Challenges to Maintaining Dignity in Care Settings

Dignity in the context of a care setting refers to treating service users as individuals and having inherent respect for their value as people. It involves taking steps such as ensuring a person’s privacy is respected, promoting their independence and communicating respectfully.

Treating people with dignity is a fundamental part of providing high-quality, compassionate care. Dignified care also plays an important role in the delivery of ‘person-centred’ care. People deserve dignity at every stage of being cared for, from washing and dressing to mealtimes to undergoing medical treatments to being able to die with dignity.

When people and their families feel that care is being given in a way that maintains dignity, they are more likely to engage with services and have a positive experience, which can enhance overall wellbeing and quality of life.

In this article we will look at some of the common challenges and barriers carers face when trying to provide dignified care and suggest some strategies that may enhance dignity in care settings.

Although this article is aimed at those working within the health and social care sector, the findings of the 2021 census suggest there may be at least 5.8 million unpaid carers in the UK. If you are caring for a loved one in an unpaid capacity, you may still recognise some of the challenges we highlight here and may find that using some of the strategies we discuss improves the quality of life for all involved.

Common Challenges to Dignity in Care Settings

People may require care for a variety of reasons such as old age, disability, cognitive issues such as dementia, mental health problems or during periods of convalescence.  

Some of the common challenges to providing dignity within care settings are:

• Intimate care – providing intimate care is a routine part of care, which includes washing or dressing a person. This should always be done in a way that promotes dignity and reduces embarrassment or shame.
• Moving and handling – it may be necessary to perform tasks in the care sector that cause discomfort or distress, such as moving or handling an individual. In such cases, it is important to minimise their distress or discomfort by carrying out these activities with care and sensitivity. Never handle a patient roughly, ask for help when needed or use assistive aids to avoid causing injury.
• Understanding consent – consent is a vital part of care work. Consent is especially important when doing tasks that are unpleasant or uncomfortable. Carers need to explain procedures to patients before carrying them out to ensure patients are prepared and consent to treatment.
• Understaffing – the health and social care sector is notoriously low paid and often understaffed, with high levels of burnout and low levels of long-term staff retention. This can lead to carers rushing calls and not completing tasks with as much care and attention as the individual deserves. In a survey by the Royal College of Nursing (RCN) of over 2,000 respondents, 1,437 (over 70%) reported sometimes feeling distressed over being unable to give the dignified care they know they should.

Additionally, people who are being cared for may perceive that some of the following barriers exist to them receiving dignified care:

Lack of personal autonomy

People may feel left out of the decision-making process, not listened to or disrespected. They may feel they lack choice and control over their day-to-day lives including what they wear, the food they eat and how their day is structured.

Communication barriers

Communication barriers can affect the quality of care a person receives. Communication barriers and issues may include:

• Having English as a second language (either the carer or person being cared for)
• Hearing problems
• Lack of understanding of non-verbal cues particularly when an individual has problems expressing their needs or preferences due to cognitive challenges

Privacy and respect

We all have the right to privacy and respect.

Privacy concerns within the care sector may include:

• The need to provide personal or intimate care that is respectful and discreet
• Ensuring residents in residential care homes have some privacy and alone time away from others when they want it
• Only sharing personal details and medical information when it is necessary and always in line with legislation and the GDPR

Maintaining independence

Trying to balance the need for a person to have autonomy and independence with providing care and support can be a challenge.

The level of involvement a person wants may not accurately reflect what is safe or appropriate for their circumstances and it is vital that caregivers are able to explain this in an understanding and empathetic way.

Promoting an individual’s independence means evaluating what they can safely and appropriately do for themselves and empowering them with the tools to do so. This may have to be regularly reviewed and adequate safeguards may need to be put in place to strike a balance between empowerment and a person’s welfare.

Strategies to Enhance Dignity in Care Settings

Dignified care is delivered with compassion, understanding and empathy. Dignified care should be person-centred and should take a holistic approach to care.

A person-centred approach

To provide person-centred care you need to be able to understand the individual you are caring for as a whole person; this includes their individual preferences, cultural sensitivities and routines.

Caring responsibilities go far beyond physical care, such as ensuring people are fed, hydrated, washed and taking their medication as prescribed. Dignified care involves taking steps to ensure that a person’s life is as enriched as possible, that they are not lonely, unhappy or in pain.

A person-centred approach acknowledges an individual’s identity. To get to know a person’s identity you could ask questions, review their notes, make observations or speak to their relatives. Person-centred care is collaborative and requires intuition and good communication skills.

