Promoting patients' dignity in an acute hospital setting Dr Lesley Baillie London South Bank University [email protected] 0207 815 8457 Background Patients’ dignity must be respected: legislation (Human Rights Act, 1998), Codes of Professional Conduct (NMC, 2004; ICN, 2001a, 2001b) and health policy (DH, 2001a, 2001b; 2006) However, patients are vulnerable to a loss of dignity in hospital (Seedhouse and Gallagher 2002; Jacelon, 2003; Matiti and Trorey, 2004). Lack of research relating to patient dignity and few studies have explored patients' perspectives. Most previous research relates to older people in long-term settings or terminal care. Aims To: Explore the meaning of patient dignity; Examine how patients' dignity is threatened; Investigate how patients' dignity can be promoted In an acute hospital setting. Research design A holistic research design to explore all the factors which could affect patient dignity – a qualitative multi-method case study (Yin, 2003) Local Research Ethics Committee gave approval The research was conducted in a district general hospital of one acute NHS Trust The study was registered with the Trust’s Research & Development Office. Research participants and setting Based on one surgical ward, specializing in urology Patients’ ages ranged from 34-92 years (mean = 64 years), 9 women and 15 men, varying socio-economic backgrounds Staff participating were ward based (registered nurses and health care assistants), visiting staff (specialist nurses, doctors and allied health professionals) and senior nurses (ward & Trust-based) Research methods Data collection method Participants Interviews 12 recently discharged patients 6 senior nurses Participant observation: 12 4hour care episodes and 12 staff handovers 12 in-patients 26 ward-based staff (nurses and healthcare assistants) 16 visiting staff (doctors, allied health professionals, specialist nurses) Informal interviews following observation Above 12 in-patients observed 13 ward staff with key involvement in the 12 observed patients' care Document analysis Ward/hospital policy documents Overview of findings Threats to patients’ dignity in hospital: environment staff behaviour patient factors Patients’ dignity in hospital: Feelings Physical presentation Behaviour to and from others Promotion of patients' dignity in hospital: environment staff behaviour patient factors Feelings associated with dignity Feeling comfortable Safe Happy Relaxed Not worried Knowing your privacy is not invaded without invitation Not feeling embarrassed Well-being Feeling in control Able to cope Confident Feeling valued Self respect Self esteem Of consequence Cared about Patients’ dignity in hospital Personal feelings – 'feeling generally happy with your surroundings and where you are and who you're with and not feeling embarrassed by whatever.’ (Mr A) ‘Feeling that you're in control of your treatment.‘ (Mrs Z) Physical presentation – 'just not showing your body to other people I think. Just keeping it covered all the time.‘ (Mrs Y) Behaviour to and from others – 'Respect from other people isn't it? Respect and people treating you as you treat them, and not making you feel small.‘ (Mrs X) The meaning of patient dignity 'Patient dignity is feeling valued and comfortable psychologically with one's physical presentation and behaviour, level of control over the situation, and the behaviour of other people in the environment'. Patient dignity How patients’ dignity is threatened or promoted in hospital Dignity and being in hospital 'It's not a comfortable environment at all, coming here. It can be pretty uncomfortable. Whatever we do is not nice. It either hurts or it's unpleasant, or they're put in an uncompromising position.' (Senior Nurse 4) 'In hospital you expect to be put into situations where you may feel a certain loss of dignity I suppose.' (Mr A) 'It's [being in hospital] like having to take a step from your outside world into a totally different one and you kind of come to terms - before you go in there.' (Mrs X) 'You leave your dignity on the doorstep and pick it up on your way out. (Mrs W) 'You've got to be cooperative in hospital in a different sort of way. You've got to submit yourself to things you wouldn't usually put up with.' (Mr B) Patients’ vulnerability : impaired health Loss of function 'Not being able to do much for herself [Mrs V, postoperatively] at the moment leaves her a bit vulnerable.' (Nurse 2) Diagnosis-related intimate procedures ‘The very fact that you have a catheter and you were having your urine bag changed every so often - it's not dignified.’ (Mr C) Psychological impact of diagnosis. 'If you're in the realms of the unknown when you're desperately ill and you don't know anything about the illness you've just got to lie back and let them [staff] deal with it.’ (Mr D) Patients’ vulnerability: older age Physical health: 'When you're sort of fairly old and they've got to come and help you do this and do that.' (Mr E) But: no clear cut link between older age and dependence - health problems were the central issue, e.g. post-operatively, Mrs V (in her 40s) was far more dependent than Mr F (in his 90s). Upbringing: 'I'm a man who was brought up in the innocent age if you want to call it that and your body being touched and played with by women and that kind of thing is a bit difficult.' (Mr G) How the hospital environment threatens dignity: lack of privacy 'You don't know what to experience in a hospital. I mean the privacy was - it's quite a shock to see people considerably worse off than you.' (Mr D) Privacy provided by curtains is easily jeopardised 'Other patients can hear [what's happening] even with the curtains round. Curtains are a visual but not a hearing barrier.' (Nurse 13) A mixed sex environment and risk of bodily exposure in hospital further threatened privacy Mixed sex environment The ward was mixed with single sex bays but due to bed shortages, ward staff were sometimes pressurised into mixing bays: 'The staff are very well aware that we do not mix the bays. And I do have fights sometimes with the managers. And I don't like it.' (Senior Nurse 1) Patients felt uncomfortable in mixed bays: ‘With all girls here, patients might not always pull the curtains round if they are getting out of bed but with a man here, the curtains have to be pulled.’ (Mrs U) Bodily exposure in hospital Occurred due to hospital procedures - was an issue because the ward was a public place and patients were surrounded by strangers. Urology patients: 'They're in for treatment of their private genitalia area so that they're always that bit self conscious - that bit aware of the bits that are exposed that shouldn't be exposed.' (Senior Nurse 3) [wearing a hospital gown] 'was one of the worst bits, to be absolutely honest - that was one bit where you hadn't got any dignity.' (Mr E) How the hospital environment threatens dignity: Hospital systems Bed management: 'I went in three different beds before I ended up in urology because they didn't have room anywhere - but being trundled around like that … you feel a bit helpless.' (Mr C) [if] 'you were treated more like a human person than on a conveyor belt that would be very nice.' (Mrs X) 'Sometimes people aren't taken as individuals, they're taken as a sort of en masse really.' (Senior nurse 4) Workload: 'I felt in hospital that the question of dignity doesn't necessarily come into question when doctors and nurses and auxiliary staff are flat-out doing what they have to do’. (Mr H) How staff behaviour threatens patients’ dignity Curtness: ‘brusque’, ‘off-hand’, ‘curt’, ‘stand-offish’. 'having a lack of conversation, doing a job in a matter-of-fact way and not bothering much about it.' (Mr F) Authoritarianism: 'One or two of them you sort of feel a bit annoyed at being bossed around.' (Mr A) 'It's like you're a thing in a bed and I'm coming round. You have to have all these tablets whether you want them or not.' (Mrs Z) How staff behaviour threatens patients’ dignity Breaching privacy A few participants identified that staff occasionally breached privacy, e.g. 'people come and peep round the curtains' (Nurse 2). Mr A explained how during a bladder washout, a staff member intruded and chatted to the nurse carrying out his procedure, which caused 'a certain loss of dignity'. Promotion of patient dignity in hospital: patient factors Attitude: rationalisation, humour, acceptance ‘Encroaching on the body’s modesty when undergoing treatment is a necessity – it’s just part of their (staff’s) job’ (Mr J) ‘If you look on everything light heartedly and you can have a laugh and a joke with the staff that's half the battle (Mr E) 'In some ways I suppose I've lost my dignity but I've accepted it.' (Mrs T) Promotion of patient dignity in hospital: patient factors Relationships with staff: ‘I know it's hard in hospital because obviously you are in pain, and you are suffering, but it doesn't cost much to be nice to people’ (Mr K) 'I didn't do anything about it. I didn't want to upset anybody because I don't want anybody taking it out on me. [Laughs] Not that they would but you know what I mean' (Mr A) Ability & control: I didn't sort of suffer with anything like that as such. I suppose it's because I was sort of younger and fitter than a lot of chaps that were in there' (Mr E) Promoting patients dignity in hospital: environment Conducive physical environment and facilities: A clean, well-maintained environment makes patients feel valued ‘This ward has more open space - it's clean and new - it makes you feel better’ (Mr L) The ward layout (small bays with a bathroom) were popular with almost all the patients ‘It makes it easier doesn't it to sort of manoeuvre about - you don't have to go walking down a long corridor with your frock [gown] flapping in your bottom' (Mr A) 'There's only five beds in a bay, so you can talk to everybody' (Mr E) Promoting patients’ dignity in hospital: Dignitypromoting ward culture and leadership Almost half the patients referred to aspects of ward culture and leadership which promoted their dignity. 