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09th May 2011

Dignity in care

Although the word and the meaning of dignity derives from the Latin dignitas, and has a long history of usage from Latin to English via French, it is a term which is so often left undefined. The most effective codification of the universal concept of dignity in care came with the publication of: Homes are for Living in, A “Model for Evaluating Quality of Care Provided and Quality of Life Experienced in Residential Care Homes for Elderly People” (HAFLI), in 1989.

Although dignity has been a key factor in judging care quality since time immemorial, with varying degrees of commitment, this was the first time that the concept had been included in a widely publicised and highly influential publication.  The publication led to a long running debate about the true nature of quality in care services, a debate which is still on-going.  Out of the concepts contained in HAFLI, and other researches, came the now widely recognised suite of core skills and attitudes which are incorporated into any competent induction and on-going training, such as the Common Induction Standards, and National Vocational Qualifications.

An understanding of dignity as it applies in a care setting is fundamental to the perceived quality of that care service. As this article was being written, a report by Ann Abraham, the Health Service Ombudsman, was published which describes some of the consequences of people providing care and support not providing a service which offers dignity. We can all cringe at examples such as the case study of Mr and Mrs J, taken from the report. Mrs J was 82 years old, and had been in a care home for nine years because of the results of dementia. Her husband visited her daily, and in his words “we enjoyed each other’s company”. One day during a visit by Mr J, Mrs J was admitted via ambulance to a hospital due to breathing difficulties. While Mrs J was being assessed, Mr J was asked to sit in a waiting room. The report details the following hours, but suffice it to say that Mrs J died while Mr J was left in the waiting room, and he did not know of his wife’s death until the care home, who were contacted by the hospital to report the death, told the hospital he had accompanied his wife and they eventually found him, where they had left him, many hours before. Following an investigation, the communication error was noted, and apologised for, but no changes were made to procedures, training, or any corrective action taken.

Those of us with a long history in care services recognise the symptoms behind the unfortunate tragedy of Mr and Mrs J. To conceive of a happily devoted couple being denied the comfort of being together at their final separation, for no reason other than “lack of communication”, is heart-wrenching. In itself the facts of the case study point to an often recognised problem – the lack of understanding that a person using health and/or social care services is a rounded and whole human being, with needs and relationships which require much more than slavish attention to “the problem” in hand at that moment. It is possible that the hospital staff dealing with Mrs J never once asked themselves what her life context was; did she have a person with her, or close to her, that they should be communicating with and also supporting through the health difficulty she was having? Did she herself have emotional needs, such as being accompanied by her life partner, as she irretrievably slipped away from him for the first and only time?


"the hospital involved carried out an investigation and plainly labelled this as a one-off aberration, needing no systemic change"

To compound the issue, it is frankly unbelievable, but unfortunately appears to be the case, that the hospital involved carried out an investigation and plainly labelled this as a one-off aberration, needing no systemic change, such as revised procedures and additional training. Therein lies the problem. The hospital appears to view a personal tragedy, which was so easily avoided, as being a one-off, when in fact it was far more likely as a result of a failure of the culture of the hospital to recognise a patient as a rounded, fully alive, fully networked person with the full panoply of personal rights and needs in addition to the health needs that were being diagnosed and treated. A failure of a culture that simply cannot see that health treatment can be entirely negated by failure to provide care and support with the context of the whole person, and that so much expensive resource is wasted if this simple concept is lost. You can almost hear the thought processes; “she is 82”, “she has dementia”, “she is almost certain to be alone in this world – old people are, aren’t they?”

The hospital in question and the particular staff did not have even a child’s concept of human dignity. As John Humphries so eloquently said while interviewing Ann Abraham on the Today programme on Radio 4 (I paraphrase slightly): What is it about years of medical training that takes a normal person and turns them into someone who does this kind of thing? (Listen to the full interview here)


"Challenges to dignity are now more likely to be around the softer issues of personal choice and control."

It is easy for those in the independent and voluntary care sector to hear of such cases and after tut-tutting, feel a glow of self-satisfaction. Those providing social care in particular can sometimes feel relatively safe, because the concept of personal dignity is so explicitly recognised as a fundamental characteristic of social care. With so much training going on, how can we have a problem? But there are problems. It is unfortunately far from unknown for independent and voluntary care services to compromise dignity. We have moved on in recent years from the days when even simple issues of dignity such as the compromises to dignity caused by the use of shared toilet and bathing facilities were the norm.

Challenges to dignity are now more likely to be around the softer issues of personal choice and control. Is it dignified for residents in a care home to be herded into situations “they all enjoy”, such as group activities, bingo and the like? Is it dignified for residents in an elderly care home to have the radio set to Radio 1 (or worse) in the corner of the lounge, just because the young carer with the task of watching over them simply cannot understand that their personal past may have been different, and their tastes are likely to differ from their own? And domiciliary care does not escape. When Social Service purchasing departments, from behind their professional shield of providing so-called holistic services, issue lists of tasks which have to be carried out in individual service user’s homes, and ticked off as completed, with little or no cultural and life history information, they can hardly complain when they find instances where carers regard their job as a list of tasks, and not providing person-focussed, individualised, sensitive and dignified support. How often does one see automated/computerised care planning systems which rely on tick boxes and core care plans, producing institutionalised output which is so far from personalised care planning that it is hardly worthy of the title “care plan”?


Dignity Enshrined in Process, Culture and Training

The answer to “the dignity question” has always been in culture and training. Constant, consistent and effective training, matched to consistent and effective leadership, and time. Effective care cultures do not spring up overnight; they need time to develop, and constant effort and leadership to maintain and improve. The procedural environment also has to support and encourage dignity. The extensive and diligent use of life history recording within the care plan, and the provision of time and encouragement for all care staff with contact with a service user to create, develop and study that life history, can contribute enormously to the sensitivity of the services and support offered. And, it has to be said by an author who has hosted and conducted many training events aimed at changing cultures, the level of enjoyment of the staff themselves when they understand the full context of those they support is tangible and highly rewarding in its own right.

With this approach in mind, it is timely that SCIE, the Social Care Institute for Excellence, has recently launched its Dignity in Care campaign. SCIE identifies eight elements in providing services which support the dignity of the user:

  • Choice and control: Enabling people to make choices about the way they live and the care they receive;
  • Communication: Speaking to people respectfully and listening to what they have to say; ensuring clear dialogue between workers and services;
  • Eating and nutritional care: Providing a choice of nutritious, appetising meals, that meets the needs and choices of individuals, and support with eating where needed;
  • Pain management: Ensuring that people living with pain have the right help and medication to reduce suffering and improve their quality of life;
  • Personal hygiene: Enabling people to maintain their usual standards of personal hygiene;
  • Practical assistance: Enabling people to maintain their independence by providing ‘that little bit of help’;
  • Privacy: Respecting people’s personal space, privacy in personal care and confidentiality of personal information; and
  • Social inclusion: Supporting people to keep in contact with family and friends, and to participate in social activities.


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