“How can nurses ensure that older people are treated with respect and dignity whilst being cared for in a hospital or in the community?”

Providing dignified care is at the very heart of nursing and is the responsibility of everyone (Royal College of Nursing (RCN) 2008). Nurses play an important part in the care of older people and quality nursing care can make a substantial difference to physical and emotional well-being (Nursing and Midwifery Council (NMC) 2008). 'Dignity' as defined by the Social Care Institute for Excellence (SCIE) (2009) is ‘A state, quality or manner worthy of esteem or respect; and (by extension) self-respect’. Adopting dignity in practice should generate an environment that supports and promotes self-respect, allowing it to flourish by the maintenance of autonomy and informed choice, NMC (2008). The 2006 Commission for Social Care Inspection (CSCI) publication ‘Living well in later life’ highlighted the lack of dignity and respect for older people in acute hospitals as a major area of concern citing that 45% of NHS resources are spent on older people and this accounts for the greatest use of acute hospital services

This discussion will identify the specific needs of the older person from a bio-psychosocial perspective incorporating complicit ethical issues. The role of the nurse in the provision of quality and comprehensive care delivery will of course be examined, integrating theory and practice and exploring the implications for inter-professional working. This personal reflection will develop personal knowledge and self-awareness, which is an essential prerequisite to maintaining patient (Marks-Maran and Rose 1997). Theory from previous modules on the pre-registration nurse-educators programme will be integrated with particular emphasis on the holistic delivery of quality care due to a comprehensive care-planning process. An exploration into the theory, disposition and value of evidence will be offered, and the skills in approaching and implementing the evidence demonstrated, supported by knowledge and evidence of national and international law, policy and procedure. These specific themes will be discussed with respect to three key issues namely - Preserving patient autonomy & choice; Ageism, prejudice & discrimination; and Dementia.

For many older people, being treated with dignity and respect includes attention being paid to the subjective elements of care (SCIE 2009). Griffin-Heslin (2005) adds a set of ‘defining attributes’ – aspects of a person’s situation that tell you that dignity is present: respect; autonomy; empowerment and communication which demonstrates quality of life. Respect and dignity make the difference between feeling valued and heard, as opposed to feeling vulnerable and ignored. (Help the Aged 2008).

Although apportioning definition and themes that constitute dignity and respect are reasonably self-evident, what has remained more complex is the maintenance of dignity in both a hospital or community setting despite the many examples of excellent practice (Lothian and Philps 2001). The National Service Framework (NSF) for Older People (DH 2001) (the Government’s 10-year vision for older people’s health and social care) acknowledged limitations in reaching the over 65’s with properly integrated health and social care services that were both fair and of high quality. This shortfall cannot be trivialized as it represents 20% of the population being ethically and economically compromised.

Let us firstly consider the ethical issue of Preserving Patient autonomy and choice. Involving a patient and their family/carers in their own care is extremely fruitful as it prevents problems by focusing on wants and needs at the assessment stage and promotes high quality inclusive care that is cost-effective and holistic (Barrett, Wilson and Woollands 2009). Nurses should not encourage the sick role for ease of care delivery and time constraints but promote autonomy and movement along the dependence/independence continuum restoring self-worth and dignity (Roper, Logan and Tierney (RLT) 2000). "Do not forget the person!” is the key message of a new multi-agency campaign that has been launched by the British Geriatrics Society (BGS) 2010, that recognises overstretched ward activity can compromise the clinicians vision as staff focus on tasks alone and lose sight of the person. Vulnerable older people deserve to be treated with dignity, respect, humanity and compassion (Help the Aged 2008). These values emphasise the importance of allowing an individual to gain or maintain control over their daily activities and in particular, their personal care. If we fail to do this, older people become frightened, bored, often more confused and more dependent, losing their dignity and individuality (BGS 2010).

Recollections from clinical placement have allowed reflections to recognise that busy periods on the ward reduce person centred care to urgent tasks (NMC 2009) de-personalising the patient experience, reducing choice and promoting dependency. Normal routine, for example, an afternoon nap, should not be discouraged simply due to the environment unless necessary to essential care delivery. Another example of this is allowing a patient to attend to their personal hygiene & dressing needs themselves where possible and allowing them the time and support to do this at their individual pace without being hurried at the convenience of the ward routines (such as mealtimes, medication dispensing ward rounds). Non-passive service users feel immediately stripped of dignity in this instance (Nay 1998, BGS 2010).

