according to the cultural, historical and philosophical contexts in which it is discussed. But we are concerned here with the practical question of supporting dignity in care in the 21st. century. Research has identified - through observation, interview and analysis - a list of attributes of dignity or factors which indicate its presence in care provision. International comparative research has confirmed that it is possible to generalise across the EU and North America about many of these attributes. Some researchers have gone on to develop means of supporting and evaluating care that preserves or creates dignity.
Everywhere, the literature reflects tensions and questions of balance: between preserving privacy on the one hand, and avoiding isolation on the other; between acknowledging autonomy and resilience, while offering close support; between actual frailty and dependence, and the need for continued usefulness; between setting clear service targets, and leaving room for flexible, holistic, personal responses.
But, at the same time, there is one very clear message from these documents. 'Dignity in care' obviously has meaning for people using care services - especially older people: this is the third key conclusion. Recognising and respecting what it means in terms of autonomy, privacy, respect, identity and sense of self-worth, and designing practice to support it, makes a critical contribution to older people's well-being. Ultimately, it may define what makes their lives worth living, right to the very end of life. Dignity is never simple, but always important.