Research Realities: Measuring Dignity in Care for Older People

A study of dignity indicators for older people exposes the factors that undermine provision of sensitive care. Jill Manthorpe assesses the results

Title: Measuring Dignity in Care for Older People

Authors: Helen Magee, Suzanne Parsons and Janet Askham

Institution: The Picker Institute Europe for Help the Aged

Objectives

The value of this study is revealed by a perceptive remark from the authors: “It is easier to make pronouncements about dignity than to ensure that dignified care happens.” This is particularly the case for anyone responsible for measuring or assessing dignity in care.

It is noted, as a preliminary, that dignified care in health and social care continues to be especially problematic for older people. The researchers heard many reasons for this, ranging from the priority given to targets and budgets which sometimes undermines dignified care to what others see as the replacement of compassionate nursing care for more technically skilled nurses. Others cite the power of ageism in society and ageist attitudes among staff.

This study reviewed qualitative research that had explored older people’s perceptions of dignified care (or the opposite) across settings of hospital, care homes and home care. It asked older people and their representatives to identify the best and most realistic indicators for dignity in care. The researchers reviewed existing measures and indicators within a set of dignity domains identified by Help the Aged.

This work was lent urgency by the government’s focus on dignity and by the changes under way in the creation of the Care Quality Commission. Many older people’s groups are keen to see that the commission shows a strong commitment to social care and is not sidetracked by NHS-related issues.

Methods

This five-month study set out to identify a group of indicators that could measure the extent to which older people are treated with dignity and respect by health and social care professionals.

The research team carried out an electronic search to find qualitative studies that explored older people’s perceptions of dignity in care in hospitals, care homes and domiciliary care. To supplement this they held focus group discussions with care home residents, home care service users, people who had recently returned home from hospital and carers.

Eleven interviews were held with key informants from organisations which the researchers say represented older people, although the extent to which, for example, the Royal College of Nursing or British Society of Geriatrics represent older people would doubtless be questioned by older people’s groups and campaigners.

In the context of these sources of information, the research team identified and developed indicators for nine domains, looking at questionnaires, assessment tools and benchmarks that are used to assess dignity in care. Many of these related to hospital care and treatment, some to care homes but few to home care. Indeed, the evidence is limited about social care, particularly new forms of social care which focus less on tasks and their completion and more on personally agreed outcomes.

Findings and analysis

There are many interesting findings in this study, including the results of further analysis of older people’s responses to the 2007 National Inpatient Survey, focusing on hospital care and treatment.

What is significant is the finding that over-70s often gave more positive answers than younger older people when asked whether they were treated with respect and dignity. They were also more complimentary about their general care, privacy, food, pain control and cleanliness. In contrast, the qualitative studies, when older people were interviewed in depth and often after they had left hospital, found numerous instances where people expressed concerns and gave instances of things going wrong.

Perhaps both methods should be used to enable these experiences to be heard.

This study focused on dignity in care in hospitals and care homes and there is less about social care. One section that covers most of these settings is that of personal care or practical assistance.

It is important to avoid confusion about the broad term personal care. The researchers note that the term “personal care” was often confused with “personal hygiene” in health care settings in social care it can be defined more widely, almost as covering the same territory as social care itself. The researchers suggested renaming personal care “practical assistance”, although this was not discussed more widely.

Social care debates, for example, have taught us that if care work is seen as purely practical then it is in danger of overlooking psychosocial interventions that often support people at home. Indicators of dignity in personal care might cover:

● Knowledge of an individual’s preferred lifestyle (including clothing preferences, routines, pets, religious and cultural preferences) and need to show respect for an individual’s preferred lifestyle, including the flexibility to meet a person’s needs.

● Timetabling of services to suit the client.

● Assistance that reflects individuals’ wishes.

● Respectful delivery of care and support.

● Support to maintain personal standards.

● Regular information about changes to help and assistance.

● Consistency of care workers.

● Respect for property and possessions.

● Enough time for home care visits.

● Regular monitoring of the service.

All this is familiar to people working in social care or commissioning services, but there is little recognition that fulfilling many of these domains will need investment. ­Pers­onalisation is one way to enhance ­dignity in such transactions and fresh indicators may need to be considered for this new world.

Recommendations

The authors conclude from their own and others’ research that we should use a set of indicators to measure dignity that includes common “core” elements, relevant to any care setting, together with indicators specific to a particular setting.

They recommend that indicators should be part of the early work of the new Care Quality Commission (CQC) so it can think about the use of indicators in its secondary legislation, regulations and compliance criteria. They advise further research to explore the perceptions that older people and professionals hold about dignity in care across various settings.

However, the researchers also note that many of those responding to their enquiries in the telephone interviews and focus groups sympathised with the pressures facing frontline staff. They say that if practitioners are to deliver care with respect and dignity then they too must be treated with respect and dignity, in contrast to the more usual situation of being poorly paid and feeling undervalued.

In a trenchant statement they propose that, before creating further indicators with which to measure their performance, it might be worthwhile considering how to promote support for care workers to help them meet the needs of older people more effectively.

This challenge draws attention to the broader context in which care takes place and the potential for thinking about dignity beyond regulatory systems. Some see dignity as fundamental to human rights. The potential for human rights legislation to help change systems and practices is illustrated in a study of instances where raising questions about human rights seemed to promote action to restore dignity in care.

The British Institute for Human Rights’ report, Changing Lives, makes clear the scope of the act to strengthen the ability of people to secure the best possible standard of services from public bodies and the right to be treated with respect, dignity and fairness. It argues that, because the government’s expressed purpose in introducing the Human Rights Act 1998 was to promote a culture of respect for human rights, it is important that public sector staff work within human rights standards and principles. They have responsibilities to ensure that services, in-house or commissioned, deliver on respect, autonomy, fairness, equality and dignity. The institute concludes there is “still a long way to go, and many people, particularly the most vulnerable, remain in need of the protections afforded by the Human Rights Act”.

Lack of dignity was a common thread in the breaches of the act that this study reported and the examples provided are inspiring learning points for practitioners.

Practice implications
For those supporting these groups of people

● How much are you and your members involved in Dignity in Care ­activities and what are the channels of communication with local dignity champions?

● What are your members’ main concerns?

For social care practitioners

● What help is available to services users to draw attention to breaches of dignity?

● How well are these connected to adult safeguarding services?

● Is dignity considered in service delivery?

For service commissioners

● What use are you making of the considerable number of current studies that explore indicators of dignity (as listed in the report)?

● How do complaints influence agreements with providers?

Links and resources

•  Measuring Dignity in Care for Older People, Help the Aged
  
• Cass E, Robbins D and Richardson A, 2006, Dignity in Care, Social Care Institute for Excellence
  
• The Department of Health in England is running a Dignity in Care campaign. This includes a Dignity Challenge (set of principles), a National Dignity Ambassador, National Dignity Tours by the minister, a measurement system for the grading of hospitals’ regard for dignity and respect among its older patients, a Dignity in Care Public Survey and the Queen Mother Award for Dignity in Care.
  
• The Human Rights Act – Changing Lives and British Institute for Human Rights

Jill Manthorpe is professor of social work and director of the Social Care Workforce Research Unit at King’s College London

Published in Community Care 15 January under the headline Assessing Dignity in Care