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Dignity and respect 

Dignity and respect
Dignity and respect

Maria Flynn

, and Dave Mercer

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date: 02 August 2021

Promoting dignity and respect

You have the right to be treated with dignity and respect, in accordance with your human rights (Dignity and respect

The concept of ‘dignity’ resides at the core of nursing practice and nursing philosophy. It is enshrined in the UK NHS Constitution and international and UK legislation around the human rights of those receiving healthcare in all settings. Failure to uphold dignified caring has been central to inquiry reports set up to investigate evidence of poor, or unacceptable, standards of care.

Dignity is a nebulous concept and there have been many attempts to identify its constituent components. Usually it is defined in terms of the moral rights, autonomy, and unconditional worth of each person. Here, though, the emphasis is on pragmatic application of nursing values and skills that can be deployed to provide respectful, empathic, and compassionate care.

Dignity, respect, and rights feature prominently in the NMC Code (Dignity and respect, emphasizing their importance to nursing practice and the prioritization of people receiving care.

Additional guidance is provided to the public regarding older people where research and media reports show little confidence in the dignity and respect accorded to this group of people when they are in hospitals and nursing homes.

In response to claims of a ‘compassion deficit’ in caring, the UK RCN has prioritized dignity as something that should be ‘at the heart of everything’ nurses do, centred on three integral dimensions:

  • Respect: acknowledging the uniqueness of each individual in the care process.

  • Compassion: not sacrificing the emotional and humanistic components of care to technical and clinical procedures.

  • Sensitivity: communication and therapeutic use of self, to show genuine concern about the other person.

Dignity can also be compromised by aspects of the physical environment in which care takes place and the way resources are utilized by nursing staff. Often, significant improvements can be made by small changes in the actions and behaviours of the professional. Examples are:

  • Ensuring the environment and facilities such as toilets and washrooms are regularly cleaned.

  • Properly drawing curtains around the bed when performing intimate or sensitive care where the person could be embarrassed.

  • Making sure that cubicle doors are closed when toilets are being used.

  • Having single-sex bays on wards where men and women are cared for together.

  • Assisting people to put on gowns and tying them securely to avoid unwanted exposure.

  • Maintaining privacy whenever the care, or conversation, requires discretion.

  • Not talking about an individual, or their health, in a public space such as the ward or bedside where other people can overhear.

  • Not assuming that you can use a person’s first name without gaining their permission, or an abbreviation of it. For example, Mr Charles Smith should not be referred to as ‘Charlie’, unless this is how he wishes to be known.

  • Avoidance of terminology that can patronize and demean the other person, such as greeting an elderly male patient by saying ‘Hiya pops’ or ‘How are you feeling today sweetie’?

  • Avoidance of jargon and acronyms as a ‘short-cut’ when communicating with a person. This may have meaning for the care team but is unlikely to be understood by non-health professionals and may well be misinterpreted.

  • Not allowing a catheterized patient to move around the ward/hospital carrying a full urine bag. These should be frequently and routinely drained and, if the person is able to mobilize, attached to the legs.

  • Acknowledging the concept of ‘treatment’ does not refer only to ‘medical treatment’ but has much broader meaning in terms of dignity and rights—caring about the person as well as for them.

The commitment to dignity should also be a central feature of the way nursing staff and other members of the clinical team work together to create, and sustain, a culture that promotes and respects the value and human rights of those in receipt of care—where clinical leaders and ward managers ‘role-model’ best practice for team members.

NICE (Dignity and respect guidelines suggest how the patient experience in adult UK health services can be constructed around good communication skills:

  • Shared decision-making where the person is actively involved in discussions and decisions about their care.

  • Use of open-ended questions to invite the person to talk; summarize at the end of discussions to check for understanding; allow time for questions to be asked and addressed, before leaving.

  • Giving the person oral and written information to promote active involvement in care and self-management.

  • Adopting individualized care that is ‘tailored’ to each person’s health and psychosocial care needs which should be regularly reviewed with the person.

