Dignity:
at the heart of everything we do
A survey of UK nurses
Kingston University & St George’s University of London
Thursday 5th March 2009
Supported by an unrestricted educational grant from
Researchers
Dr Lesley Baillie, London South Bank
University
 Dr Ann Gallagher, FHSCS, Kingston University
and St George’s University of London
 Professor Paul Wainwright, FHSCS, Kingston
University and St George’s University of
London
Supported by:
 Pauline Ford - Dignity Lead at the RCN
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Background
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Dignity: a complex concept and a central
value in nursing
United Kingdom health and social care
policies emphasise dignity in care
But:
• Research and media reports regularly identify
dignity deficits in care
The Royal College of Nursing Dignity
Campaign
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The RCN is the major professional
organisation and trade union for UK nurses
The RCN’s Dignity Campaign aims to:
•
•
celebrate dignifying care and redress deficits in care
demonstrate that the RCN is responding to an issue of
professional and public concern.
Initial scoping exercise
The RCN Dignity survey – to gain the
perspective of all members of the nursing
workforce – challenges & opportunities
Questionnaire Development
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Developed by project team members
Questions informed by:
• the dignity research literature
• policy documents
• meetings with key stakeholders
Piloted over 3 weeks
Final version completed by 20 stakeholders
An electronic survey, posted on the RCN web-site in
February 2008
Questionnaire link emailed to 70,000 RCN numbers
Respondents
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2048 registered nurses, health care assistants
and students
Broadly reflected diversity of UK nurses:
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a wide range of roles, in diverse practice contexts with
client groups with different needs and of all ages
wide cross section: age, gender, ethnicity, employing
organisations, work roles and experience
Possibility of bias
Findings: Initial and continuing
dignity education
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Most respondents recalled learning about dignity in
in the classroom, the practice placement and from
the mentor/supervisor.
The majority of respondents agreed that this learning
influenced their practice.
Regarding the development of understanding –
professional practice, feedback from patients, good
role models and personal experiences of care either
for themselves or for a friend or relative.
Dignity & Physical Environment
Dignity & Physical Environment
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Maintains/Promotes
Prevents/diminishes
Well-fitting curtains
Use of clips & “do not disturb”
signs
Private rooms for consultations
Aesthetically pleasing – space,
colour, furnishing, décor.
Cleanliness.
Single sex accommodation
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Overcrowded, poorly screened
Ill-fitting curtains
Lack of treatment/private/day
rooms
Cramped, old-fashioned
“Shabby”, “neglected”
Mixed sex accommodation
Physical environment
“An environment
that is cared for
communicates
that care is
present in that
environment”
Matron, Acute
Hospital
“if it looks like it's
broken then we
communicate that
we feel the
patients are only
worth second rate
equipment - does
not inspire
confidence”
Physical Environment
“I believe there is
always a way
around obstacles
and primarily it is
you yourself your
actions, standards
and behaviour that
delivers care”
Clinical Nurse Specialist,
Acute hospital
“There are more
important things than
the physical
environment. You can
treat people with
dignity in the car park
if you have to”
Practice development nurse,
Acute hospital
Individual practitioner, team and
organisational prioritisation of dignity
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Most respondents gave dignity a high priority
Some respondents would like to give dignity
a higher priority than they actually can
Most responded that their organisations and
teams also gave dignity a high priority.
However, some respondents felt that their
organisations did not give dignity as high a
priority as they might wish.
Dignity & the Organisation
Dignity & the Organisation
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Maintains/Promotes
Prevents/diminishes
Positive staff attitudes,
awareness and knowledge
Adequate resources – human
and material
Good leadership &
management
Dignity-promoting role
modelling
Good teamwork
Positive culture & philosophy
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Negative staff attitudes, lack of
awareness and knowledge
Lack of resources – human and
material
Poor leadership & management
Lack of positive role modelling
Poor teamwork
Low morale and motivation,
short-term contracts & workload
Impact of Government targets
The Organisation
The importance of role modelling:
“I have recruited a
competent team
who role model
and challenge one
another”
Manager, Care Home
“Unless someone comes
around to role model and
challenge poor standards
then talking about it is
not the best solution.
Again it results in being a
tick box exercise to meet
the government agenda”
Staff nurse, acute hospital
The Organisation: impact of
NHS targets
Organisations that are
“target led not patient led”,
managers who slavishly
focused on “quantitative
targets” rather than “softer
quality issues” in care, a
perception that patients were
“rushed in and out”.
Consultant Nurse, Acute Hospital
“Pressure to move
patients out of A&E
due to four hour
target means
patients being
moved before care
completed (they
may be soiled,
distressed, dying);
lack of beds and
lack of single sex
accommodation and
side rooms”
Do you ever feel distressed because you are
unable to give the kind of dignified care you
know you should?
