Improving Dignity for

Older People in HospitalChristine Norton PhD MA RN

Florence Nightingale Professor of Nursing

Imperial Healthcare & King’s College London

Team: Marcelle Tauber-Gilmore, Sue Procter, Corina

Naughton, Zainab Zahran, Gulen Addis + students

Aim of the study

To improve the delivery of dignity in the care

to older adults during acute hospital

admission through a staff led intervention

Research Questions

1) Can a supported dignity programme impact on

the quality of interaction between staff and

older patients and improve patient experience?

2) Can improvement be sustained once support

is withdrawn?

Background

• Dignity a particular issue in acute care

(Francis and others)

• Pace of modern hospitals is challenging to

dignity and person centred care

• We obtained 2 year funding from Burdett

Trust for Nursing

• 3 phases:

– Systematic review

– Interviews, survey and observations

– Dignity intervention

Dignity definitionThe Steering Group’s agreed definition of dignity:

“Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others.

Dignity in care means the kind of care, which supports and promotes, and does not undermine or erode, a person’s self-respect regardless of any difference.

[Patient] 'Being treated like I was somebody'.”

Incorporated:

-The Royal College of Nursing's dignity definition (2008) and

-Social Care Institute for Excellence (SCIE) Dignity in Care Research Overview Guide using Policy Research Institute on Ageing and Ethnicity (PRIAE) and Help the Aged, (2001)

-Opinions of the Steering Group (2014)

Review and interviews• Systematic review: interventions for dignity

in acute care: none!! (Lots of descriptions

and recommendations but never tested).

Plus no outcome measures tested.

(Zahran et al, J Clin Nursing 2016)

• Views of older people and staff about

dignity. Agreed about what dignity is. Care

inconsistent and continence a challenge.

Staffing levels and organisational culture

central. Lack of training. (Tauber et al, J

Clin Nursing 2017).

• “maybe its more recognisable when its not

there” (doctor)

• “he [nurse] spoke, he held me, he cuddled

me, and encouraged me to scream it out, to

let it out. And I did. And the panic passed”.

(Patient 6)

• “when you are in hospital you forget about

privacy, you’re here as a patient” (Patient 1)

• “I asked for a bed pan because I was so

exhausted. A girl (HCA) came in, turned off

the buzzer and said: we are doing handover,

no-one can help you now” (Patient 5)

Pre-post control group design

17 units

3 sites

Intervention

N=12

Intervention engaged

N=3

Min engagement

N=9

Control

N=5

N=5

Data Collection• August 2014 – September 2015.

• Non-participatory observations• Only staff interactions with consented patients recorded

• 45-60mins and recorded by trained observers

• Interaction labelled as Positive, Negative or Neutral

• Verbal and/or non-verbal communication

• Observer’s reflection & contextual comments

• Interviews• Two questions strands; ‘Self’ and ‘Organisation’

• Similar questions for staff and patients

• Patient Dignity Survey• Six questions and opportunity to leave a free text comment

• Ideally completed by any ward patient aged 65 yrs & over

• Collected monthly (Friends & family test)

-48 patients

-125 hours of

observation

-651 interactions

-51 interviews overall

-13 patients (aged 68-91yrs)

-38 staff (13 RGNs, 9 Drs, 4 OTs, 3

Physio, 3 Pharm, 3 ST/N, 2 HCAs

&1 Ward Admin)

-5693 responses

Pre, during & post

intervention

Time

:

Interaction

Description:

Between: Code: Verbal/N

on-

Verbal:

Length of

Interaction

Reflections

0956 Care task (bed

bath)

Nurse

& Patient

+ V Long Behind curtain. Lovely explanation & instruction

from nurse, encouragement pt. Pt expressed

preference for shave, nurse agreed. Pt thanked

nurses, acknowledged by nurse. Friendly. Warm.