  • To allow for feedback on services and care standards, each person should be clearly informed about ways of voicing concerns or making a complaint.

  • Encouraging all staff to participate in ongoing CPD and inter-professional learning.

  • Developing self-awareness and critical reflection of practice where personal feelings and observations are explored in the context of larger organizational, cultural, and political events.

Nursing identity

The provision of dignified care is inextricably linked to the formation and maintenance of a professional nursing identity. Learning strategies that nurture this should be central to academic programmes leading to nurse registration and professional development, and embedded in the clinical areas in which nurses train and work.

Learning is most powerfully experienced when it is situated within social practices and relationships, and contextual rather than individual. A vital component of positive learning, like communication itself, is authenticity or genuineness where the experience is relevant to the everyday lives of those taking part.

Nurses, for example, who have responsibility to mentor learners in a clinical or community context should ensure that teaching or support is delivered in a way that includes discussion or involvement with all those involved and the opportunity to critically reflect on the outcomes. This means that analysis of the issue(s) should move beyond the micro-dynamics of the interaction and take into account differences in organizational power and status which frame communication.

Social inclusion is pivotal to holistic practice, individualized care, and maintenance of dignity where good communication and interpersonal skills play a key role. The next sections consider the importance of healthcare communication with regard to older people, people who live with dementia, individuals with a learning disability, and those who have mental health issues or experience psychological distress.

Communicating with older people

Globally, there is a growing elderly population. Historically, in a clinical context, those aged over 65 years were collectively described as ‘geriatric’ or ‘psycho-geriatric’. This reflects the dominance of the medical model in defining and constructing the ageing body according to universal sets of diagnoses or typologies. The legacy of this patho-biological perspective persists in the altered status accorded to older people in industrial societies where economic productivity and spending power represent cultural capital; in short, identity and citizenship are constructed by market forces.

With improved standards of living and advances in medical technologies and treatments, many people are living longer lives. Current best practice in health policy and nursing focuses on the care of the ‘older person’, recognizing that while illness and degenerative conditions can be associated with age, many senior citizens enjoy healthy and fulfilling lives.

A generic set of principles are helpful in communicating with older people, but they do not replace making an individual assessment based on therapeutic relations and observations. As with any communicative interaction, the environment needs to be taken into account. For some older people, there may be a deterioration of vision, hearing, and memory, though it should never be assumed that they are ‘blind’, ‘deaf’, or ‘demented’. If the ward/room is busy or noisy, this will produce unwanted distractions and impediments. Therefore, try to:

  • Minimize the background noise levels, and do not shout.

  • Arrange furniture in a way that invites face-to-face talk.

  • Speak softly and slowly, using familiar words and short sentences.

  • Talk with the person, rather than to them, and actively listen to what they are saying.

  • Reinforce what you are saying with non-verbal signs and gestures.

  • Use written information, with a larger font size, if it helps the person to understand what you are saying to them.

  • Allow the person time to take in, and reflect on, what you are saying, and do not rush the conversation.

  • Avoid complex terminology or nursing/medical jargon.

  • Ensure that prescription sensory aids (e.g. spectacles, hearing aids) are available if required by the older person.

On busy hospital wards or in care homes for the elderly, routines and rituals can take precedence over caring for and about people. Just because someone is staring at the television does not mean they are watching it, or even interested in the programme.

In environments where the radio is permanently playing, talk in general is impeded. In this regard, the concept of ‘institutionalization’ is of interest. Originally employed by the sociologist Erving Goffman in the 1960s, it described the process by which ‘mental patients’ became institutional products—a stripping of identity, damaging of selfhood, and ultimately dehumanization of the ‘inmate’. There is still much to learn from this work.

Communication with the older person should not always be about clinical care or nursing decision-making. Rather, talk has therapeutic value in, and of, itself.

