Summary of the impact

The research has led to a clear and accepted definition of dignity which have been adopted by health care organisations and professionals. It has raised the awareness of professionals and carers of the needs and means to enhance patient's dignity. Resources have been developed and used to train and support staff to improve attention to patient dignity. The research has also influenced changes in national policy such as reducing use of mixed sex accommodation, and changes to healthcare practices such as improved hospital gown design and use of bed curtain clips and notices. The resources on patient dignity continue to be disseminated and adopted and inspired the Velindre Cancer Centre group which won the 2013 Nursing Times Dignity Award.

Underpinning research

Patient dignity is a complex and multi-factorial phenomenon. WHO research identified the importance of dignity to patients (Valentine et al. 2008, Soc Med Sci., 66(9), 1939-50) and respecting people's rights to dignity is a core health care value. Despite increasing concern about hospital patients experiencing indignity, little research about patients' dignity in acute hospital settings, particularly from the patient perspective, had been performed.

The research underpinning this Impact case was conducted by Lesley Baillie (Principal Lecturer) at London South Bank University (LSBU) between September 2004 and April 2007.

Baillie's study investigated the meaning of patient dignity, threats to patients' dignity, and how patient dignity can be promoted in acute hospital settings. A qualitative, multi-method case study was carried out in an acute hospital in England, focused on adults. Data were collected from: post discharge interviews with 12 patients; participant observation of patient care (n=12 of 4 hours each) with follow-up interviews with 12 patients and 13 staff; observation of 12 staff handovers; interviews with 6 senior hospital nurses; and analysis of hospital documents. The data were analysed thematically using the framework approach (1-4).

Key insights emanating from the research were:

• Patients felt that dignity primarily related to their feelings (feeling comfortable, in control and valued), their physical presentation (being dressed appropriately, not having their bodies exposed) and behaviour to and from others.
• Patients' impaired health threatened their dignity due to loss of function, psychological impact and intimate procedures. Patients promoted their own dignity through their attitudes and relationships with staff.
• Lack of privacy in hospital threatened dignity, heightened by bodily exposure and mixed sex accommodation. The exposing nature of hospital gowns was a key issue from patients' perspectives.
• Staff behaviour had an important effect on patients' dignity and related to interactions with patients and provision of privacy. Threats to dignity arose from staff interactions that were curt or authoritarian, and from breaching privacy, for example, entering curtained bed spaces while patients were exposed, without warning. Staff behaviour promoted dignity by providing privacy and through interactions that made patients feel comfortable, in control and valued. While few staff recognised that their interactions affected dignity, patients considered that staff interactions had a major effect on their dignity.
• Hospital systems threatened dignity, mainly due to bed management issues, while a conducive physical environment and a dignity-promoting culture and leadership promoted patient dignity.

Patients' dignity is diminished or preserved by staff behaviour and interactions and by privacy in hospital. Educating staff to recognise patients' vulnerability to indignity in hospital, for example, the impact of hospital gowns, mixed sex accommodation and lack of vigilance in keeping bed curtains closed, was an important aspect of improving patient dignity. The research concluded that there is a need for staff to be proactive about reducing patients' bodily exposure, to bring about increased privacy and for staff to reflect on their interactions with patients in ways that preserve dignity by helping patients to feel comfortable, in control and valued.

References to the research

Details of the impact

In 2008, as a direct result of her research into patient dignity, Lesley Baillie was approached by the Royal College of Nursing (RCN), the leading professional body for Nursing in the UK, and invited to be an expert consultant to its campaign `Dignity at the heart of everything we do'. The Director of Nursing and Service Delivery, RCN, has provided a statement to evidence Baillie's contribution and the reach (410,000 nurses, midwives, healthcare support workers and students) and impact of the campaign (1)

Drawing on Baillie's research, the RCN commissioned a scoping survey of the nursing workforce to explore barriers and facilitators to dignified care. Baillie devised the survey questions and developed a working definition of dignity for the survey. The results of the survey of 2000 RCN members was instrumental in the planning and direction of the campaign (2).

The dignity definition, published in the survey report (2, page 8) has led to a clearer understanding nationally of the meaning and scope of dignity in health care and has been adopted by NHS Trusts and used to inform dignity policies, for example Royal Lincolnshire Hospitals (3).The survey results were presented at a national conference to launch the campaign in 2008, which was attended by over 100 senior nursing representatives (1). The campaign featured at the RCN's 2008 Congress attended by Alan Johnson MP (Secretary of State for Health at the time). Baillie's team sought clarification from the Minister about when mixed sex accommodation would be eradicated. Johnson promised that they would be and this was widely reported in the press (4). Following on from this, in January 2009, Johnson announced that from April 2010, the standard contract for NHS patients would be same sex accommodation and this policy has been fully implemented with hospitals having to report any breaches monthly.

