Theme 2 focuses on the influence of ‘people’ influences on the preservation of dignity in care and has two sub-themes: staff behaviour; and patient characteristics. The ‘people’ are the staff and patients interacting in a care setting. In the context of the dignity encounter described by Jacobson (2009b), the ‘people’ are the ‘actors’. The term ‘staff’ is used to describe anyone employed to deliver care and may include nurses and nursing students but also healthcare assistants, carers, medical staff and other healthcare workers. The term ‘patients’ is used to identify anyone receiving care, including service-users and clients. A deliberate effort has been made to focus on findings specific to the preservation of dignity.
2.4.1 Staff behaviour
Brenda … returns from theatre … Carol, a staff nurse, is with her, checking her observations, asking if she has any pain. Again, the curtains are closed, Carol speaks in a quiet voice simply explaining what she is doing, what will happen next and when she can have a drink. (Observation: Elm Ward, Meadowfield Trust, Afternoon) (Tadd et al., 2011, p. 212)
The above observation illustrates some of the key aspects – providing privacy, communicating effectively and demonstrating respect – of the influence of staff behaviour on the preservation of dignity. Findings from this review suggest that staff behaviour is crucial to the preservation of dignity in care. This seems to be accomplished by staff behaving in a manner which demonstrates respect and helps build relationships with patients and their relatives. Aspects of staff behaviour of
93 greatest significance to the preservation of dignity in care appear to be verbal and non- verbal communication and the role of the nurse in dignifying care activities.
2.4.1.1 Verbal communication
The importance of verbal communication being polite and courteous is consistently noted (Blomberg et al., 2015; Bridges, Flatley and Meyer, 2010; Webster and Bryan, 2009). One aspect often raised by patients is the importance of being called their preferred name (Baillie et al., 2009; Cairns et al., 2013; Matiti and Trorey, 2008; Woolhead et al., 2006). Findings indicate that this is often not done. A patient’s comment that, “I feel it is no longer me as a person they address” (Matiti and Trorey, 2008, p. 2715), suggests that using a preferred form of address acknowledges the patient as a person. Woolhead et al. (2006) note that many older people participating in their focus groups “particularly disliked” the use of first names without consent and ‘pet names’ such as ‘love’ or ‘dear’ because they felt humiliated or patronised by them. Another important aspect of verbal communication is providing explanation and information about care (Bridges, Flatley and Meyer, 2010; Heijkenskjöld, Ekstedt and Lindwall, 2010). This is seen as a requirement for person-centred care; enabling patients to participate in their own care (Bridges, Flatley and Meyer, 2010; Heijkenskjöld, Ekstedt and Lindwall, 2010; Lin, Tsai and Chen, 2011). Speaking softly is identified as important because it helps to protect confidentiality (Lin and Tsai, 2011). Speaking gently helps offer reassurance to patients and calm aggressive behaviour (Hall, Dodd and Higginson, 2014; Heggestad, Nortvedt and Slettebø, 2015). Related to these findings about the tone of speech is the avoidance of condescension – ‘talking down’ – to patients (Heggestad, Nortvedt and Slettebø, 2015; Woolhead et al., 2006).
Several authors note the importance of conversation between staff and patients and distinguish this from simply giving or receiving information (Baillie, 2009; Kinnear, Williams and Victor, 2014; Lin, Tsai and Chen, 2011; Lin and Tsai, 2011). Bridges, Flatley and Meyer (2010) suggest that conversation helps preserve dignity because it
94 enables patients and staff to connect with each other. For Blomberg et al. (2015, p. 680), this signals the importance of staff “getting to know and be known” by patients. Also important is that staff initiate conversation, because this acknowledges patients as persons (Baillie, 2009; Heijkenskjöld, Ekstedt and Lindwall, 2010; Kinnear, Williams and Victor, 2014; Lin, Tsai and Chen, 2011). Initiating conversation may be regarded as helping to level the balance of power in interactions between staff and patients, thus enhancing the conditions in which dignity is more likely may be promoted (Jacobson, 2009b).
2.4.1.2 Non-verbal communication
Findings from this review also highlight the importance of non-verbal communication to the preservation of dignity in care. Jacobson (2009b, p. 4) describes aspects of non- verbal communication as the “gestures that set the underlying tenor” of an interaction. Respect is demonstrated by staff paying attention to the patient and listening is frequently identified as important (Heggestad, Nortvedt and Slettebø, 2015; Kinnear, Victor and Williams, 2015; Lin, Tsai and Chen, 2011; Webster and Bryan, 2009). Similarly, eye contact (Lindwall and von Post, 2014; Matiti and Trorey, 2008; Woolhead et al., 2006), gentleness (Hall and Høy, 2012), kindness (Ariño-Blasco, Tadd and Boix-Ferrer, 2005), and appropriate touch (Blomberg et al., 2015; Woolhead et al., 2006) are all noted as being characteristic of dignity-preserving interactions. Seemingly ‘little things’, such as offering a coffee and a warm welcome, are also noted as being important (Rehnsfeldt et al., 2014). Several authors also identify the act of sitting down with patients to engage in conversation as dignifying (Ariño-Blasco, Tadd and Boix-Ferrer, 2005; Hall, Dodd and Higginson, 2014; Heggestad, Nortvedt and Slettebø, 2015; Heijkenskjöld, Ekstedt and Lindwall, 2010).