Older people may have fewer visitors, spending a lot of time on their own. Possibly feeling embarrassed to interrupt younger, and busier, nurses, they can retreat into themselves—passively responding only to requests, rather than actively initiating engagement. Nurses can employ communication skills to help older people maintain a sense of independence and agency, allowing them to retain a degree of control in their lives. General principles could include:

  • Acknowledgement of the older person as an individual with unique personal qualities.

  • Involvement of the older person through conversation and discussion that is shared and reciprocal.

  • Valuing choice by allowing older people to actively participate in decision-making about everyday activities.

  • Ensuring that the older person feels they are at the centre of any communicative episode, and using verbal and non-verbal techniques to reinforce this message.

Communicating with people who live with dementia

Another dynamic of people living longer is the increased likelihood of their becoming, at some point, more reliant on health and social care provision. Though the older population is a heterogeneous social group, some will develop disorders in communication as a product of ageing and clinical conditions like Alzheimer’s disease and other forms of dementia.

The progressive and degenerative decline of cognitive abilities commensurate with the pathophysiology of the illness means there is a real need to maintain contact with ‘reality’ through communicative strategies. Over time, there will likely be a significant decline in memory and language use. This will impact on the ability of the individual to organize their thoughts or to rationalize their behaviours.

An unfortunate ‘side effect’ of the dementia process is that it triggers a parallel social process where the individual is at risk of being marginalized, both within the family and the wider informal support networks.

It is easy for the person with dementia to retreat into an inner, and silent, world—losing touch with, and failing to recognize, friends, loved ones, or the names of professionals who care for them. These people should be treated no differently to other older adults in terms of communication. However, there are some important issues that need to be incorporated into nurse–person interactions:

  • Speak clearly and slowly, and keep the content uncomplicated.

  • Communication is about more than ‘talk’ alone. When speech is difficult for the older person, non-verbal factors can assume more importance, so nurses should use gestures and cues accordingly (e.g. accompanying a conversation with a ‘friendly smile’).

  • Remembering the specific impact of dementia on the language use of an individual, nurses will most likely need to take a lead in initiating and prompting talk. Encourage them in this, and do not try to hurry the conversation by finishing sentences or making an assumption about what they are struggling to articulate.

  • One way of ‘making contact’ with an individual who has become withdrawn is to focus on events that have personal meaning. Here, personal histories, memories, photographs, or music can offer productive avenues for talk—but they must also be deployed sensitively to avoid causing distress or recall of painful moments.

  • If it feels appropriate, touching the arm or holding the hand of the other person can convey reassurance and a sense of ‘being there’ for them.

  • Because of progressive neural damage within the brain, it is important not to feel emotionally slighted by a sudden change of mood in the other person, but to accept this as a symptom of the disease process.

  • Even if you have been working with someone with dementia for a considerable period of time, they may not recognize the longevity of the relationship. Be calm and patient in your approaches, and do not allow yourself to become frustrated.

  • ‘Active listening’ is particularly important when communicating with this group of people, that is using the full range of therapeutic and communicative responses to engage the interest and attention of the other person.

  • Of great importance is that nurses do not contradict the person with dementia. Their version of the world may not be factually accurate, but it represents the version of ‘reality’ in which they are currently living (see also Dignity and respect Chapter 18, Neurological conditions).

Communicating with people with a learning disability

Learning disability is a collective term for a wide spectrum of people, and the degree of impairment will range from very mild to profound.

Some will communicate easily with nursing staff, whilst others will need time, support, and possibly the involvement of a speech and language therapist (Dignity and respect The nursing role is to provide education and promote health, rather than simply manage a clinical episode.

People living with a learning disability experience physical health problems as a result of complex factors unrelated to their individual conditions. This can result from lifestyle, income/economic factors, or lack of access to health screening.

Individuals who are prescribed anti-psychotic medication can experience damaging iatrogenic side effects where the ‘problem’ is induced as a by-product of treatment. Individuals with a learning disability are at an increased risk of developing heart disease and type 2 diabetes, often made worse by poor diet, lack of exercise, and obesity.