'There's a very caring, respectful approach. The ward is friendly - there's a nice feel about the place. People on this ward are sensitive to making you feel dignity is promoted all the time' (Mr M) 'I think that goes down to the sister that was on the ward. I think she was brilliant with her staff - everybody has a massive amount of respect for her’ (Mr H) 'We're quite a good team. We're here for the patients. Want to deliver the best for them. I like to think we're quite patient focused and like to treat the patients as individuals’ (Senior nurse 4) Promoting patients’ dignity in hospital: Support from other patients Camaraderie between the patients who understood what each other was going through and supported and helped each other. o the comfort of being on a ward with patients with similar conditions: 'all in the same boat' o ‘Everybody realises there's something going on behind those curtains but - so what - they're all in the same boat' (Mr C) o 'The patients are quite respectful in this ward - they were quite friendly’ (Mr G) o 'Everyone [other patients] seems to root for everyone else’ (Mrs S) How staff behaviour can promote patients’ dignity in hospital: providing privacy Providing environmental, body and auditory privacy: ‘The nurses there were straight round with the curtains as soon as anything happens' (Mr K) 'The staff who bring the water round know not to go in if the curtains are round' (Nurse 1) ‘You should never expose any more of the body than absolutely necessary when carrying out care’ (Nurse 1) ‘You have to be aware that voices carry’ (Nurse 15) When Mrs V was too unwell 'couldn't be bothered' to maintain her own dignity, ‘staff stepped in and straightened me up' saying things like 'you don't want the men seeing you’ How staff behaviour can promote patients’ dignity: Therapeutic interactions Interactions that make patients feel comfortable : use of humour, reassurance, friendliness and professionalism: the staff: 'were all a good laugh, which helped all the way round, basically'. (Mr E) 'They're [nurses] friendly - they put you at ease’ (Mrs U) A professional manner portrayed efficiency and competence and inspired confidence in patients, making them feel safe and comfortable. Mr G talked of the nurse's approach while taking his catheter out saying that: 'she did it very nicely without any bother or fuss or anything'. How staff behaviour can promote patients’ dignity: Therapeutic interactions Interactions that made patients feel in control: explanations and information giving, offering choices, gaining consent and promoting independence: ‘She [Nurse 14] said 'Would you like your paracetamol now?' Not 'Here's your paracetamol' or 'Here's your tablets' without telling me what they are' (Mrs Z) 'Telling you exactly what's going on - if people say what's going to happen that makes you feel more able to cope'. (Mrs X) How staff behaviour can promote patients’ dignity: Therapeutic interactions Interactions that made patients feel valued: helpfulness, consideration, showing concern for patients as individuals and courteousness 'From the cleaner to the sister, I got the same respect, which was nice' (Mrs W) 'If you say you can't get to the toilet they'll bring you a commode - never make a fuss'. (Mrs Z) 'Staff were always concerned about you. As much as they have twenty other odd patients but they did always enquire how you were'. (Mrs R) 'It wasn't assumed that I wanted to be known as my Christian name' (Mrs W). Conclusions Feelings are central to dignity: physical presentation and behaviour to and from others affects patients’ feelings Patients are vulnerable to a loss of dignity in hospital due to their health condition which led to their admission The hospital environment and staff behaviour may increase or decrease patients’ vulnerability to a loss of dignity occurring. Patients' use their own strategies to counteract threats to dignity, with varying success. Promoting dignity in an acute hospital setting Fundamental structural environmental aspects needed Bed management: a single sex environment, minimal transfers and patients with similar conditions sharing their environment. A dignity promoting leadership and a whole ward culture and commitment to patients' dignity. Staff all have individual responsibility to behave towards each patient in a way that promotes dignity during every interaction. Many patients place strong emphasis on their own role in promoting their dignity, using rationalisation and building relationships to make them feel more comfortable But not all patients are able to promote their own dignity and they are more vulnerable References DEPARTMENT OF HEALTH (2001a) Essence of Care: Patient-focused benchmarking for health care practitioners. London: DH. 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