Promoting wellbeing, maintaining identity and supporting self-esteem

A person’s wellbeing includes the state of their mental health, their sense of hope and positivity, their levels of self-esteem and how effectively they can interact with activities they enjoy.

When caring for an individual it is important to consider different aspects of their wellbeing, including:

• Spiritual/religious
• Emotional
• Social
• Physical
• Mental

A person’s identity is closely linked to the different aspects of their wellbeing. Identity relates to our individual feelings, experiences, attitudes and goals. Dignified care acknowledges and encompasses a person’s identity and considers how their current situation may be influencing their identity, for example:

• An individual who was used to living an active lifestyle and socialising will crave the opportunity to be able to go out and take part in activities again
• An individual who had close family ties will feel lonely and unloved if they are suddenly isolated
• Someone who has recently lost their husband or wife may be grieving and seeking ways to commemorate and remember them

Dignified care should take into account a person’s individual needs and find ways to deliver care that meets them.

Using effective communication techniques

Good communication in the care sector is:

• Understanding
• Empathetic
• Positive
• Non-judgemental
• Appropriate

It may help to employ some active listening techniques, which include eye contact, looking for non-verbal cues such as body language and asking for clarification.

Effective communication should not be condescending or patronising, which links back to treating people as individuals.

Good, clear communication can help to build good relationships between carers, the people they care for and their families. Good communication can also help carers to better meet both the practical and emotional needs of the people they are caring for.

Promoting autonomy and choice

Choice is closely linked with dignity and respect. When someone requires care, they lose some of their autonomy and sense of control over different aspects of their life. Dignified care tries to allow people to have as much autonomy and choice as is practical and safe.

Caregivers should try to involve individuals in decision-making processes whenever possible, respecting their choices and preferences, for example:

• The food they eat
• The people they see and interact with
• The places they visit
• The entertainment they can access (including TV shows, newspapers, streaming services, crossword puzzles, board games etc)

Training and education for caregivers

The best way to address the common challenges to maintaining dignity in care settings is to ensure that care workers are thoroughly trained and have access to the resources they require to deliver high-quality care.

• All care workers should have an understanding of relevant law and legislation including the Health and Social Care Act 2008, the Care Act 2014, the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS)
• Completing the Care Certificate should be seen as a foundational step to be built on and incorporated into continuous learning schemes
• Encouraging a culture of continuous learning encourages care workers to strive to consistently improve their knowledge and build on their existing skills
• Leading by example, which means those at the top showing a commitment to high standards, continuous improvement and the regular monitoring and review of services

Carers should also know who to report concerns to if they feel a person is not receiving dignified care for some reason, or if they feel there are safeguarding concerns, for example the patient is at risk of abuse or neglect. Systems should be in place to allow for reporting and whistleblowing.

Creating ‘needs led’ care plans

To maintain dignity within care settings, care plans should be drawn up that involve users in the design and delivery of the services they are accessing. Dignified, person-centred care plans are made by finding out what is important to an individual, what matters most to them and how to match these findings with their care needs.

Tips for designing a care plan

• Write in the first person, e.g. ‘I want to choose the clothes I wear each day’
• Ensure the plan reflects an individual’s strengths and abilities
• Individuals should have as much choice as possible over the decisions they make

For a care plan to be needs led rather than service led, it should focus on how to tailor support to an individual rather than how to fit an individual into pre-existing plans or services.  

Real-Life Examples

Dementia is an incurable syndrome that affects around 55 million people worldwide. It causes cognitive decline and can affect our memory, behaviour, speech, thoughts and feelings.

Dementia is a progressive condition that will usually get worse over time, causing sufferers to need increasing amounts of help with day-to-day activities such as washing, dressing, cleaning, mealtimes and general organisation. People with dementia can also become erratic, agitated and confused. Needless to say, it is a condition that often requires significant care but is also met with a lot of resistance and refusal. This can cause a lot of stress to patients and caregivers which can cause significant challenges in maintaining dignity within care settings.

In southwest France, there is a care setting called Landais Alzheimer that is trying out a new, more dignified approach to dementia care. Landais Alzheimer is a village with a difference – all of its 120 inhabitants have dementia.