Health needs can be unmet in mainstream primary healthcare services that are poorly equipped or trained to engage with this client group and/or their carers. Life expectancy has increased for people with learning disabilities, but mortality and morbidity rates still remain higher than in the general population.

People with a learning disability have typically grown up and lived with ridicule, bullying, and discrimination. They may be uncomfortable with strangers or uneasy in unfamiliar environments like a clinic or a hospital ward. In circumstances like this, it is important that your approach and presentation of self are welcoming and friendly. This can be reinforced using non-verbal language and cues to reinforce the message of spoken words.

Though adult general nurses use the term ‘patient’ routinely, people with a learning disability may be more accustomed to ‘self-advocate’ or ‘peer advocate’. This is one way organizations promoting inclusive working resist diagnostic medical discourse in favour of a social model of disability.

National campaigning groups for the learning-disabled community offer generic guidelines. These recommend that you:

  • Remember everyone is an individual and everyone is different.

  • Do not make assumptions about a person’s ability to understand what you are saying to them.

  • Speak clearly and slowly, allowing the person time to process what you are asking or telling them.

  • Avoid using jargon or technical language that is more difficult to understand.

  • Use open-ended questions that invite the person to communicate with you.

  • Always check that what you say has been understood by using polite clarification.

  • Observe body language, gestures, and other non-verbal communication of the other person for cues, and also use these to reinforce your message.

For individuals who have greater difficulty in communicating with others, specific techniques have been developed and include:

  • Signing systems like Widgit (Dignity and respect or Makaton (Dignity and respect which are based on British Sign Language (BSL).

  • Commercially produced easy-read pictures and illustrations, or your own quick drawings, to complement spoken and written language.

Communicating with people experiencing mental ill health and psychological distress

From psychiatric illness to mental health movement

For nurses who focus exclusively on caring for individuals diagnosed with a mental illness or personality disorder, communication and therapeutic use of self are the most important attributes of a caring role. But the move from a coercive and controlling system of institutional incarceration to a democratized mental health movement signals the ongoing struggle of service users and survivors, and new ways of engaging with professionals.

From the mid-nineteenth century until around the mid 1960s, psychiatry, located in asylums and mental hospitals, attempted to apply the scientific principles of biomedicine to ‘mental diseases’. The power of the medical model has proved remarkably resistant over the years; it continues to dominate the language of healthcare, discourses of aetiology, disease classification, taxonomy, diagnosis, prognosis, and treatment.

The Diagnostic and Statistical Manual (DSM), published by the American Psychiatric Association (APA), is an influential source of information for diagnosing mental disorders. It has grown massively in volume since the first edition in 1952. This trend has not been without controversy, given that it proclaims a scientific delineation between ‘normal’ and ‘deviant’ human beings.

Historically, the nursing profession responded to diverse care needs in terms of self-contained branches such as mental illness, learning disability, adult, and child nursing. This organization of the profession may have utility in relation to specific health and social care needs but masks the universality of ill health, regardless of structural markers such as age, ethnicity, social class, and gender, and promotes a psyche (mind)–body (soma) split.

Regardless of a particular health condition, there is always an affective or psychic component, and general nurses will frequently encounter persons with more serious mental health problems. Nurses should be proficient in effective communication skills to assist in identifying and alleviating psychological components of ill health and supporting those in their care with pre-existing mental health needs.

Those who oppose the institutional apparatus of psychiatry in contemporary society talk about a ‘post-psychiatric age’—one which recognizes social and cultural contexts, puts ethics before technology, and works to minimize pharmacological control and coercive interventions.

This brief account of ‘psycho-politics’ is instrumental in framing the discussion that follows—one premised on the philosophy and principles of mental health nursing, rather than psychiatric nursing, of recovery, not cure. It is about working with human needs, not diagnostic descriptors.