The NMC produced “Guidance for the care of older people” in 2009 that highlights three main fundamentals to provide the basic care in a protected and effective way to older people which are: People, Process and Place. People: that discusses the role of the nurse and the qualities required to deliver safe, effective, quality care. Process: which aims to deliver care that promotes dignity by nurturing and supporting the older person’s self-respect and self-worth and Place: involves various settings in the community or hospital that holds responsibility of care.

This guidance reflects the obligations placed on public authorities by the Human Rights Act 1998 that incorporates the European Convention on Human Rights into our law. Citizens of the UK have certain rights of which there is a legal obligation to uphold. The five pillars of the Act (freedom, respect, equality, dignity and autonomy) may all be used to sway conclusions for dignity and the delivery of dignified care (RCN 2009). Biosocial needs command respect and this gives older people the right to make decisions about their care and living choices, without recrimination, respecting the older person as an unique being and not just a condition to be treated (Seedhouse 2000).

Providing Guidance from the voluntary sector, Help the Aged produced ‘The Challenge of Dignity in Care: Upholding the rights of the individual’ 2007, a report which aims to challenge the concept of dignity in care and to become involved in the emergent debate about what older people expect from the dignity in care concept, and how this is measured in the health and social care environment. The report draws conclusions that aim to reflect and rectify the inconsistencies in the reality of ward life care that can compromise the vulnerable, citing that simply producing documentation to improve dignity in care is not likely to be entirely successful (Help the Aged 2007). It is the implementation of policy, people and process (NMC 2008) in a multi-agency environment and the connection between the appropriate systems that combine care that ascertains whether choice is indeed present and if there is, in fact, dignity in care.

When addressing the choice deficit, the Single Assessment Process was introduced in the NSF for Older People (2001) (Standard 2: person centred care), with the focus of encouraging and facilitating choice for the recipient of care, especially at point of delivery to create services, flexible in structure to maintain community living. This embraces a more holistic approach to care, recognising the individual’s quality of life beyond the illness without disrupting established multi agency support and welfare assistance that may otherwise be compromised. This new philosophy no longer places people in pre-existing services with the expectation to adjust, but places the emphasis on the service to adjust to the person (Centre for Policy on Ageing 2010).

Wilde (2002) argued that if shared multi agency procedures were not implemented in favour of a single professional assessment, appropriate domains could be restricted, resulting in the loss of essential information perhaps even unnecessary or inappropriate hospital admissions as a consequence. The single assessment process, therefore, should be embraced by all professions as a measure to determine older people’s needs and thence updating care plans to meet these needs could defeat the many inequitable and fragmented services associated with older people’s care (DH 2001, Wilde 2002).

As a result, and as a means to give people a greater control over their care services, Direct Payments, introduced by the Community Care (Direct Payments) Act 1996 offer those partaking in community care some self-direction. Pioneered originally by the Disabled People’s Movement, patients acquire and manage their own care services as a result of an assessment. Research by Clark, Gough and Macfarlane (2004) found that older people receiving Direct Payments reported feeling happier, more motivated and having an improved quality of life, with a favourable outcome on their social, emotional well-being and physical health. The report highlights, however, the essential role that Social Services play within the Direct Payments process and the infrastructure undoubtedly needs investment to ensure community support is available.

Whilst considering recommendations regarding patient choice, it would appear that training and education must be provided to ensure staff develop procedures and ways of working that support older people and their families to be more involved in the decision-making process. Training should also ensure processes are transparent, informative and reactive, particularly in an elderly setting such as specified elderly wards or in the community. Issues surrounding dignity and ongoing initiatives should be included in information for patients and exploration of alternative ways of engaging with older people from vulnerable groups is an area of development particularly in the community using advocates and volunteers (Commission for Healthcare Audit and Inspection (CHI) 2007).

Appendix A represents ideals attained by the individual (Matiti 2002 cited in Matiti, Cotrel-Gibbons and Teasdale 2007) through the practice of socialisation and highlights aspirations of care. This diagram helps to realize the complexity of achieving sensitive care delivery. Listening to what patient’s say and taking time to communicate in the way that is best for the individual allows the nurse to provide care in a way that respects the rights to privacy and dignity, working with the key stakeholders to ensure preferences are taken into account when decisions are being made (Hudson and Moore 2006). Nurses can promote techniques to facilitate independent functioning, which provide direct support to restore a patient’s ability to carry out daily activities of living (RLT 2000, Orem 2001).

