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The essence of this essay is to give an in depth understanding of the concept of dignity in the care system. This essay will focus on the issues discussed in the group Enquiry Based Learning (EBL) presentation; define and critically analyse the concept of dignity from different perspectives, in relation to its abstract and subjective nature. How dignity is maintained by health professionals, influenced by cultural differences, and look at some current initiatives used to promote dignity in practice.
Furthermore, I will focus on my experiences in practice to illustrate the concept of dignity, using relevant theories to support my discussion. I shall conclude using Gibbs's framework to reflect on the group presentation.
I have chosen to focus solely on Dignity of identity as it relates to my chosen area of nursing. Nordenfelt identifies four concepts of Dignity: Dignity of Menschenwürde, Dignity of merit, Dignity of moral stature, and the Dignity of personal identity.
In my definition of dignity, I will dicuss definitions that relates to elderly people in care. As an adult nursing student specialising in the care of the elderly, who are the main users of health services, the knowledge gained in the process of this essay will be applied to every adult in my care.
Definitions of the concept of 'Dignity'
Dignity is a difficult concept to define, and has a strong association with respect. Dignity is defined as being worthy of respect. (DH,2003) cited from Andrew and Alison however, The Social Care Institute for Excellence (SCEI; 2006) pointed out that although defining dignity may be difficult, 'people know when they have not been treated with dignity and respect.'
The definition of dignity from the oxford dictionary talks about the innateness of dignity in human as it is natural. This is also embedded in Article 1 of the United Nations General Assembly Declaration of 1948, reiterate in 1996 by the United nations International Bill of Rights, which states, "that all human beings are born free and equal in dignity and rights" (United Nations, 1996).(matiti).
From the EBL group presentation Professor Lennart Nordenfelt's theories on dignity were discussed; firstly, Dignity of merit- based on hierarchical position in society, dependent on economic/social class can be hereditary. Secondly, Human Dignity gives rise to the value of being human, and the Dignity of moral stature based on a person's moral autonomy/integrity and, lastly Dignity of identity which focuses on human being's self-respect, including notions of integrity and autonomy, and may be violated when a person is prevented from doing what they want to do or are entitled to do, or by physical assault and humiliation. The last aspect of Nordenfelt's definition of dignity, which is the dignity of personal identity, is the one that can be related to the elderly. Due to possible limited capabilities associated with ageing individuals they could be subjected to their dignity being violated, as their condition may result in them being dependent on others for their daily activities of living, thus depriving them of their right from doing what they would want or entitled them to do, which may bring about physical assault and humiliation. *missing quote to be inserted, upon confirmation of source**
The Royal college of Nursing (RCN) has made it clear that dignity applies equally to those who have capacity and those who lack it. Everyone has equal worth as human being and must be treated as human beings and must be treated as if they are able to feel, think, and behave in relation to their own worth or value.
*missing Dignity in Care quote to be inserted, upon confirmation of source**
It is evidenced from my research on the definition of dignity that people perceive dignity differently due to its subjective nature. Nonetheless, there is no general agreement on what dignity actually means. Julie Clark, 2010. However, there is a consensus that it is a value possessed by every human being. Everyone irrespective of circumstances should be treated with dignity.
Nordenfelt argues that, "Menschenwurde is the basic platform. Each older person has his or her intrinsic value, which entails a number of rights, among other the rights of the UN Declaration. People do not lose any of these rights because they have reached a particular age." **(Dignity in care for older pp)** Badcot states that, Kant I Cited in Gallagher et al 2008 holds that human beings posses dignity because "they are rational, autonomous creatures with intrinsic value who can pursue and determine their own ends". Kant's definition of dignity in relation to 'intrinsic value' appears to rely upon possession of autonomy.
"Treating patients or clients with dignity is considered as part of providing them with quality care and allowing them to experience quality of life which can be violated according to Nordenfelt due to their circumstances; illness or old age." (Dignity in Care text book)
PROMOTING DIGNITY IN CARE
It is of paramount importance that healthcare practitioners promote dignity in care at all times. There are conditioning factors and attributes that have been put in place to govern dignity in care situations.
One of the most important conditioning factors is for the nurse to gain a full understanding of the concept of promoting dignity in order to provide good nursing care to our adult patients.
In care situation, dignity may be promoted or diminished by the following factors; physical environment, organizational culture and the attitude and behaviour of the nursing team in the way care are carried out. There are several ways in which patient's or client dignity can be promoted.
According social institute of excellence (2010) there are 8 main factors that promote dignity in care. Few of which I will explain with example.
