Promoting patients' dignity in an acute hospital setting

1
Promoting patients' dignity in an acute hospital
setting

• Dr Lesley Baillie
• London South Bank University
• baillilj_at_lsbu.ac.uk
• 0207 815 8457

2
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.

3
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.

4
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 Trusts
  Research Development Office.

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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)

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Research methods
Data collection method Participants
Interviews 12 recently discharged patients 6 senior nurses
Participant observation 12 4-hour care episodes and 12 staff handovers 12 in-patients 26 ward-based staff (nurses and health-care 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
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Overview of findings

• Patients dignity in hospital
• Feelings
• Physical presentation
• Behaviour to and from others

• Threats to patients dignity in hospital
• environment
• staff behaviour
• patient factors

• Promotion of patients' dignity in hospital
• environment
• staff behaviour
• patient factors

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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

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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)

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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'.

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Patient dignity
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How patients dignity is threatened or promoted
in hospital
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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)

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Patients vulnerability impaired health

• Loss of function
• 'Not being able to do much for herself Mrs V,
  post-operatively 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)

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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)

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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

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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)

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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)

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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)

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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)

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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'.

22
Promotion of patient dignity in hospital patient
factors

• Attitude rationalisation, humour, acceptance
• Encroaching on the bodys modesty when
  undergoing treatment is a necessity its just
  part of their (staffs) 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)

23
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)

24
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)

25
Promoting patients dignity in hospital
Dignity-promoting 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)

26
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.
• the comfort of being on a ward with patients with
  similar conditions 'all in the same boat'
• Everybody realises there's something going on
  behind those curtains but - so what - they're all
  in the same boat' (Mr C)
• 'The patients are quite respectful in this ward -
  they were quite friendly (Mr G)
• 'Everyone other patients seems to root for
  everyone else (Mrs S)

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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

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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'.

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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)

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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).

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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.

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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

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References

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