Now to consider how it is essential for healthcare professionals to deliverer care that is holistic and does not reinforce Ageism, prejudice and discrimination (NMC 2008). Ageism can be defined as a set of beliefs, attitudes, norms, and values used to justify age based prejudice and discrimination (Nelson 2002). Prejudicial attitudes towards older people, old age, and the aging process may result in discriminatory practices against older people. This may manifest into poor institutional practices and policies that perpetuate stigma and disenfranchise older people which one may argue, is a form of opression. Deregatory comments and labels are commonplace and mainly go unchallenged, unlike racism for example (Wilkinson and Ferraro 2002). Older people have their place in society defined by capitalist need and parallels can be drawn with disabilities where absence from the labour market devalues and marginalizes individuals (Nelson 2002).

The Human Rights Act should protect the person regardless of their economic status, race, gender or age, from becoming second class in citizenship. Prejudice is apparent though and DH (2007) highlights no injustice of inequality being greater than the public health disparities that scar our nation. This has not remained unchallenged and policies are in place to guide practice for all service professionals to promote care embracing dignity and choice (RCN 2008). Individuals have rights, but should not be required to stand up for them (DH 2007). The changing attitudes have to come from the face-to-face interactions that nurses participate by recognising empathetically an individual’s illness, physical restrictions, pain, mental health and advancing years increase vulnerability. Individuals should never be made more vulnerable by entering the hospital environment (RCN 2008).

There is however, considerable evidence of discrimination against the elderly within the healthcare system (Wilkinson and Ferraro 2002). Most damning is that this becomes increasingly apparent during screening procedures and subsequent treatment decisions (Help the Aged 2007). An example of injustice is that younger patients are likely to receive a broader treatment scope than their elder counterparts, especially with surgical procedures. This can in part be rationalised by older patients being less tolerant to invasive remedies and statistically more likely to encounter complications during surgery that may prove fatal (Wilkinson and Ferraro 2002). The tragedy here is that such persuasive arguments breed inequalities as treatment priorities for the elderly patient gravitate more toward symptom relief than prevention or cure (Thompson 1995). Legislation does exist to address this with the Equality Bill forbidding unjustified discrimination, allowing the individual to champion their rights (Harman 2008). The reality is that any legal process can be slow and untreated illness is no ally of time, leaving those most vulnerable at the mercy of pre-determined values (Nelson 2002).

When applying this theory to practice, one must consider that older people form a large social group in their own right which can often be classed as vulnerable and have their own specific needs that must be assessed in a comprehensive and holistic manner in order to deliver quality individualized care (RLT 2000). A 2006 report (Barnes, Blom, Cox, Lessof, and Walker) argued that social exclusion was multi-dimensional. The authors described seven dimensions of social exclusion: social relationships; cultural and leisure issues; civic activities; basic services; neighbourhood; financial; and material goods. While not all of these dimensions are central to dignity in care, Help the Aged (2007) argue that these dimensions although obliquely are still relevant as dignity within the care setting cannot be separated from the dignity of the entire person. They go on to state that care services fail to maximise and promote social inclusion, and therefore compromise dignity.

CHI (2007) cite the profound effect the lack of dignity and respect has on older people in a healthcare setting, stating the possible implications to emotional well-being this failure by nursing staff could have. To recognize and treat this vulnerable group with value and worth; should result in an equal chance of recovery that is often hindered by the delivery of sub-standard care that does not acknowledge the wants and needs these patients aspire to be treated with (Foote and Stanners 2002). Older people deserve to be informed and given the right to contribute to decisions about their care (DH 2006a). Fragmented services and variations in the delivery of care are detrimental to older people’s emotional and physical well-being and result in longer hospital stays (CHI 2007). Nurses must not possess the attitude that old age is an illness in itself, but promote an equal approach to delivery of services where age is irrelevant to the care patients receive (RCN 2008).

The identification of many challenges of attitudes within practice that require improved performance from nurses is apparent within clinical placement. Reflection has enabled the emerging clinician to realize that knowledge and skills must be present to eliminate inaccuracies in assessment and are critical to dealing with sensitive issues pertinent to conditions such as dementia, end-of-life care and confusion. It would appear advantageous for post registration nurses to attend training courses on equality and diversity, with a multi-faceted approach to dignity being mandatory and a recurrent event (CHI 2007, Gallagher, A., Wainwright, P., Baillie, L. and Ford, P (2009). Experience drawn informs that the inclusion within the pre-registration nursing programme does not entirely facilitate the knowledge deficit in the hospital environment and therefore nurses must ensure all members of the healthcare team are realizing the aspirations of dignified care (Corley 2000).

