Dignity in Practice: An Exploration of the Care of Older Adults in Acute NHS Trusts
Maintaining dignity is important to older people especially during periods of acute illness requiring admission to hospital. Anecdotal, and some research, evidence together with independent reports, have indicated that older people are often not treated with dignity while receiving hospital care but little direct evidence about the factors within the care environment that impact on the provision of dignified care or about the impact of professional behavior on the maintenance of patient dignity is available. This study set about to explore these factors.
Win Tadd – Principal Investigator
Dr Win Tadd spent many years as a nurse and senior lecturer in the UK and Australia. She was awarded an International Fellowship by the Hastings Centre, New York in 1989, a UKCC Scholarship in 1997 and is currently a Reader in Cesagen, School of Social Sciences, at Cardiff University.
She chaired the Welsh Government’s National Coordinating Group on Dignity in Care from 2007 – 2011 and is a member of the Advisory Board of Stroke Cymru.
Her research focuses on the ethical aspects of ageing and care of older people. She coordinated the EU project Dignity and Older Europeans, the largest comparative study undertaken in this area. Her other European work explored the information needs of older disabled people (Infopark), Virtues and Chronic Illness and The value of ethical codes in nursing.
Michael Calnan – Co-applicant
Professor Michael Calnan is a medical sociologist who is interested in the Sociology of Health. Illness and Health policy and has published extensively on wide range of health related topics. His books include: Health, Medicine and Society. Key Theories, Future Agendas’ (2000); ‘Work Stress: the making of a modern epidemic ' (2002), ‘Trust Matters in Health Ca re (2008) and The New Sociology of the Health Service (2009).
His current research interests include: (1) the study of trust relations in health care and has a new book due out in 2012 entitled ‘Trusting on the Edge ‘ about Trust in Mental Health Care and has just started a new ESRC funded study on Trust, Risk and Uncertainty in NICE decision making and (2) the study of ageing and health care specifically exploring through theoretical and empirical analysis the concept of dignity and the provision of health and social care for older people.
Tony Bayer – Co-applicant
Professor Tony Bayer is Head of the Section of Geriatric Medicine in Cardiff University and Director of the Memory Team, a long established clinical service for people presenting with dementia and their carers. He has published widely in the field of geriatric medicine, with current research interests centring on epidemiology, assessment and management of cognitive decline and neurodegenerative disease, frailty and ethical issues and older people. He is Editor-in-Chief of Reviews in Clinical Gerontology, a member of the Global Aging Research Network (GARN), the European Collaborative Geriatric Research Network (Geronto-Web) and the Scientific Advisory Panel of Alzheimer Europe.
Alexandra Hillman – Research Associate
Dr Alexandra Hillman is a research fellow working in the field of medical sociology. She currently holds a Wellcome Trust fellowship award to explore the social and ethical implications of early detection and diagnosis of dementia in memory clinics.
Alex has worked on a number of collaborative projects that have drawn on ethnographic and qualitative methods to explore aspects of social life. Although her work has focussed predominantly on medicine, healthcare and older people, she has been involved in studies that explore a variety of social issues including: the identities of ‘looked after’ children and young people, the uses and impacts of remote monitoring devices for chronically ill people, the socio-cultural aspects of healthcare provision and older people’s experiences of acute and emergency medical care.
Sian Calnan – Research Associate
Siân read Psychology at Bristol University and then qualified as an Occupational Therapist at the London School of OT. She worked for some years as an Occupational Therapist in the community before moving into management as Business Manager for the Occupational Therapy and Sensory Disability Service in Kent and then into local government corporate policy and performance both in Kent and later Bristol. Throughout her career she has been actively involved in research. Her MPhil was based on a research study she carried out for the Department of Health and was concerned with the relationship between the perceptions of illness and old age and its impact on illness behaviour At Kent County Council and Bristol City Council she promoted research activities and carried out her own research to ensure evidence based practice.
Simon Read – Research Associate
Simon Read is a Research Associate at Cesagen in Cardiff University, contributing to studies regarding ageing and the ageing society. His work on the Dignity in Practice project has been primarily focussed on the dissemination of the research findings.