Baillie worked on the campaign resources for the RCN (supported financially by Smith and Nephew and Help the Aged). Based on her research, Baillie led the development of a practice support pack, which comprised a DVD with facilitator's guide and additional resources e.g. pocket guides (5). In 2008-2009, the packs were distributed widely across the UK, to nursing teams in both NHS and private healthcare organisations (1). In total, 3,746 packs were distributed and a further 1,087 packs were purchased subsequently by other UK and overseas organisations (1); the packs remain available to purchase, with supporting resources free to download (5). A key feature of the campaign was local launch events where the RCN's campaign team prepared local campaign leaders to use the campaign pack with their nursing teams. As an example, the Supportive Care Lead Nurse at the Velindre Cancer Centre in South Wales (which provides specialist cancer services to over 1.5 million people in South East Wales) attended a local session and took away the practice support pack. They found the materials so `powerful' that they formed a Patient Dignity Group. The resource prompted them to think more deeply about what dignity really meant and to feel that, as nurses, they could do something to improve dignity for their patients (6). An article in a professional journal reviewing the campaign reported that the practice support pack was being used by health and social care practitioners across the UK (7), and quoted the RCN Dignity Campaign lead reflecting that "anyone with a little confidence has been able to run a training and development session. These sessions are about enabling other people so that they can change their practice" (7). The article reports examples from NHS Trusts that had made improvements as a result of the campaign resources, for example, in the Isle of Man, staff improved bed curtains so that they maximised privacy and Guy's and St Thomas' NHS Trust promoted improvements in staff interactions with patients (7). The active campaign finished in 2009 but the RCN's Dignity section and resources remain on the RCN website (5).

Baillie, together with another consultant, conducted an early stage evaluation of the campaign in 2009 at seven UK sites, using a multi-method case study approach (8, 9). The evaluation indicated that the campaign resources were well-received with the practice support pack triggering staff to reflect on their own practice and behaviour, for example, becoming aware of talking over patients during ward rounds (8, 9). A Deputy Chief nurse at one of the NHS Trusts said: `The very clear feedback that we've had is that it's enabled staff to actually realise and have more insight into their own practice' (8). The evaluation found that as a result of the campaign resources, some changes in practice had already been made and these related to improvements in privacy, the care environment and staff interactions with patients and families (8, 9). Improvements in privacy included: obtaining dressing gowns for patients to wear over their theatre gowns when walking to theatre, implementing `do-not-disturb' signs for curtains, taking patients to the bathroom rather than them using a commode at the bedside, and instigating a policy to ensure that inpatients attending outpatient appointments were dressed in their own clothes rather than gowns whenever possible (8, 9). Care environment improvements included improving facilities for families in intensive care, personalising the care home environment, and developing a private room for breast feeding mothers on a children's ward (9).

Further examples of change as a result of the campaign include, for example, one large hospital, Guy's and St. Thomas' (GST) which introduced 120 Dignity Champions and adopted a "no interruption" rule (7). Independent Consultants interviewed staff at the Heart Hospital, London, who introduced Dignity Champions and a "goody bag" scheme allowing older patients to bring comfort items from home, they provide patients with hot drinks throughout the night and wherever possible provided patients with food and drink of their choice (10).

The Velindre Cancer Centre's Patient Dignity Group was inspired by the RCN Dignity campaign and has continued to develop (6, 11), indicating the sustainability of the campaign and its impact on practice. The Group, now multi-disciplinary, meets four-monthly and works on continued improvements. The group's work led to the Centre being short-listed for the 2013 Nursing Times Dignity award (12), which they subsequently won.

Sources to corroborate the impact

1. Statement: Director of Nursing and Service Delivery, Royal College of Nursing
2. Baillie, L., Gallagher, A., Wainwright, P. (2008) Defending dignity: opportunities and challenges for nursing. London: Royal College of Nursing. Available from:
   http://www.rcn.org.uk/__data/assets/pdf_file/0011/166655/003257.pdf
3. Dignity in care definition, Royal Lincolnshire Hospitals website:
   http://www.ulh.nhs.uk/for_patients/dignity_in_care/definitions.asp
4. Carvel, J. (2008), The Guardian. May 1^st. Available from:
   http://www.theguardian.com/politics/2008/may/01/alanjohnson.nhs
5. Royal College of Nursing. Dignity — publications. Available from:
   http://www.rcn.org.uk/development/practice/dignity/rcn_publications_and_resources
6. Contact: Supportive Care Lead Nurse at the Velindre Cancer Centre.
7. Duffin, C. (2009) Dignity in all we do. Nursing Standard 23(49), 18-19.
8. Baillie, L., Gallagher, A. (2010) The RCN Dignity campaign: exploring enablers and challenges. Journal of Research in Nursing 15:1, 15-28. DOI: 10.1177/1744987109352930. Available from:
   http://jrn.sagepub.com/content/15/1/15
9. Baillie, L., Gallagher, A. (2011) Respecting dignity in care in diverse care settings: strategies of UK nurses. International Journal of Nursing Practice, 17, 336-341. DOI: 10.1111/j.1440-172X.2011.01944.x
10. Independent Consultants Report (The Innovation Partnership, 2013). Contact: Managing Director, The Innovation Partnership.
11. Velindre Cancer Centre. Dignity Code. Available from:
    http://www.wales.nhs.uk/sites3/page.cfm?orgid=357&pid=57561
12. Velindre Cancer Centre. Patient Dignity group short-listed for (and winners of) the 2013 national Nursing Times Award for enhancing patient dignity.
    http://www.wales.nhs.uk/sites3/news.cfm?orgid=357&contentid=28640