Dignity can be promote by health care professionals by involving patients in their own care, empowering to make their own decisions and choices concerning their care.
Treating patient or client as an individual involves listening to them and to avoid caring for them as a group, encouraging independence and giving time and choice. For example, give patient choice of how they would like to be dressed by asking them to choose cloths of their choice.
When communicating with patient, it is important to express respectful verbal and non verbal communication; Listening, responding, allowing time and use of therapeutic communication when required.
Healthcare professionals should cultivate the habit of approaching patient in an appropriate manner thus, with respect and professionally.
Providing patients with necessary information regarding their health, results in them having sense of value.
Explain procedure to gain consent cooperation prior every procedure and including them in their care by giving them choice and freedom to express their feeling of makes them feel a sense of belonging and that nurses are not dominating the care they offer. Maintaining privacy is important. For example, during procedures, curtains should be pulled around patient's bed using peg, to ensure privacy.
Keeping the environment clean is very important. For example, a commode should not be left at the patient's bed side after use. It is concluded that reflection on, and improvements to, the care environment makes a significant contribution to patients, relatives and staff feeling valued and respected.(Matiti)
"When dignity is present people feel in control, valued, confident, comfortable and able to make decisions for themselves. When dignity is absent people feel devalued, lacking control and comfort. They may lack confidence and be unable to make decisions for themselves. They may feel humiliated, embarrassed or ashamed.
It is of paramount important to organise and involving elderly people in stimulating activities, particularly those in a nursing home in as this will help to prevent isolation.
According to 2008 Gallagher et al it states "that old age may intimidate dignity due to the fact that the amount of social inclusion and participation are limited".
When patient and client are not treated with respect and dignity it tends to gave negatives impact on their wellbeing thus affects them psychologically and socially.
dignified treatment correlate most closely with high satisfaction with the hospital stay, thus indicating that patients who perceive that they are treated with dignity are happier with their overall hospital experience. (matiti) (chochinov et al, 200b) Matiti) indicated a link between loss of dignity and various negative effects, such as psychological and symptoms distress, heightened dependency needs and loss of will to live
It is affirmed by legislation and ethical of the profession that, all healthcare professionals to at all times promote patients' dignity and respect. (chochinov et al, 200b) Matiti) indicated a link between loss of dignity and various negative effects, such as psychological and symptoms distress, heightened dependency needs and loss of will to live
INITIATIVES TO PROMOTE DIGNITY
The desire to restore dignity to the heart of nursing is an attempt to challenge and redress some of the delegation and overspecialisation that has occurred over the past decade, which have perpetuated the perceived erosion of care (Scott, 2000). However, (Maben and Griffiths, 2008). From dignity champion exerts that Campaigns for dignity in care may not necessarily result in the change of values, attitudes and beliefs that are perceived to be lacking in nursing
As it has been stated that dignity is difficult to define and that care professional might not be equipped with the necessary skills and Knowledge required of them to treat client with dignity however, there are governing bodies which are in place to help health practitioner in using initiatives to promote dignity. These initiatives are readily available as a guide to healthcare/care provider in order to effectively and adequately treating client with respect and dignity. Adherence to these initiatives, consequently result in meeting clients needs as individual and providing quality care.
Design for patient's dignity is another body that promotes dignity. They have created a number of initiatives to help practitioners in care setting. These includes, universal gown which caters to all sizes as well as cultural and religious beliefs. The gown also covers all part of the patients body including the front and the back which gives patients privacy and allows them to feel secure and many more.
http://www.designcouncil.org.uk/our-work/challenges/Health/Design-for-Patient-Dignity/Case-studies/ - 23 December 2012
My home life focuses on elderly people, this is why it has been chosen
my home life movement is also a governing body who formed a variety of initiative which aspire for best practice includes a sense of security; this involves gaining trust and maintain confidentially unless on a need to know basis. A sense of significance allowing them to feel sense of worth and valued , recognising their presence, listening and understanding their needs, empowering them in order for them to make choices and decision about their lives. A sense of continuity
All of these initiatives help to promote their dignity because they feel a sense of belonging. (Nolan et al's 'Senses Framework').
From my research it is evidenced that several research have been carried out to promote dignity in care settings.