In-depth interviews were conducted with
- recently discharged older people, their relatives/ carers to learn about their experiences of care
- acute service managers in 4 large NHS Trusts to explore how they ensure people receive dignified care.
- ward staff working in acute wards to ascertain what enhances or detracts from their ability to provide dignified care.
The interviews were followed by observation of care in 16 acute hospital wards. From the findings, recommendations for use by policy makers, providers and all occupational groups across the NHS were developed to ensure older people are treated with dignity at all times.
Whose Interests Matter?
This theme shows that all individuals working in the NHS are motivated to represent patients’ interests but these motivations are frequently compromised by systemic and organisational factors. Setting acute Trust priorities on the basis of measurable performance indicators; a culture of blame; the management of ‘secondary risks’; high bed occupancy rates together with increased specialisation and rationalisation all impact on the care of older people resulting in them being continually moved within the system. Furthermore, local ward cultures have developed in the context of untenable staffing levels that operate within a strictly demarcated and hierarchical division of labour. This results in a failure to provide continuity of care or care which protects and promotes the individual’s dignity.
Right Place, Wrong Patient
This refers to the almost unanimous view expressed by all staff that the acute hospital is not the ‘right place’ for older people. In this theme, the key message echoed by staff at all levels in each organisation, that the acute hospital is not the ‘right place’ for older people is explored. The prevalence of this view results in the physical environment, staff skills and education and the organisational processes acting as barriers to delivering dignified care to older people.
Because acute wards are poorly designed to meet the needs of their main users, those over 65 years, they are not ‘fit for purpose’ as a place to treat older people with dignity, as the physical environment is confusing and inaccessible. The staff, whilst doing their best, are often ill-equipped in terms of their knowledge and skills to care for older people whose acute illness is often compounded by physical and mental co-morbidities. The atmosphere on the wards can be characterised as one of frenetic activity with little opportunity for engagement with individuals. That many interviewees recognised these issues but concluded that it was the older person who is in the ‘wrong place’, together with the assumption that there must be a better place for ‘them’ to be, suggests an underlying and widespread ageism.
Seeing the Person
This theme focuses on the impact of encounters that take place within the acute setting and the influence of these on the experience of dignity for patients, their relatives and staff.
Key elements of dignified care include: respectful communication; respecting privacy; promoting autonomy and a sense of control; addressing basic human needs such as nutrition, elimination and personal hygiene needs in a respectful and sensitive manner; promoting inclusivity and a sense of participation by providing adequate information to aid decision-making; promoting a sense of identity; focusing on the individual and recognising human rights. Undignified care is that which renders individuals invisible, depersonalises and objectifies people, is abusive or humiliating, narrowly focused and disempowers the individual.
The degree to which staff are treated with dignity and respect by their colleagues, managers, patients and carers is also variable and the role of the ward manager in promoting a respectful working environment is critical. The inability to deliver appropriate standards of care because of systemic or organisational factors was often seen to impact on staff members’ sense of dignity and resulting in demoralisation.
DVD - ‘Dignity: A tale of two wards’.
A multi-professional, evidence-based training DVD has been developed. The events and dialogue are all drawn from the interviews and fieldwork and with the help of a scriptwriter have been developed into a screenplay ‘Dignity: A tale of two wards’.
Professional actors were commissioned alongside members of staff from an NHS Foundation Trust to play the characters portrayed and the film was shot on location in an NHS Trust.
The DVD together with guidance notes for its use will be distributed to every NHS Trust/LHB in the UK and could play a very useful role in staff training, recruitment and induction, and work with Trust boards to ensure greater awareness of the importance of providing dignified care, as well as the impact of undignified care on individuals.