Dignity initiatives in Landais Alzheimer include

• The ratio of inhabitants to healthcare professionals is 1:1 (plus additional volunteers) allowing for better interactions and higher levels of care and attention
• People are encouraged to be part of a community: Villagers live in groups of up to eight, with communal kitchens and living spaces to promote socialising
• No one is isolated: There are no set hours for visiting, allowing family and friends to come and go as they please
• Independence is upheld: The village has amenities including a restaurant and villagers are encouraged to engage in activities, such as visiting the theatre or going to the grocery store (where no money is needed)

Prof Hélène Amieva is one of the experts who is monitoring the effects of this unique social experiment. So far, she believes preliminary findings are encouraging and show positive outcomes for families and patients alike. Usually, cognitive decline is noted when people enter a care home or other institution, but that has not been the case in Landais Alzheimer, where residents thrive despite their challenging circumstances.

A similar approach is being trialled in Warwick, England, inspired by a purpose-built Dutch facility – The Hogeweyk Dementia Village. Residents can reside in the Woodside Care Village, designed to look and function like a mini town, and enjoy the benefits of higher than average ratios of carers to patients and increased freedom and enrichment.

These types of community-based facilities have been found to:

• Reduce levels of loneliness, aggression and depression in dementia patients
• Slow down the rate of cognitive decline
• Improve relationships and collaboration between caregivers and the family members of patients

More countries are now looking into these non-traditional care models and are considering opening up their own, similar facilities.

It is possible that these types of dementia-friendly villages may shift from being isolated experiments to becoming a more integrated part of person-centred care in the future.

Overcoming Institutional Challenges

Institutional challenges that may affect the quality of care people receive include how supportive the environment is, what the organisational culture is like and how far institutional policies influence standards.

Good planning and record-keeping within institutions allow for dynamic reviews and consistency of service. Organisations should be able to provide accurate, up-to-date information on the people they care for to all staff and agency staff, allowing for continuity of care. This means that individuals are more likely to have their wishes adhered to and their dignity upheld, no matter who is on duty.

Supportive environments

Creating a supportive environment includes finding ways to minimise triggers and stressors for the individual, such as:

• Lights
• Sounds
• Temperature
• Odours
• Textures

Small, simple changes can help to make environments more suitable for residents, reducing distress and making them feel more relaxed. To achieve this, good, honest communication is key.

Aspects of the physical environment that support or promote dignity include

• Private spaces/rooms
• Privacy screens or curtains
• Use of ‘in use’ or ‘do not disturb’ signs
• Single-sex spaces
• Good housekeeping

Aspects of the physical environment that may prevent or diminish dignity include:

• No private rooms available, only wards/shared spaces
• Sheer or ill-fitting curtains
• Overcrowding
• Lack of space
• Mixed sex accommodation
• Poor housekeeping and hygiene standards

A supportive environment also requires consistency, which includes adequate staffing levels and good organisation to enable carers to get to know the people they care for. This encourages a stable service with good rapport between service users and carers, increased engagement and decreased resistance.

Providing advocacy

Advocates can provide a voice to marginalised groups and people who are vulnerable. Advocates work hard to:

• Defend and safeguard the rights of individuals
• Try to ensure that people have their wishes and views taken into consideration when important decisions are being made
• Mediate between parties in difficult situations or when communication has broken down
• Lobby for changes to policy to strengthen the rights of individuals

Organisational culture

To provide great care, institutions need to have adequate staffing levels with competent managers in charge who set a good example for all to follow.

Some organisations choose to appoint a dignity champion. Dignity champions work within the care service and have special skills and training that allow them to guide and teach their co-workers on how to treat the people they care for with kindness, respect and dignity.

Aspects of the organisation that help to maintain/promote dignity:

• Positive attitudes from all staff
• Good training, awareness and knowledge amongst carers
• Adequate distribution of resources
• Clear roles and responsibilities
• Evidence of teamwork
• A supportive culture where staff can go to supervisors/managers for advice, support and help
• Feedback is collected and acted upon

Aspects of the organisation that may prevent/diminish dignity:

• Negative attitudes from staff and low morale
• Poor organisation, chaotic environment
• Underfunding
• Lack of staff and resources
• Low morale and inconsistency (including a reliance on agency workers and short-term contracts)
• Lack of care and accountability

Conclusion

Treating people with dignity is of fundamental importance in the care industry. Pressure to meet targets, understaffing and a lack of training and awareness can cause standards of care to fall short, which has a negative impact on service users.

As a caregiver or healthcare worker, we encourage you to consider some of the strategies discussed in this article and implement dignity-enhancing strategies in your daily practices. Providing more dignified care will boost the overall wellbeing of the people you care for and will help to foster a more supportive and respectful environment.