The lived experience of mental health

Globally, mental health ‘problems’ represent a growing public health concern. A corollary of this is measured in suicidal and self-harming behaviours and physical conditions such as ischaemic heart disease. In the UK, it is estimated that one person in four is likely to experience mental health issues and psychological distress. In this chapter, we restrict our discussion to the expressions of mental illness and emotional issues most likely to be encountered by adult general nurses.

It is important to remember that general nurses will be caring for the person in the context of a physical illness. They are not expected to engage therapeutically with any identified mental disorder. As such, the presentation of self, language use, and communication skills will be sufficient to assist in undertaking regular nursing duties.

If someone is admitted who has a previous history or a diagnosis of mental illness, it is important to ensure that any prescribed medications are recorded on the patient prescription sheet and dispensed at the appropriate times.

If someone is behaving in a way that causes concerns about their mental health, this should be reported to the care team, and a referral for specialist assessment requested.

Supporting people living with a thought disorder

In psychiatric literature, certain experiences, which are subjectively experienced, have been explained as evidence of a ‘major mental illness’ or ‘psychotic episode’. This could, if serious and enduring, support a diagnosis of schizophrenia. Bipolar disorder (previously known as manic depression) shares the same sort of symptomatology, accompanied by extreme mood swings, from elation (mania) to hopeless despair (depression). Features of an enduring psychotic illness include:

  • Talking in a way that does not make any sense to other people, and referred to as disorganized thinking.

  • Having fixed beliefs about the world that do not match up with the way others see them, referred to as delusions.

  • Hearing (auditory) or seeing (visual) things that do not exist, referred to as hallucinations.

  • Becoming inward-looking and isolated.

  • Being suspicious about the actions of other people.

  • A loss of interest in life and the immediate environment.

  • Disrupted sleep patterns.

  • Lack of attention to personal hygiene, appearance, or dress.

Supporting people who are experiencing a low mood

In the past, depression was sometimes referred to as ‘the common cold of psychiatry’. This now sounds dismissive and patronizing to people who live with a depressive disposition, but it remains the case that it is one of the most frequently encountered mental health problems worldwide.

Depression has been variously defined as aneurotic, or minor, type of mental illness. However, such does not convey the deeply disabling distress and suffering that accompany depressive episodes. Symptoms include:

  • Feeling of sadness, remorse, or irritability.

  • Losing interest in things that were once enjoyable.

  • Diminished levels of energy or motivation.

  • Poor levels of concentration.

  • Feeling tired for much of the time, accompanied by altered sleep patterns.

  • A lack of confidence which can develop into self-loathing and a sense of feeling/being worthless.

  • A loss of interest in intimacy, accompanied by sexual self-doubt.

  • Having the feeling things are ‘so bad’ that life is no longer worth living.

Historically, depression was subdivided into reactive and endogenous types. The former described the onset of depression as a response to something in the life-world of the person (e.g. bereavement), whilst the latter referred to forms of depression that lacked any external reference points, seeming to originate from within the individual themselves.

Presently, such distinctions have been largely abandoned, and psychiatrists tend to make diagnostic decisions in terms of primary (internal locus) or secondary depression (external locus).

Supporting people who feel anxious

Anxiety is often a component of depressive disorders and, when the manifestations are severe, is equally debilitating. Like low mood, anxiety is a part of everyday life that all people will experience at some point in their lives (e.g. attending for an interview or feeling really nervous before taking an examination).

Where anxiety becomes a recurrent, repetitive, or defining feature of somebody’s life—to the extent that treatment in primary care services is required—it is spoken about as ‘generalized anxiety disorder’. The physical and psychological features include:

  • Increased blood pressure and a rapid heartbeat.

  • Feelings of sickness, nausea, and breathlessness.

  • Constant state of agitation, without any way to exercise this.

  • Disturbed and restless sleep patterns.

  • Overwhelming sense of dread.

  • Lack of energy and lethargy.

  • Inability to think in a logical or rational way.

  • Emotional lability and tearfulness.