Social conversation

1001 Pharmacist

& Patient

- NV Brief Pharmacist stood at the end of patient bed, looking

at bed side folder. Patient trying to ask a question

about a medication. Pharmacist ignores patient,

leaves folder on the bed and walks away

Observer’s Name: Observer’s Signature

Ward: Date:

Time Observation Period Started: Time Observation Period Finished:

Total Number of Interactions: Positive: Neutral: Negative:

Quality of Interaction (QUIS) Observation Tool:

Categorised:

Positive: warm, respectful, sensitive

Neutral: basic care functional

Negative: cold, insensitive, unhelpful,

disrespectful

Some fluidity positive to neutral

Electronic Survey• Were the healthcare staff caring and

compassionate?

• At any point during your stay did you feel ignored

by staff?

• Did you feel the staff treated you as an individual

person?

• Were you given privacy when discussing your

condition, treatment or care?

• Where possible, did staff give you choices?

• Where possible, were your preferences respected?

• Response options: Never, Sometimes, Often,

Always.

Intervention

• Monthly feedback on Dignity Survey & observation data to ward manger (face-to-face/ email) (8 wards)– Sustaining strengths

– Care Concerns

• Bespoke teaching sessions as requested– Communication training (1 ward 1hr*4 weeks),

continence and dementia,

• Discussion and debrief of specific patient experiences (1 ward -5 sessions)

• VERY LIMITED ENGAGEMENT (too busy, even when supported)??

• No MDT- delivered to nurse only

Bespoke dignity feedback by

ward

• Staff Reaction to feedback:

• Shock, dismay

• More doom and gloom

• But

• Can try harder

• Did not realise that is how we came

across

Observation data

42

38

20

Overall % (n=651)

Positive Neutral Negative

A nurse was at the

patient’s bedside inserting

a new cannula. The clinical

task was done in silence.

When the nurse spoke to

the patient, they said “I

need to flush it.”

Discharge nurse and a

patient discussing the

patient’s discharge. Clear

explanation from the nurse

about options. Patient

asking questions; the

nurse was listening and

responding to questions.

Nurse and patient both at

ease, open and friendly.

ward clerk enters a side

room and passes a

message on to the nurse

and leaves. The ward

clerk did not knock on the

door before entering or

acknowledge the patient

Outcomes: Dignity Survey

0

10

20

30

40

50

60

70

80

90

100

Caring &Compassion

Ignored byStaff

Treated asindividual

Privacy Given Choice PreferencesRespected

Pre: Always (n=3611) Post:Always (n=2082)

Dignity improvement sustained

p=0.04

22

22.6

23

21.4

21.6

21.8

22

22.2

22.4

22.6

22.8

23

23.2

Pre Post Six-months Follow-up

Mean Score

Max potential score 24

Comments

Strengths

• “I was always treated with

dignity. The staff made

me feel safe and valued”

• “Very caring nurses, but

they need to speak to

patients more.”

Concerns

• “Depending on the staff

that were on shift you

either had a pleasant

experience or an

appalling one.”

• [made to wait for bedpan]

“Incontinent of urine for the

first time in my life. I’m 68

years old and a retired

teacher. This is not

supposed to be the way

someone in genuine need

is treated.”

Trust feedback event

• Dramatised: entrenched poor behaviour, stealth and

robotic care- based on observation data

i) Role-modelling and leadership

i) Support (from individual line manager,

senior management or the organisation)

i) Culture (locally and organisationally)

i) Education, training and development

i) Communication

Learning & Next Steps

• Monthly dignity survey & observation feedback

valuable but time consuming to sustain

– Potential for quarterly

• Wards had limited capacity to actively engage in

quality improvement interventions

– Specific project e.g. continence more traction

• Trust developed leadership programme for different

nursing bands

• Film illustrating impact poor quality interactions

(10mins)- reflection tool to aid the revalidation

process

Dignity in acute care

• Very difficult to implement interventions

• Feasible to influence by simple feedback?

• Students really enjoyed observations

• Simple scores (high) maybe hide actual

experiences?

• Dedicated strategies- MDT

– Training? Actors really engaged staff

• Time & staffing

• Talk & Listen –’whole team’

• Continence