Supported by an unrestricted educational grant from Dignity: at the heart of everything we do A survey of UK nurses Kingston University & St Georges University.

Supported by an unrestricted educational grant from

Dignity: at the heart of everything we do

A survey of UK nursesKingston University & St George’s University of London

Thursday 5th March 2009

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

Background

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

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

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

2048 registered nurses, health care assistants and students

Broadly reflected diversity of UK nurses:• 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

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

Maintains/Promotes

Well-fitting curtains Use of clips & “do not disturb”

signs Private rooms for consultations Aesthetically pleasing – space,

colour, furnishing, décor. Cleanliness. Single sex accommodation

Prevents/diminishes

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”

“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”Matron, Acute

Hospital

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”

“There are more important things than the physical environment. You can treat people with dignity in the car park if you have to”

Clinical Nurse Specialist, Acute hospital

Practice development nurse, Acute hospital

Individual practitioner, team and organisational prioritisation of dignity

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

Maintains/Promotes

Positive staff attitudes, awareness and knowledge

Adequate resources – human and material

Good leadership & management

Dignity-promoting role modelling

Good teamwork Positive culture & philosophy

Prevents/diminishes

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”

“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”

Manager, Care Home 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”.

“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”

Consultant Nurse, Acute Hospital

Fig 30: Are You Ever Distressed?

223

1437

387

0

200

400

600

800

1000

1200

1400

1600

Always (10.9%)

Sometimes (70.2%)

Never (18.9%)

Do you ever feel distressed because you are unable to give the kind of dignified care you know you should?

Care activities

CARE ACTIVITIESFactors that render patients vulnerable to loss of dignity

Support with hygiene and dressing, elimination, nutrition

Communication Intimate procedures

/examinations Invasive/technical

procedures Exposing procedures Medical procedures

Medicine administration Moving and handling Physical health check Emergency care Admission/transfer/ discharge/appointments Mental health care

Additional factors

Staff behaviour. Example: • medical practitioner reluctance to prescribe adequate pain

relief for a person with terminal illness Patient individual factors. Examples:

• Immunizations with young, frightened girls

• Day case admission of a person unable to speak English High number of staff needed. Examples:

• 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 environment

Side rooms; Quiet/private room/area; Bathroom/toilet 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 people in the environment

Staff: number present, gender; Other patients; Family;

Ward visitors/public

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 in control

Explanations and information giving; Choices and negotiation; Gaining consent

Helping patients feel valued

Giving time; Concern for patients as individuals; Courteousness

Physical actions

Preparation• Procedure

• Environment

• Timeliness

• Equipment

• Staff management

Promoting independence Physical comfort

Practice initiatives to promote dignified care

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

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

A renewed commitment to single sex wards Staff/patient ratios must be sufficient to provide

dignified care Sufficient investment in healthcare

organisations

Recommendations: meso levelRole of organisations

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 levelThe role of individual accountability

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 macroDevelopment & 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

ImplicationsFor 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.

Supported by an unrestricted educational grant from

Thank you for your attention

Questions & Discussion