Dementia is a collection of related various illnesses of the brain with an ongoing decline of the brain and its abilities that is usually progressive and eventually severe (Alzheimer's Society 2010). Whilst dementia is a disease…..old age is not; and quality healthcare should involve a comprehensive and holistic assessing process that determines a patient’s needs without the assumption that all older people have cognitive decline, hearing impairment and memory loss (Hines 2000).

Dementia is now recognised as an urgent challenge to the health and social care services. The condition is most prevalent in advancing years, indiscriminate of lifestyle and renders people vulnerable, dependent and stripped of dignity (The Alzheimer’s Society 2009a). The National Audit Office report ‘Improving services and support for people with dementia’ (2007) states that there are at least 560,000 people in England that have dementia and, this figure is predicted to rise by over 30 per cent over the next 15 years in line with increased life expectancy. To meet this challenge and protect those vulnerable, the DH’s “National Dementia Strategy” (2009) aims to advance public awareness of dementia, provide diagnosis, improve prognosis and the quality of care received. The proposals are comprehensive and include the introduction of a dementia specialist into every hospital and care home.

The current reality that exists for dementia care is, however, much more sobering. The Alzheimer's Society's “Counting the Cost” report (2009a) reveals unacceptable variations in care experienced by those with dementia; offering findings that indicate persons with dementia admitted to hospital for other procedures spent longer on wards than those without the condition. The report’s conclusions suggest a lack of specialist dementia skills disadvantage as many as a ¼ of patient’s occupying hospital beds. Recommendations have been tendered to address this imbalance such as the “Putting Care Right” campaign (The Alzheimer’s Society 2009b) which targets reducing average hospital stays for those with dementia by approximately one week by improving general nursing knowledge and experience when working with the condition. Currently, despite dementia patient’s occupying so many hospital beds, there is not yet any mandatory training in dementia care (Rippon 2010).

Over the last decade, emphasis has been placed on older people using healthcare, aptly, as these are the patients with less autonomy who rely heavily on the actions of others to preserve their dignity. This natural progression towards dependence that occurs with age should not necessarily be an adjunct to a tacit decline of respect and dignity. Dignity can only be present where a patient is treated as an individual, not merely the physical condition and where there is equilibrium of jurisdiction between the care-giver and beneficiary. In hospital, the community or care home, patients must be confident that asking for help does not equate to a loss of respect and dignity. Dignity thrives, where high quality, patient-centred care is maintained (Birrell, Thomas and Alban Jones 2006).

To achieve this, nurses must possess effective communication skills that strengthen the practice of assessing, care planning and the progression of the therapeutic relationship between care givers and recipients. For this to be accomplished, nurses must possess knowledge of the normal decline of the ageing process. Lapse in communication abilities may inhibit a patient’s aptitude or willingness to communicate and have a negative affect on self-esteem (Miller 2002).

Evidence suggests language can be overtly offensive and stigmatising, resulting in a barrier to the realization of delivering dignified care. Placing older people in a inferior role by infantilising them with language can result in becoming internalised by the patient, sharing the stereotype and adopting negative views of themselves which cascades into loss of empowerment taking on the ‘sick role’ and becoming mere recipients of care, lacking in confidence, self-esteem and labelling oneself as a ‘Nuisance’ or ‘Burden’ (DH 2006b)

The normal degenerative effects of dementia present as a decline in a patient’s communicative ability, as the disease worsens and patient’s become progressively difficult to understand. Physical and emotional obstacles that may compromise quality of life become apparent and present challenges to nurses and families (Richter, Roberto and Bottenberg 1995). Communication is elementary to the treatment process and the assessing stage must collate information about a patient’s social history, medical condition and any lapse in communicative ability that will prove invaluable when considering adaptations to care delivery (Orem 2001, Richter et al. 1995). Only a full, holistic assessment can help reach the person behind the label of dementia, allowing nurses to enter a patient’s world, rather than force them into the health arena. An inadequate assessment may lead to presenting behaviours being misinterpreted and emotional needs ignored (Feil 1992, Sabat and Harre 1992).

Care delivered by strangers can be bewildering but for people with dementia, a hospital stay can be a terrifying experience resulting in behaviour that presents as challenging (Rippon 2010). People with dementia may sometimes behave in a challenging way for example aggression or shouting out. This can be very distressing for patients, carers and nurses. By understanding what may cause this type of behaviour and learning how to deal with it, nurses can recognise triggers of aggression and why being in a hospital environment can make this behaviour worse. Recognising these reasons and providing person-centred care can very often begin to alleviate behaviour brought on by the unfamiliar environment and changes in care practice married with the physical effects of dementia (DH 2009).