2.4.1.3 Dignifying care activities
Closely related to communication is the role of staff in managing dignity-threatening care activities. Such care activities are a necessary and unavoidable aspect of being a patient. How nurses and other staff manage them seems to help preserve dignity in
95 care. Important aspects relate to privacy, consent and maintaining identity. Privacy is consistently stressed by all groups of participants as being fundamental to dignity in care. Assisting patients with personal hygiene, elimination, eating and drinking and intimate care procedures such as urinary catheterisation are all identified as activities most likely to threaten dignity (Baillie, 2009; Baillie et al., 2009; Baillie and Gallagher, 2011).
Strategies to minimise this threat include closing curtains or screens and asking before entering (Hall, Dodd and Higginson, 2014; Webster and Bryan, 2009). Findings from this review include the importance attached to staff seeking consent before undertaking activities (Cairns et al., 2013; Hall, Dodd and Higginson, 2014; Kinnear, Williams and Victor, 2014). Closely related to this is enabling the patient to exert control over their situation by offering and respecting choice around activities; for example, when to dress and what to wear, when and what to eat (Baillie et al., 2009; Hall and Høy, 2012; Lin, Tsai and Chen, 2011; Lin and Tsai, 2011). Høy, Wagner and Hall (2007) relate choice and control to the need to respect autonomy and to further lessen the risk by facilitating their independence as much as possible. Bridges, Flatley and Meyer (2010) highlight the importance of enabling the patient to maintain their identity through, for example; personal belongings such as photographs, and assisting the patient to maintain their physical appearance (Baillie and Gallagher, 2011; Hall and Høy, 2012; Hall, Dodd and Higginson, 2014).
So far, the role of staff in preserving dignity has been discussed and the findings of this review highlight the importance of communication and dignifying care activities. One of the valuable aspects of Jacobson’s framework is its focus on interaction and the importance attached to the role of all those involved (Jacobson, 2009b). In the context of care, this encourages consideration, not just of the staff involved but the patient, too.
96 2.4.2 Patient characteristics
Resilience
The response to such vulnerability has been related to another patient characteristic that influences the preservation of dignity in care: resilience. van Kessel (2013) notes that resilience is often defined as the ability to recover – to ‘bounce-back’ – in the face of adversity, such as hospitalisation or increasing dependency. This ability seems to be related to both personal and social resources (van Kessel, 2013). Personal resources may include a person’s attitude and sense of purpose, while social ones seem to centre around relationships with others (MacLeod et al., 2016). These resources are reflected in findings from this review.
Franklin, Ternestedt and Nordenfelt (2006) describe personal resources as strategies to enhance self-esteem and identity, such as access to their personal belongings and reflecting on photographs of family or their role as a parent or grandparent. Maintaining physical appearance and as much independence as possible in self-care also seem to be important (Hall and Høy, 2012; Matiti and Trorey, 2008; Oosterveld- Vlug et al., 2014). Oosterveld-Vlug et al. (2014) also stress the importance of a person’s ability to be assertive about their own care. In addition, being able to help others, recognise something positive in everyday life, and being of value also seem to contribute to a person’s ability to preserve dignity (Franklin, Ternestedt and Nordenfelt, 2006; Tranvåg, Petersen and Nåden, 2015; van Gennip et al., 2013). The findings also stress the importance of spiritual belief, the ability to use humour to deal with threats to dignity and to adapt to or accept changes in functional capacity (Baillie, 2009; Oosterveld-Vlug et al., 2014; Oosterveld-Vlug et al., 2013; van Gennip et al., 2013).
Social resources are resources external to the person which seem to influence their resilience (van Kessel, 2013). A key social resource seems to be the opportunity to experience positive interactions (Tranvåg, Petersen and Nåden, 2015). Interactions with family are an opportunity to experience love and affection while those with a
97 wider social network may provide a sense of social inclusion (Tranvåg, Petersen and Nåden, 2015). The significance of family involvement is rarely discussed in the literature reviewed in Chapter 2, but is identified explicitly by Bridges, Flatley and Meyer (2010) and Baillie and Gallagher (2011). Warm, kind and gentle interactions with staff are identified as being crucial to a person’s sense of recognition as a fellow human being (Tranvåg, Petersen and Nåden, 2015). This echoes the findings of Baillie (2009) about the importance attached by patients to their interactions with staff. Baillie (2009) also notes that only a few staff members attached importance to staff- patient interactions; suggesting staff place less importance on the quality of their interactions with patients. van Gennip et al. (2013) illustrate the impact of relationships on resilience with this participant’s comment:
they can still see me as the person I once was. Not Mrs So-and-So, not the patient, no, ‘me’. (van Gennip et al., 2013, p. 1085)
In summary, findings from this review indicate that staff behaviour and patient characteristics exert a profound influence on a person’s experience of dignity in care. Communication and dignifying care activities that are inherently threatening to a patient’s dignity are highlighted as key aspects of staff behaviour. The patient’s vulnerability and resilience are identified as key patient characteristics. Interacting with each other, these seem to help make it more or less likely that dignity in care will be preserved.