‘Panic disorder’, or ‘panic attack’, is used to describe the condition of people who experience extreme elevations of anxiety. In these situations, physical symptoms such as extreme tachycardia or severe breathlessness are common. These episodes are described in terms of trauma and terror and can rapidly spiral into total loss of control. In parallel, these individuals may feel unable to leave their home, avoiding other people, places, or situations that could trigger another panic attack.

Engaging people who live with ‘personality disorder’

The concept of ‘personality disorder’ is a more recent addition to the diagnostic lexicon of psychiatry. It has not been without its critics, particularly those who express concern about an increasingly medicalized world where diagnosis and treatment can be understood in terms of social control.

As it suggests, a diagnosis of personality disorder constructs the mental health problem in terms of who a person is, rather than what a person has. The diagnostic criteria focus on persistent ideas, attitudes, beliefs, and behaviours that have a negative impact on how the individual is able to function in everyday social life.

There are a number of sub-categories of personality disorder, including narcissistic, schizotypal, paranoid, and antisocial. Diagnosis of the latter is typically associated with actions that cause harm to others and law-breaking behaviours. The attribution of negative characteristics, in what can appear as a judgement of the person’s ‘self’, has witnessed a long history of personal shame and collective stigma to those people described in terms of having a personality disorder. Latterly, though, there is a more enlightened acceptance of this group in terms of real healthcare needs.

In terms of general nursing practice, though, it is more likely you will encounter individuals identified as having a ‘borderline personality disorder’ (BPD). There is a reminder here of the early origins of the concept of personality disorder, as a way of describing individuals who could be categorized as neither ‘psychotic’ nor ‘neurotic’, that is they were situated at the ‘borderlines’ of psychiatric diagnosis. Typical features of BPD include:

  • A weakened sense of self or identity that changes in relation to different people or contexts.

  • Acting in an impulsive manner, but feeling bad about this after the event.

  • Experiencing emotions intensely, but with regular mood swings.

  • An overriding sense of abandonment, and a struggle to maintain attachments and relationships.

  • Difficulty in handling frustration, and occasional angry outbursts.

  • Brief psychotic episodes.

  • Feelings of suicide or self-harm.

Talking with people, and not to disorders

As mentioned previously, the focus of the general nurse in working with people who have mental health problems or experience distress as a product of their clinical treatment is about the person, rather than their diagnosis.

The best way to engage in a positive and productive way with people is to embrace the core conditions of a humanistic and person-centred approach: empathy, genuineness, and unconditional positive regard (see also Dignity and respect Chapter 6, Communication in a healthcare context). The following suggestions may provide a helpful framework:

  • The foundation to any meaningful interaction is based on respect and trust.

  • The basis for this is establishing a therapeutic relationship with the other person.

  • Some people, because of their mental health needs, are vulnerable to ridicule, abuse, and exploitation.

  • As a nurse, you have a duty of care and an advocacy role, to act in their best interests and safeguard their well-being.

  • If people are quiet or withdrawn, make an effort to talk to them and keep them involved.

  • Where people appear overly worried or suspicious, be sure that you explain everything in an easily understandable way.

  • Allow time for the other person to ask questions and address their concerns.

  • Always explain what will happen during the day, so that people are informed and prepared.

  • If someone becomes anxious or experiences panic, speak clearly, slowly, and calmly.

  • Encourage the person to relax and breathe slowly; offer reassurance, and stay with them until the anxiety subsides.

  • To the extent that it is possible, try to keep the intrusion of external, environmental stimuli to a minimum.

  • Some people may describe events in a way that you do not understand, but accept this as their interpretation, and do not challenge it or attempt to persuade them differently.

Useful sources of further information

Department of Health. Personality disorder: no longer a diagnosis of exclusion—policy implementation guidance for the development of services for people with personality disorder. Dignity and respect

MIND. Understanding personality disorders. Dignity and respect

National Institute for Health and Care Excellence (NICE). Guidelines for borderline personality disorder. Dignity and respect

Rethink Mental Illness. Depression: what are the symptoms of depression and how is it diagnosed?Dignity and respect