Familiar routines should be established in the assessing process such as washing, incontinence & toileting requirements and nutrition to allow sensitivity and alleviate any stress based on the unfamiliarity of the healthcare setting. Talking to patient’s and regular carers about preferences in care delivery encourages compliance and promotes autonomy and dignity, simply providing support where needed. Incontinence can be humiliating as hygiene is a very personal issue. Becoming incontinent can make it feel as if one is losing control. This can affect a person's sense of dignity and self esteem (Gallagher, Li, Wainwright, Rees Jones and Lee 2008). People with dementia may become incontinent for a number of reasons. Non-medical reasons may include forgetting to go to the toilet, not recognising they need to go the toilet or forgetting where the toilet is which is of course much more likely when thrust into a new environment (Alzheimer’s Society 2010).

Those embarking on the pre-registration nurse-educator programme are given the knowledge and skills to provide dignified hygiene and dressing assistance. Within clinical placements, the opportunities to be ambassadors of change and invoke best practice in delivering dignified care are manifold (NMC 2009). Examples are, slowing down the basic cares process to allow older patient’s to be as involved in their own care as possible, and keeping those unable to self-care covered whilst being washed, instilling privacy and respect at the expense of time constraints sometimes offered by non-registered members of the healthcare team. It is vital that more personalised care is always provided with the recognition that each person with dementia is an individual, whose routines and needs that are unique to them must be appropriately assessed to deliver person-centred dementia care (Alzheimer’s Society 2009b).

When forming a conclusion, it seems that care which supports dignity must be at the heart of any quality agenda in health and care services (Help the Aged 2008). Upon deliberation, the title for discussion, suggests that without careful scrutiny, care offered with the best of intentions may still compromise respect and dignity for the older person. This deviation from the expectations of both the carer and patient is a complex arena with undercurrents that lay much deeper than ward and community interactions. There are sociological arguments for instance; maintaining usage of terminology such as ‘the elderley’ marginalizes the uniqueness of the individual who is unwittingly joining in orchestrated cluster groups to receive pre-determined pathways (Thompson 1995).

Dignity requires recognition of the person. It infers flexible empathetic care of which lip service is paid to although actions not always delivered. Nurses must ensure dignity continues to be a vital tenet in care settings (Help the Aged 2008). For dignity to flourish as the universal norm, it requires not only the reduction of indignity but the active promotion of dignity and carries the responsibility of all multi-agency professionals to shift attitudes that do not respect autonomy, promoting meaningful activity that supports people to make choices embracing a person-centred approach (Hudson and Moore 2006).

As a social convention, if it is felt that the users of a facility are of worth, care and attention must be paid to ensure non-judgemental nursing is of a high standard. (NMC 2009). The need for equal care delivery of older people may seem obvious yet Thompson (1995) argues that failure to do so in its mildest form is not considering the holistic needs of our patients and is not only neglectful and inconsiderate but in it’s most serious form amounts to elder abuse; ill-treatment in which vulnerable older people are exploited or harmed which is of cause failure to provide dignified care.

Staff attitudes and behaviour included infantilising and patronising approaches, respondents to a DH survey (2006b) said, "the use of endearments such as sweetheart and darling should be banned from health care language. These terms are predominantly used in communicating with older people and it is inappropriate, demeaning and patronising". Not only did the survey indicate that the more casual use of language undermined dignity: it further, in many instances appeared incongruent to the medical condition, reinforcing the assumption that the nurse was addressing any patient and not the individual.

What should become second nature within nursing is the acceptance that effective communication has clinical benefits (Miller 2002). Staff behaviour and attitudes have the potential to enhance dignity, empower understanding, alleviate hopelessness and facilitate the holistic pathway (CSCI 2006, NMC 2009). This can be achieved immediately and simplistically by remembering the social norms and mores that guide correct behaviour within our society (Siviter 2008). Approaching a patient should involve honouring courtesy such as agreeing appropriate terms of address. Nursing practice should demonstrate more allowance for listening and adapting our assistance to meet a patient’s needs especially during more intimate but routine care such as dressing and grooming. Anything falling short of this is neither collaborative nor patient-centred, lacks respect and dismisses dignity (Gallagher et al. 2008).

