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Lack of dignity for older patients on hospital acute wards

01 July 2011

Elderly patients receive varying standards of dignified care on NHS hospital wards, new research by Cardiff and Kent Universities has found.

The research discovered:

• Poorly-designed wards which were confusing and inaccessible for the elderly
• Boredom through lack of communal spaces and activities
• Concern about nearby patients of opposite gender
• Demoralised staff who were also ill-equipped with the skills to care for the elderly
• Organisational problems causing patients to be frequently moved within the system

The Dignity in Practice study follows a number of national reports showing that the NHS does not always treat older people with care, dignity and respect and that the lack of dignified care provided in acute NHS Trusts is a major source of complaint. The aims of the research were to identify in a systematic way the quality of dignified care experienced by older people admitted to acute NHS Trusts and if and why there were variations in its provision. The study was led by Dr Win Tadd of the ESRC Centre for the Economic and Social Aspects of Genomics (CESAGEN) at Cardiff University, with Professor Michael Calnan, School of Social Policy, Sociology and Social Research at the University of Kent.

The study examined provision of dignified care across 16 wards in four acute NHS Trusts in England and Wales. The researchers observed practice on the wards and interviewed patients, families, ward staff and managers. They found that the majority of staff were concerned to provide dignified care to older people but that care provision was variable. In none of the sample of wards studied, was care either totally ‘dignified’ or totally ‘undignified’. The variations occurred from ward to ward, in the same ward when different staff were on-duty, and at different times of the day.

In the four Trusts selected, the 16 acute wards were generally seen to be poorly designed to meet the needs of their main users, older people, and not ‘ideal’ as a place to treat older people with dignity, as the physical environment was frequently confusing and inaccessible. Many older people commented on the disempowering nature of acute wards and the boredom resulting from the lack of communal spaces and activities. This can add to the disorientation experienced by many older people on admission to hospital. The majority of older people interviewed expressed concern about being in close proximity to patients of the opposite gender.

The majority staff view was that, while doing their best, they were often ill-equipped in terms of their knowledge and skills to care for older people, especially when an acute illness is compounded by physical and mental co-morbidities. Staff workload on the observed wards allowed little opportunity for engagement with individuals. Many of the staff interviewed recognised these issues but concluded that it was the older person who was in the ‘wrong place’. This, together with the assumption that there must be a better place for patients to be, could suggest an underlying ageism.

The research also showed that NHS staff are motivated to represent patients’ interests but were frequently frustrated by systemic and organisational factors. Many of the staff interviewed mentioned several factors which all impacted on the care of older people resulting in them being frequently moved within the system. These included: the setting of acute Trust priorities on the basis of measurable performance indicators; a culture of blame; the management of ‘secondary risks’; high bed occupancy rates together with increased specialisation and rationalisation. These resulted in a perceived drain on hospital resources and an inability to deliver appropriate standards of care. These systemic and organisational factors were also found to impact on the sense of dignity experienced by many of the ward staff interviewed, resulting in their demoralisation.

The findings were backed up by four stakeholder workshops involving 150 NHS staff, voluntary bodies and policy makers from across England. Stakeholders agreed that the research findings were typical of their local organisations as well, suggesting that the findings are widely applicable.

Dr Win Tadd, who led the study, said: "The first of the six core values in the NHS Constitution is ‘respect and dignity’ and there is evidence that positive health and social outcomes result from ensuring patients receive dignified care. However, this study reflects the findings of many recent research studies and independent reports highlighting the lack of dignity for older people in acute hospital wards, and provides greater understanding of the factors that enable and inhibit dignified care. There is a fundamental need for more widespread recognition that the people who most frequently arrive at acute hospitals as patients, namely, the old, the frail and those with dementia are deserving of dignified care."

The study was commissioned and funded by the National Institute of Health Research Service Delivery Organisation and managed by the Department of Health and Comic Relief under the PANICOA ( Prevention of Abuse and Neglect in the Institutional Care of Older Adults) initiative. The full report can be downloaded from http://www.sdo.nihr.ac.uk/project.php .


Ends

Notes to Editors

1. Dignity in Practice was a large ethnographic study involving 176 interviews and in depth observation built on evidence from the Dignity and Older Europeans study (2005) and examined the provision of dignified care in four acute NHS Trusts in England and Wales. Interviews were held with: older people following discharge (n=40); their family members or carers (n= 25); senior trust managers (n=32) and ward staff (79). The interviews were complemented by 617 hours of direct observation of the care provided in 16 wards across the four study sites.

2.The National Institute for Health Research Service Delivery and Organisation (NIHR SDO) programme was established in 1999. It aims to improve health outcomes for people by commissioning research evidence that improves practice in relation to the organisation and delivery of healthcare. It also builds research capability and capacity to carry out research amongst those who manage, organise and deliver services, and improves their understanding of the research literature and how to use research evidence. The goal of the programme is to identify, prioritise and refine the research needs of the NHS management community. The programme commissions research that will be of great value in shaping and contributing to decision-making and in promoting the more effective use of research evidence by NHS managers.

3.The National Institute for Health Research provides the framework through which the research staff and research infrastructure of the NHS in England is positioned, maintained and managed as a national research facility. The NIHR provides the NHS with the support and infrastructure it needs to conduct first-class research funded by the Government and its partners alongside high-quality patient care, education and training. Its aim is to support outstanding individuals (both leaders and collaborators), working in world class facilities (both NHS and university), conducting leading edge research focused on the needs of patients. www.nihr.ac.uk

NHS disclaimer
The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the SDO programme, NIHR, NHS or the Department of Health.

4. Cardiff University is recognised in independent government assessments as one of Britain’s leading teaching and research universities and is a member of the Russell Group of the UK’s most research intensive universities. Among its academic staff are two Nobel Laureates, including the winner of the 2007 Nobel Prize for Medicine, University President Professor Sir Martin Evans.
Founded by Royal Charter in 1883, today the University combines impressive modern facilities and a dynamic approach to teaching and research. The University’s breadth of expertise in research and research-led teaching encompasses: the humanities; the natural, physical, health, life and social sciences; engineering and technology; preparation for a wide range of professions; and a longstanding commitment to lifelong learning. Three major new Research Institutes, offering radical new approaches to neurosciences and mental health, cancer stem cells and sustainable places were announced by the University in 2010. www.cardiff.ac.uk

For further information, please contact:

Dr Win Tadd
School of Social Sciences
(Cesagen)
Cardiff University
029 2087 0037
e-mail: TaddW@cardiff.ac.uk

Stephen Rouse,
Public Relations Office,
Cardiff University.
029 2087 5596
e-mail: RouseS@cardiff.ac.uk