Column

Undignifying institutions with good intentions

Everybody agrees dignity is crucial. For example, the UK Patient’s Charter explains that patients can ‘...expect the NHS to respect your privacy, dignity and religious and cultural beliefs at all times and in all places.’

And the United Kingdom Central Council for Nurses, Midwives and Health Visitors Code of Professional Conduct ordains that ‘...in the exercise of your professional accountability, (you) must recognise and respect the uniqueness and dignity of each patient and client.’

Yet in the very institutions that nail mission statements like these to their lobby walls staff report: ‘I think I would say things like having spare clothes (affect dignity), if patients like don’t have any, instead of just putting on nighties.’

‘... lack of resources and certain things not working like, showers not working, call bells, the place being dirty, looking like a pigsty...’

‘Linen, towels in the morning, we haven’t enough towels. We use pillowcases for drying patients and they say ‘where is the towel?’ and we say ‘they didn’t come yet…’

‘…we are still acutely short of staff and you often have to choose between who needs you more... one has either a choice of doing say antibiotics on time or attending to someone who calls...’

These remarks typify recent comments about dignity made by staff in North London elderly care institutions. They reveal a yawning gap between aspiration and reality. And there is good reason to suppose the gap will remain so long as resources are stretched and we fail to give non-clinical priorities the practical attention they deserve.

It’s plain to see. Where peoples’ circumstances and capabilities do not match they are likely to feel undignified. For example, if facilities are so stretched that patients have to wash and dress where other patients may see them, circumstances (inadequate privacy) undermine a capability (to protect oneself from embarrassment).

There is a direct relationship between resource levels and dignity – the better the resources (money, time, staff, energy, enthusiasm, commitment), the richer the circumstances, the more likely it is that patients will be dignified. Inevitably, as resources diminish the most obvious priorities (like administering and recording medication and making sure meals are served according to the timetable) are protected at the expense of the less tangible (like caring and promoting dignity).

The explicit activities are often dignity promoting themselves – judicious medication promotes dignity because it improves both capabilities and circumstances, for example. However, if the less overt aspects of institutional life are neglected as clinically dominated systems automatically preserve their ‘vital functions’, enormous indignities can quickly become routine.

Examples abound in staff comments. When a patient’s bed space is frequently changed and the patient feels a consequent lack of control and self-worth, then the institution has created a dignity undermining circumstance. When patients are dried with pillowcases rather than towels, when staff shout at residents unnecessarily, when showers are not repaired, or when patients are left sitting in a place they don’t want to be simply because no-one has asked if they would like to be moved, the institution itself undermines the capabilities of already vulnerable people.

The uncomfortable fact is that the set-up and circumstances of at least some elderly care institutions are weakening the capabilities of at least some residents. And wherever this is true health care institutions have – inexcusably – become undignifying institutions, whatever it says in the foyer.