Proven Practice: Maintaining older people’s dignity

The Social Care Institute for Excellence presents updated guidance on achieving dignity in care for older people

Scie’s Dignity in Care guide was first launched in 2006 to support the Department of Health’s campaign of the same name. It has been one of Scie’s most popular products ever since.

New information has been added to some sections since the launch, but the whole guide has now been updated to take into account the latest research.

Throughout the guide, the focus is on what older people and others who use services have said about why dignity is important and – often more easily described – what it is that threatens dignity.

Key factors

Research shows there are eight main factors that promote dignity, all of which contribute to the person’s sense of self respect.

• 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 say; ensuring clear dialogue between workers and services.
• 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.
• Eating and nutritional care. Providing a choice of nutritious, appetising meals that meet the needs and choices of individuals, and support with eating where needed.
• 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.
• Social inclusion. Supporting people to keep in contact with family and friends, and to participate in social activities.

Pain management

Pain management was not included as a factor in the previous version of the guide. It can be defined as “any intervention designed to alleviate pain and/or its impact, such that quality of life and ability to function are optimised”.

There is a lack of information available about pain, and people may not readily associate it with dignity in care. Yet badly managed or unacknowledged pain has emerged from consultations with service users as one of the most powerful threats to people’s dignity. In a Department of Health survey of almost 300 dignity champions, pain was rated fourth out of 15 issues relating to dignity.

Pain is often a particular issue for those nearing the end of life. At this time, the relationship between people and care professionals is very important, and good pain management is a vital component in ensuring dignity is promoted and protected. It is particularly important for people to be able to prepare for death with their loved ones and so careful consideration of pain relief that affects consciousness or cognitive ability is essential.

Pain can be viewed as an inevitable part of old age, but if it is identified and managed it can hugely improve the quality of life of individuals. Older people are more likely to suffer pain due to physical conditions, such as arthritis, but they are less likely to complain about it. They are also less likely to follow a medication regime.

It is important to be aware that people with dementia, learning difficulties or communication problems, including language barriers, may be unable to say that they are in pain.

This means it is likely to be under-diagnosed and under-treated. Pain can exacerbate the behavioural and psychological symptoms of dementia and result in challenging behaviour. A study into the care and treatment of people with dementia in hospital found that 51% of carers were dissatisfied with pain recognition and 71% of nursing staff wanted more training in recognising pain in people with dementia.

Case study: Living with constant pain and depression

Janet Allcock, 73, is a retired healthcare worker and housewife living in Eastbourne. Here she describes what it is like to be living with constant pain.

“It’s very hard for me to actually give you a time when the pain started because it has been from various causes. When I look back, the arthritis must have started at least 20 years ago.

“It’s a pain that varies from a stabbing, like a hot knife going through a joint, to something like a continual pressure that [makes] you want to try and move the joint and get rid of it, but it just doesn’t go.

“And together with the pain, depending on the severity, goes the depression, because I do find it’s a very depressing illness. When you’ve got something, you’re constantly feeling, knowing, that it’s always going to be with you.

“I feel reluctant to keep going and pestering my doctor about my pain because when you get to my age, and especially if you’re a woman. You feel he’s going to think I’m being neurotic, and because pain can’t be seen, it’s probably not easy for him to actually understand how much pain I actually am in.

“So you try to manage it yourself, which I do. I do try to take my medication regularly and as I should do. Although it goes very much against the grain to take so many tablets.

“Very often, with many experiences in life, we can share them with somebody or we can get somebody else to help us make it better, or they can make it better for us. But chronic pain is something which nobody really wants to know about and this results in a feeling of ‘you’re on your own’.

“It would make a difference if there was somebody who really understood what it was like to be in pain and would be available to talk to when it was really getting me down.”

From Pain in Older People by Arun Kumar and Dr Nick Allcock © Help the Aged 2008

Practitioners’ messages

• People may not report pain, but it can have a significant impact on dignity and well-being and it can be identified and treated.
• Pain in people with cognitive impairment, including learning disabilities and dementia, is under-diagnosed and under-treated because they are often unable to say they are in pain and staff are often unable to identify the signs.
• Pain should be included in assessments and pain assessment tools should be used if people have communication difficulties.
• Pain can cause people to wake at night and restlessness should trigger concerns about whether the person is suffering pain.
• Use of bank and agency staff can reduce pain-recognition – regular staff know the person and are therefore more likely to be able to identify pain-related behaviour.

Research abstracts

Author Department of Health

Title With respect: dignity in homecare and residential care

Publisher Department of Health, 2009. CD ROM, booklet

Abstract This training programme and resource provides materials to use in ensuring that residential and home care staff are trained to provide more dignified and respectful services to older and vulnerable people. It explains the context of the Department of Health’s Dignity Challenge, defining dignity and providing the criteria for best practice. It contains everything required to offer training to individuals or groups, in modular or whole sessions.

Author SCHOFIELD Pat; AVEYARD Barry; BLACK Catherine;

Title Management of pain in older people: a workbook

Publisher Keswick: M&K, 2007. 82p.

Abstract A self-directed study workbook designed to provide a basic introduction to the management of pain in older people. It explores the nature of the problem, discusses the importance of communication and outlines practical assessment techniques. Approaches to pain management are also covered and include medication and sensory environments.

Author MAGEE Helen; PARSONS Suzanne; ASKHAM Janet;

Title Measuring dignity in care for older people

Publisher Help the Aged, 2008. 86p.

Abstract This study was carried out to identify indicators of dignity in care for older people. The aim was to make recommendations on the best way to measure each of the Help the Aged domains of dignified care: personal hygiene; eating and nutrition; privacy; communication; pain; autonomy; personal care; end-of-life care and social inclusion.

This article is published in the 10 June 2010 edition of Community Care magazine under the headline Maintaining Older People’s Dignity