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 of London Thursday 5 th March 2009

Researchers Dr Lesley Baillie, London South Bank University Dr Ann Gallagher, FHSCS, Kingston University and St Georges University of London Professor Paul Wainwright, FHSCS, Kingston University and St Georges 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 RCNs 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 ed 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

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

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 HomeStaff nurse, acute hospital

The Organisation: impact of NHS targets Organisations that aretarget led not patient led, managers who slavishly focused on quantitative targets rather than softer quality issues in care, a perception that patients wererushed 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

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

Care activities

CARE ACTIVITIES Factors 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 level Role 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 level The 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 Ps – 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 Pocket guide

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.

Supported by an unrestricted educational grant from Thank you for your attention Questions & Discussion