Dignity in Practice Executive Summary (follow link to SDO website)
Dignity in Practice Full Report (follow link to SDO website)
For copies of the DVD 'Dignity: A tale of two wards' contact firstname.lastname@example.org
Peer Reviewed Papers
Hillman A., Tadd W., Calnan S., Calnan M., Bayer A. and Read S., Risk, governance and the experience of care. 2013, Sociology of Health and Illness [In press]
Tadd W, Hillman S , Calnan S, Calnan M, Bayer A and Read S., From right place – wrong person, to right place – right person: dignified care for older people. 2012 HSRN/SDO supplement of the Journal of Health Services and Research Policy [In press]
Calnan,M, Tadd, W, Calnan, S, Hillman, A, Bayer A and Read S ‘I often worry about the older person being in that system because often they – they’ve got more needs, are more vulnerable’: Providing dignified care for older people in acute hospitals Ageing & Society. [Accepted for publication]
Tadd, W; Hillman, A; Calnan, S; Calnan, M; Bayer, A; Read, S. Right place - wrong person: dignity in the acute care of older people. Quality in Ageing and Older Adults, 2011; 12(1): 33- 43
Read S, Tadd W, Calnan M, Hillman A, Calnan S and Bayer T. (September 2011) Dignity in practice? British Geriatrics Society Newsletter
The Ageing Society and the Social care System: Why acute services are failing older people and what changes in acute services are needed to ensure older people are treated with dignity. Britain 2012: ESRC.
Calnan M, Tadd W, Hillman S , Calnan S, Bayer A and Read S ‘Right Place – Wrong Patient’: why acute hospitals do not work for older people. Open Lecture, December 2011, Suffolk.
Tadd W. Transforming patients' experience – Why it matters to staff. Kings Fund Transforming Patient Experience Annual Conference. November 9 2011 King’s Fund: London.
Tadd W, Hillman S , Calnan S, Calnan M, Bayer A and Read S., (2011) From right place – wrong person, to right place – right person: dignified care for older people. Aintree NHS Foundation Trust, Senior Manager's Workshop, September 23rd 2011, Liverpool.
Calnan M, Tadd W, Hillman S , Calnan S, Bayer A and Read S ‘Right Place – Wrong Patient’: why acute hospitals do not work for older people. Health Policy and Politics Network Conference, September 2011, Oxford.
Tadd W, Hillman S , Calnan S, Calnan M, Bayer A and Read S., (2011) ‘From right place- wrong person to Right place right person’ invited presentation Delivering Better Health Services, 2011 Joint HSRN and SDO Network Annual Conference, 7 and 8 June 2011, Liverpool.
Calnan M, Tadd W, Hillman S , Calnan S, Bayer A and Read S ‘Right Place – Wrong Patients’: how do acute trusts provide dignified care for older people?. June 2011, Gateshead NHS Trust.
Tadd W, Hillman S , Calnan S, Calnan M, Bayer A and Read S., (2011) Keynote presentation ‘Dignity in Care: The reality of making it happen in practice’Dignity in Care Conference: Because it matters, hosted by Shrewsbury and Telford Hospital NHS Trust and Staffordshire University, Faculty of Health, Shropshire Education and Conference Centre 12th May 2011.
Tadd W. and Calnan M., (2011) ‘Dignity in practice: an exploration of the care of older adults in acute NHS trusts’ SDO Network Chief Executives’ Forum, May 5th London and May 19th 2011 Nottingham.
Hillman A, Tadd W, Calnan S and Calnan M W, Embodiment, identity and accomplishing dignity: Caring for older people on acute hospital wards, World Congress of Sociology held in Gothenburg, Sweden, July 11 to 17, 2010.
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A. and Read, S. Risk, governance and the experience of care. Sociology of Health and Illness.
The Dignity in Practice study has also generated considerable interest:
2000 hits on the British Geriatrics Society website in the first week of publication of the study report.
The report was the subject of a King's Fund blog (www.kingsfund.org.uk/
Radio Wales interview with Win Tadd
Following the publication of the study Win was invited to submit evidence to the NHS Confederation/Age UK/LGA Commission on Dignity in Care and is a member of the Academic reference group for the Commission
Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts was commissioned and funded by the National Institute for Health Research Service Development Organisation programme (NIHR SDO). The management of the project and subsequent editorial review of the final report was undertaken by the Policy Research Programme Central Commissioning Facility (PRP CCF) as part of the Prevention of Abuse and Neglect in the Institutional Care of Older Adults (PANICOA) initiative - please visit www.panicoa.org.uk for more details. As the SDO programme had no involvement in the management or editorial review of the project, they may not be able to comment on aspects of this website.