One of these initiatives is Dignity in Care network set up by SCIE (SOCIAL CARE INSTITUTE FOR EXCELLENCE).The 10 point Dignity Challenge is the framework and the 'gold standard' this initiative aims to restore dignity at the heart of the health and social care orofessionals
Initiatives from the department of health including the National Service Framework for older people, the follow-up Next steps document and the Dignity in care Campaign incorporating the dignity challenge, all aim to promote the necessary changes in culture that are needed to ensure that older people and their carers are treated with respect, dignity and fairness. The Department 's Essence of care: Patient-focused benchmarks for clinical governance also offers a framework for healthcare professionals to use in measuring their practice relating to privacy and dignity.
The Healthcare Commission report Caring for Dignity (2007) maintains that dignity is 'a human rights issue' and should be the underlying principle when delivering services. However, there is little guidance and no way of measuring how well a service respects a person's privacy and dignity. Dignity is a complex concept which means different things to different people, but is de¬ned as being made up of two parts: having self-respect and being respected by others.
Maintaining dignity helps to preserve our self-worth and identity; this is particularly important in care settings where residents are often vulnerable, and caring practices can make people feel undigni¬ed owing to their personal and intimate nature. It is often easier to identify when dignity has been lost rather than when it is being maintained.
(Nursing & Residential Care, August 2009, Vol 11, No 8)
(Privacy and dignity in continence care: research review)
that devalues and does not respect the dignity of the individual should be confronted. Mrs Hussein's smiled and said "thank you". My mentor replied that "it is our job to care for patients needs.
Mrs Hussein's dignity of identity was compromised as the care assistant took the advantage of Mrs Hussein's condition to violate her dignity of identity for her own conveniences. Professor Wilfred exerts that "Dignity is promoted when individuals are enabled to do the best within their capabilities, exercise control, make choices and feel involved in the decision making that underpins their care." I had my clinical placement in a stroke ward where i came in contact with people with different types of stroke and those on rehabilitation pathway. There were several instances where I experienced how patient's dignity was being maintained and conversely, compromised. For the purpose of this essay a pseudonym will be used in order to protect confidentiality (Nursing and Midwifery Council's code of conduct 2009).
I cared for Mrs Hussein, a 75 years old, Asian woman who was admitted into the ward with ischemic stroke which left her with right sided weakness of both limbs. (Walsh 2002) defines a stroke as an interruption of the blood supply to a part of the brain and the development of neurological deficits.
Mrs Hussein's health condition required her to be dependent on carers has she requires help for almost all her activities of daily living. During the morning shift I supported the care assistant to wash her. We sought for her consent and asked if she would like to have her bath, curtains were pulled around using peg and her private part covered with towel until the private part needed to be washed, ensuring that her privacy and dignity were maintained. The Nursing and Midwifery council (NMC 2009) exerts that people should be treated with respect and dignity.
After we finished bathing her, I headed to her cupboard to get her cloths, but the care assistant said she is wearing the hospital Gown because she is incontinence of both urine and faeces. Mrs Hussein said she does not want the Gown that she prefers her own clothes because the hospital gown does not cover her body properly, she explained. Unfortunately, her request was ignored. Despite the code of conduct (NMC2009) that states that "You must listen to the people in your care and respond to their concerns and preferences". Also, International Journal of Nursing Practice 2011; 17: 336-341 also asserts that "Listening to patients is a necessary precursor to respecting their dignity in care and in supporting their sense of their own dignity"
Mrs Hussein was not looking happy as her wish was ignored. I intervened by moving closer to her, held her hand used the therapeutic communication skill. I held her hand to explain to her that I will get one of the carers that will assist in changing her to her own cloth. The attitude and communication skills of the individual practitioner can do much to ensure that these and other similar experience are not made worse. Matiti
I reported the situation to my mentor and she came with me to change her. ". According to Wilfred (professor in dignity of older people) Any practice
Those patients on rehabilitation pathway were at all times given the choice of what to we particularly the women were encouraged to wear their personal cloths as they may need to go for physiotherapy. This is done at all times to maintain patient's dignity.
I also experienced an 82 years old man who was admitted into the ward and was confused. Due to his condition he always undressed himself. This resulted in making the decision for him to be relocated to the side room. The idea of being in the side room alone led to him not be attended to as he was confused and could not use the call bell
Control of the bowel and bladder is something which people develop as small children and loss of this important to preserve a person's privacy and dignity during such care. Sufferers to feel child-like and stigmatised. Older people with continence problems often feel a loss of dignity in care settings (Nursing & Residential Care, August 2009, Vol 11, No 8
During my placement I also noticed that when there was a shortage of staff, the patients dignity tends to be diminished. For example, in the stroke ward where I was, patients who were unable to feed for themselves required assistance but due to the shortage of staff patients had to wait for turns to be fed as a result, their food must have gone cold which then diminishes their dignity because if they were able to feed themselves they would not have to wait for assistance. The hospital toilets particularly, the ones in shared bays are relatively small for carer to manoeuvre which sometimes subject patient's dignity being diminished.
