This guest blog was contributed by Brendan McCormack, Professor of Nursing Research from the University of Ulster, Northern Ireland and a trustee of Age UK.
The Commission on Dignity in Care is well into its programme of work. As the Chair of the ‘Academic Reference Group’ I had the pleasure of being in attendance for one of the ‘oral evidence’ sessions, which had a primary focus on evidence-based tools and processes that would help ensure dignity in care.
I take away some impressions that are largely positive but which also raise some challenges to the way forward. The evidence presented highlights reasons why we need to be focusing on dignity (even if many of us regret that we are still needing to do this given the developments that have happened over many years of service improvement work). Some reflections from me on the evidence are presented here.
Firstly, throughout the day, a number of new models that are influencing the way care cultures in hospital and LTC facilities are developing and being transformed, locate themselves within models of relationships. The most significant of these is that of ‘relationship-centred care’ which is sometimes presented as an advancement of person-centred care. Some of the problems with this claim relate to the way in which person-centred care is defined, particularly when the dominant discourse of person-centred care as being about individual choice, autonomy and rights. At the level of values and principles, relationships are only 1 key component of personhood and person-centredness. However they are not the only part and thus relationships have to be placed alongside other characteristics of personhood, such as – space, place, aspects of ‘self’, existential time and issues associated with human rights and dignity. However, irrespective of these conceptual issues and challenges, we can never deny the importance of relationships in all of our lives.
The second issue relates to the importance of interdependent relationships. The idea of seeing care relationships as interdependent is hugely important and reinforces my own position (adapted from the philosopher Margaret Meade), i.e. ‘that I as a nurse can learn as much from a patient/resident as a patient/resident can learn from me’. The idea of interdependence raises significant and important considerations about multiprofessional working that seemed to come in and out of conversations today. We all accept that the only way that the cultures of care settings can change is through a concerted multiprofessional effort. Thus the challenges associated with enshrining dignity in all our work is not just a nursing issue. It is my view that the Royal Colleges, National Associations and Unions can take a significant and lead role in ensuring that all professionals see this as a priority.
Thirdly I believe we need to stop saying that we ‘can’t measure dignity’ – because we can. But to do so requires creativity and embracing of evaluation methodologies that are not the common parlance of health service managers nor indeed the majority of health service researchers. A pluralistic approach to measurement and evaluation is needed – approaches that integrate staff and service user voice with survey data as well as observations of practice. Additionally, we need to be more open to proxy measures of dignity and embrace them as key indicators of a complex phenomenon.
Finally, I believe the evidence presented made it strikingly clear that one cannot think about having dignified care for patients/residents if staff feel demoralised, put upon, not valued and disenfranchised. The need to develop ‘nudges’ to changes practice that are locally developed, owned by practitioners and embedded into the everydayness of practice is paramount. The holders of a workplace culture are the staff set within a macro culture of regulation, policy and economics and so we ignore the need to develop effective workplace cultures at our peril.
So yes, I believe we do have solutions that are informed by international evidence, are locally grown and are shown to be effective. What we need now are levers for change that ensure that executive leaders cannot ignore these solutions whilst they are lured by quick-wins and short-termism.