The views of older people and health professionals about dignity in acute hospital care.

AIMS AND OBJECTIVES: To report the findings from interviews conducted as part of a wider study on interventions to support dignified care in older people in acute hospital care. The data in this study present the interview data. BACKGROUND: Dignity is a complex concept. Despite a plethora of recommendations on how to achieve dignified care, it remains unclear how to attain this in practice and what the priorities of patients and staff are in relation to dignity. DESIGN: A purposive sample of older patients and staff took part in semi-structured interviews and gave their insight on the meaning of dignity and examples of what sustains and breaches a patient's dignity in acute hospital care. METHOD: Thirteen patients and 38 healthcare professionals in a single metropolitan hospital in the UK interviewed. Interviews were transcribed verbatim and underwent a thematic analysis. RESULTS: The meaning of dignity was broadly agreed on by patients and staff. Three broad themes were identified: the meaning of dignity, staffing level and its impact on dignity, and organisational culture and dignity. Registered staff of all healthcare discipline and student nurses report very little training on dignity or care of the older person. CONCLUSION: There remain inconsistencies in the application of dignified care. Staff behaviour, a lack of training and the organisational processes continue to result in breaches to dignity of older people. Clinical nurses have a major role in ensuring dignified care for older people in hospital. RELEVANCE TO CLINICAL PRACTICE: There needs to be systematic dignity-related training with regular refreshers. This education coupled with measures to change the cultural attitudes in an organisation towards older peoples' care should result in long-term improvements in the level of dignified care. Hospital managers have an important role in changing system to ensure that staff deliver the levels of care they aspire to.

Development of tools to measure dignity for older people in acute hospitals.

BACKGROUND: Dignity is a concept that applies to all patients. Older patients can be particularly vulnerable to experiencing a loss of dignity in hospital. Previous tools developed to measure dignity have been aimed at palliative and end-of-life care. No tools for measuring dignity in acute hospital care have been reported. OBJECTIVES: To develop tools for measuring patient dignity in acute hospitals. SETTING: A large UK acute hospital. We purposively selected 17 wards where at least 50% of patients are 65 years or above. METHODS: Three methods of capturing data related to dignity were developed: an electronic patient dignity survey (possible score range 6-24); a format for nonparticipant observations; and individual face-to-face semi-structured patient and staff interviews (reported elsewhere). RESULTS: A total of 5,693 surveys were completed. Mean score increased from 22.00 pre-intervention to 23.03 after intervention (p < 0.001). Staff-patient interactions (581) were recorded. Overall 41% of interactions (239) were positive, 39% (228) were neutral, and 20% (114) were negative. The positive interactions ranged from 17%-59% between wards. Quality of interaction was highest for allied health professionals (76% positive), lowest for domestic staff (22% positive) and pharmacists (29% positive), and intermediate for doctors, nurses, healthcare assistants and student nurses (40%-48% positive). A positive interaction was more likely with increased length of interaction from 25% (brief)-63% (longer interactions) (F[2, 557] = 28.67, p < 0.001). CONCLUSIONS: We have developed a simple format for a dignity survey and observations. Overall, most patients reported electronically that they received dignified care in hospital. However, observations identified a high percentage of interactions categorised as neutral/basic care, which, while not actively diminishing dignity, will not enhance dignity. There is an opportunity to make these interactions more positive.

Systematic review: what interventions improve dignity for older patients in hospital?

AIMS AND OBJECTIVES: To review the evidence for interventions to improve dignity for older patients in acute care. BACKGROUND: High profile cases have highlighted failure to provide dignified care for older people in hospitals. There is good evidence on what older people consider is important for dignified care and abundant recommendations on improving dignity, but it is unclear which interventions are effective. DESIGN: Narrative systematic review. METHODS: The Cochrane library, MEDLINE, EMBASE, CINAHL, BNI and HMIC electronic databases were searched for intervention studies of any design aiming to improve inpatients' dignity. The main population of interest was older patients, but the search included all patients. Studies that focused on 'dignity therapy' were excluded. RESULTS: There were no intervention studies found in any country which aimed to improve patient dignity in hospitals which included evaluation of the effect. A narrative overview of papers that described implementing dignity interventions in practice but included no formal evaluation was, therefore, undertaken. Five papers were identified. Three themes were identified: knowing the person; partnership between older people and health care professionals; and, effective communication and clinical leadership. The effect on dignity of improving these is untested. CONCLUSIONS: There are currently no studies that have tested interventions to improve the dignity of older people (nor anyone else) in hospitals. Further research using well designed trials of interventions is needed. There is also a need to develop and validate outcome measures for interventions to improve dignity. RELEVANCE TO CLINICAL PRACTICE: At present nurses lack robust evidence on how to improve dignity. There is ample evidence on what undermines patients' dignity and there is a need to develop and test interventions designed to improve patient dignity.

Socio-phenomenology and conversation analysis: interpreting video lifeworld healthcare interactions.

This article uses a socio-phenomenological methodology to develop knowledge and understanding of the healthcare consultation based on the concept of the lifeworld. It concentrates its attention on social action rather than strategic action and a systems approach. This article argues that patient-centred care is more effective when it is informed through a lifeworld conception of human mutual shared interaction. Videos offer an opportunity for a wide audience to experience the many kinds of conversations and dynamics that take place in consultations. Visual sociology used in this article provides a method to organize video emotional, knowledge and action conversations as well as dynamic typical consultation situations. These interactions are experienced through the video materials themselves unlike conversation analysis where video materials are first transcribed and then analysed. Both approaches have the potential to support intersubjective learning but this article argues that a video lifeworld schema is more accessible to health professionals and the general public. The typical interaction situations are constructed through the analysis of video materials of consultations in a London walk-in centre. Further studies are planned in the future to extend and replicate results in other healthcare services. This method of analysis focuses on the ways in which the everyday lifeworld informs face-to-face person-centred health care and supports social action as a significant factor underpinning strategic action and a systems approach to consultation practice.

Clinicians, market players or bureaucrats? Changing expectations of the general practitioner role in the English and Welsh NHS, 1991-2005.

PURPOSE: The purpose of this paper is to explore the variety of mechanisms applied since 1991 to engage English and Welsh general practitioners (GPs) in local health services planning and implementation. DESIGN/METHODOLOGY/APPROACH: Three qualitative case studies. FINDINGS: The paper identifies three types of mechanism: separation, alliance and integration. "Separation" characterises the relationship between most GPs and health authorities during the 1990s; alliance refers to the cooperative arrangements between groups of GPs and health authorities such as GP commissioning pilots, total purchasing, primary care groups and local health groups; integration refers to the integration of most health authority functions with primary care organisations (primary care trusts--PCTs and local health boards). Alliance models appear to have been most successful in promoting GP engagement in local planning and implementation; the necessarily bureaucratic nature of PCTs an local health board has alienated many. PRACTICAL IMPLICATIONS: As yet, the National Health Service (NHS) lacks organisational arrangements which permit GPs a primarily clinical focus while ensuring that their knowledge and advice is available to those carrying out administrative functions. Practice-based commissioning may provide a means of improving such arrangements. ORIGINALITY/VALUE: The paper combines a number of features in health services and policy research. Few studies of primary health care organisations in the mid-2000s have been undertaken; the Welsh NHS is very under-researched; organisational analysis of the NHS is more often based on analysis from the outside rather than grounded in the felt experience of NHS personnel; and the historical perspective is often neglected.