It is believed that one of the factors inhibiting dignity in practice is as result of the healthcare professionals not adequately equipped with the necessary skills and knowledge required of them to be able to carry out their work effectively. Also, the fact that the concept of dignity is a very difficult to define, it is difficult to give a specific definition that may be used to underpinned practice.
(Anderberg et al, 2007). Therefore, there is need to help healthcare workers in practice to identify practical ways of promoting patient and client dignity
Patient dignity is feeling valued and comfortable psychologically with one's physical presentation and behaviour, level of control over the situation, and the behaviour of other people in the environment (Baillie, 2007, p.247).Matiti
Within healthcare settings, how patients feel they are viewed by staff caring for them, or how staff feel they are viewed by colleagues and patients, can affect self esteem. If a person's own standards are met, they develop a sense of pride, have high self-esteem and feel worthy. Matiti
Access to lavatory/bathroom facilities - There is often insufficient access to lavatory/bathroom facilities with staff unavailable to help and alternatives, such as commodes, offered that people found embarrassing and undignified. This diminished their dignity and result in the patient not wanting to call for toilet. Pulling of curtains during procedures is crucial at all times.
Dignity in care is not the sole responsibility of one professional group: all health and social care professionals need to be dignity champions. Nurses are more aware and informed of the different dimensions of people's Wilfred (professor in dignity for older people) nursing times
REFLECTION ON EBL
Reflection is a process of reviewing an experience to describe, analyse, evaluate and to inform learning of practice (Reid 1993) cited in Sully and Dallas. Gibbs reflection cycle process (1988) will be used to reflect on my presentation. This comprises of six features and listed below in chronological order.
DESCRIPTION: reflecting on the EBL process, on the first week, trigger was given to the group to analyse and discuss the implication for practice. We worked, strived and researched together as a team for four weeks. The process started by electing chairperson and a scribe. Thereafter, topic was shared amongst us as subgroups to research upon, which we all came to agreement. According to (Thompson et al 2006) working together is the nature of nurse education to explore theoretical and clinical principle and applied them to practice.
Each week, prior to the presentation date each subgroup came up with their research and we discuss on our research and asked every member of the group for an individual input before the arrival of our facilitator. Finally, research carried out was put together and we decided between ourselves who would like to present. In the end we were all happy with our performance and the marks awarded, as the marks will be added to individual final marks.
FEELINGS: Feelings and thinking are considered the most essential aspect of the reflective process; therefore, great care should be taken during this process (Ely and Scott, 2007). Prior to the presentation, we were overwhelmed with feelings of nervousness and jittery, as well as incompatibility of the group members. There was a fear of time management, as we had only 30 minutes to present. Presenters had rehearsed before the proper presentation was carried out to ensure that we bit the time. In the end, the time management was perfect and our presentation was splendid.
EVALUATION: The good thing about the teams was that there is always a good turnout for extra meeting out the normal class hour. Although, some do came late for sessions but get the group informed. Working as a team was a great experience; it gave me more confident and better understanding of the topic. The EBL presentation has shown me how to develop my knowledge and skill, effective listening skill was observed at the time of the presentation. However, on the last meeting day before the presentation, there was issue of summarizing two different slides on the power points this brought a bit of argument but it was summarised and we all settled amicably. The presentation provided me with an in-depth knowledge of the dignity in care. According to (Elly and Scott 2007) evaluation process is a stage that enables one to reflect on the performance of your experience, what was wrong and right about your experience.
ANALYSIS: in the process of EBL study i developed the knowledge and skill of gathering and sharing information, effective communication and listening skills as well as the spirit of working together for the benefit of achieving common goal. Also, the process gave me the privilege to gain in-depth insight on how dignity can be promoted in care setting, initiatives to promote dignity and the impact of undignified care on the elderly and the vulnerable people in general. Analysis is the process of making sense of the whole experience or situation and putting it in context (Bulman and Schutz 2008).
ACTION PLAN: when next the opportunity of group presentation arise, I will try and volunteer to take part in presenting for the group as this will help boost and build my communication skills and developed confidence to face the audience. Action plan according to (Ely and Scott 2007) is a way of planning for the future and organising yourself in case similar events occur in the future.
Conclusion: This essay has provided me with relevance information regarding EBL presentation, the trigger and the use of Gibbs reflective cycle 1988.