Fig 30: Are You Ever Distressed?
1600
1437
1400
1200
1000
Always (10.9%)
Sometimes (70.2%)
Never (18.9%)
800
600
387
400
223
200
0
Care activities
CARE ACTIVITIES
Factors that render patients vulnerable to loss of
dignity
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Support with hygiene and
dressing, elimination,
nutrition
Communication
Intimate procedures
/examinations
Invasive/technical
procedures
Exposing procedures
Medical procedures
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Medicine administration
Moving and handling
Physical health check
Emergency care
Admission/transfer/
discharge/appointments
Mental health care
Additional factors
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Staff behaviour. Example:
•
medical practitioner reluctance to prescribe adequate pain
relief for a person with terminal illness
Patient individual factors. Examples:
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Immunizations with young, frightened girls
Day case admission of a person unable to speak English
High number of staff needed. Examples:
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patients with spinal cord injury requiring manual evacuation
of faeces needing to be log-rolled by five staff members,
chaperones needing to be present for intimate examinations,
positioning very obese patients for enema administration.
Importance of privacy, communication & physical
actions
Privacy
Physical
Side rooms; Quiet/private room/area; Bathroom/toilet
environment use; Curtains/screens/blinds; Curtain clips/pegs/signs;
Managing smells; Auditory privacy
Staff
behaviour
Discretion; Respect for personal space; Prevent/manage
interruptions; Sensitivity to culture/religion
Managing
Staff: number present, gender; Other patients; Family;
people in the Ward visitors/public
environment
Bodily
privacy
Covering body; Minimising time exposed; Privacy during
undressing; Clothing
Communication
Helping
patients feel
comfortable
Sensitivity; Empathy; Developing
relationships; Non-verbal communication;
Conversation; Reassurance;
Professionalism; Family involvement
Helping patient Explanations and information giving;
in control
Choices and negotiation; Gaining consent
Helping
patients feel
valued
Giving time; Concern for patients as
individuals; Courteousness
Physical actions
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Preparation
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Promoting independence
Physical comfort
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• Procedure
• Environment
• Timeliness
• Equipment
• Staff management
Practice initiatives to promote dignified care
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Organisation of care: a wide range of new services and
practice developments for diverse client groups
Staffing: Leadership, teamwork, staffing levels and mix, staff
support, culture/ethos.
Education: role-modelling, training and promoting awareness.
Patient/client involvement: obtaining feedback, working in
partnership, and information development so that choice could
be facilitated.
Privacy enhancement: the physical environment, staff
behaviour, managing people in the environment, bodily
privacy
Recommendations – macro level
Role of government
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Consideration of the paradoxical effects of
health policy:
• if government is serious about delivering dignified
healthcare services there must be a serious
debate about the impact of targets on dignity and
care
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A renewed commitment to single sex wards
Staff/patient ratios must be sufficient to provide
dignified care
Sufficient investment in healthcare
organisations
Recommendations: meso level
Role of organisations
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Sufficient investment in the physical care environment to
demonstrate that staff and patients are valued and
respected, including adequate standards of cleanliness
and sufficient material resources
Nursing and other care staff should be involved in the
design of health care environments
Organisational cultures and ways of working must make
patient care high priority
Organisations must develop policies and practices that
support dignity in care:
• the development of an ethical climate,
• organisational values,
• systems for reporting and whistle-blowing
Recommendations: micro level
The role of individual accountability
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Individual nurses and other professionals must take
opportunities to develop their understanding of
dignity in care
Individuals should be reflective, engage in critical
self-scrutiny and invite feedback from others
Attitudes and behaviours that diminish dignity must
be challenged - individuals should know how to
influence change and report dignity deficits
All healthcare staff should be aware of the potential
to enhance dignity by role modelling
Conclusion &
Next Steps
Largest reported survey of nursing workforce perspectives on
dignity in care
Dignity and 3 P’s – People, Place and Process
 Levels of response to maintain dignity in care – micro, meso
and macro
Development & planned evaluation of RCN Dignity Campaign
resources:
• An e-learning resource to help individuals gain greater
understanding and personal awareness of Dignity
• Principles of Dignity for emergency care settings
• A practice support pack with DVD and influencing toolkit will be
available from autumn 2008.
• Pocket guide
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Implications
For practice – practical guidance regarding how we should
understand and respect the dignity of individuals within
organisational and political contexts
For education – consider the use of multimedia, facilitate time
and space for reflection on factors that promote and diminish
dignity
For research – develop the philosophical dimensions of dignity
(what, for example, is the relationship between dignity and
autonomy?); explore the perspectives of patients, carers and
practitioners; evaluate the impact of dignity materials;
Investigate cross-cultural perspectives on dignity; and need to
approach the development of a dignity tool critically.
Thank you for your attention
Questions & Discussion
Supported by an unrestricted educational grant from