The facilitation of patient dignity is a personal process that is founded upon identifying and addressing an individuals expectations. There are influences that compromise care such as resources, prioritising care and respecting other patients (Appendix A). This echo’s Seedhouse’s (2000) view that dignity is about aligning a person’s needs with circumstance. Dignity therefore, depends on context and consists of nurse-patient interactions representing opportunity to demonstrate respect and dignity of patients.

What is apparent from this discussion is that dignity is everybody’s business. The responsibility to ensure the older person remains an individual and unique during care procedures is the duty of policy makers, care providers and the patient’s themselves (Hudson and Moore 2006). Robust mechanisms have been identified to direct practice to fulfil this and it is apparent to an emerging clinician that the promotion and maintenance of dignity should not be merely a favourable adjunct to the patient experience, but rather the very heart of how nurses deliver care (CHI 2007).

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APPENDIX A - Important aspects of patient dignity in healthcare settings

Adapted from Matiti (2002), cited in Matiti, Cotrel-Gibbons and Teasdale (2007).
References

Alzheimer's Society (2009a) [online] Counting the Cost. Available: http://alzheimers.org.uk/site/scripts/download_info.php?downloadID=356

Alzheimer's Society (2009b) [online] Putting Care Right. Available: http://alzheimers.org.uk/site/scripts/documents_info.php?categoryID=200149&docum entID=1107 Alzheimer's Society (2010) [online] Coping with Incontinence Factsheet. Available: http://www.alzheimers.org.uk/factsheet/502

Barrett, D., Wilson, B., and Woollands, A. (2009). Care Planning. A guide for Nurses. Harlow: Pearsons Education

Barnes, M. Blom, A., Cox, K., Lessof, C., and Walker, A. (2006) [online] Social Exclusion of Older People: Evidence from the first wave of the English Longitudinal Study of Ageing. Office of the Deputy Prime Minister. Available: http://docs.google.com/viewer?a=v&q=cache:ECO3sWVrmcYJ:www.communities.gov.uk/documents/corporate/pdf/143834. [16/04/10].

Birrell J., Thomas P. and Alban Jones C. (2006). Promoting privacy and dignity for older patients in hospital. Nursing Standard. Vol. 20, Iss. 18, pp. 41-46.

British Geriatrics Society 2010. [online] Do not forget the person!! Available: http://www.bgs.org.uk/campaigns/dignity2010.html [14/05/10].

Centre for Policy on Ageing (2010) [online] The Single assessment Process (SAP) Available: http://www.cpa.org.uk/sap/sap_about.html

Clark, H., Gough, H. and Macfarlane, A (2004) It pays dividends: direct payments and older people. Bristol: The Policy Press.

Commission for Healthcare Audit and Inspection (2007) [online] Caring for dignity A national report on dignity in care for older people while in hospital Available: http://www.chi.gov.uk/_db/_documents/Caring_for_dignity.pdf

Commission for Social Care Inspection (2006), Audit Commission and Healthcare Commission: Living well in later life: A review of progress against the National Service Framework for Older People. London: CHI

Community Care (Direct Payments) Act 1996 [online] Office of Public Sector Information. Available: http://www.opsi.gov.uk/acts/acts1996/ukpga_19960030_en_1 [14/05/10].

Corley, G. (2000) Older People and Their Needs: A Multidisciplinary Perspective. London: Whurr Publishers

Department of Health (2001) [Online] National service framework for older people. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066 [14/05/10].

Department of Health (2006a) [Online] Our health, our care, our say: a new direction for community services. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4127453

Department of Health (2006b) [Online] Dignity in Care public survey. Available: [http:/ / www.dh.gov.uk/ en/ Publicationsandstatistics/ Publications/ PublicationsPolicyAndGuidance/ DH_4139552]

Department of Health (2007) [online] Dignity security and independence in old age. Available: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_5209513

Department of Health (2009) [online] National Dementia Strategy. Available: http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/NationalDementiaStrategy/index.htm

Feil N (1992) Validation therapy. Geriatric Nursing. Vol. 13, Iss. 3, pp. 129-133

Foote, C and Stanners, C. (2002) Integrating Care for Older People. London:Jessica
Kingsley

Gallagher, A., Li, S., Wainwright, P., Rees Jones, I. and Lee, D (2008). [Online] Dignity in the care of older people – a review of the theoretical and empirical literature. BMC Nursing . Vol. 7, Iss. 11 Available: http://www.biomedcentral.com/1472-6955/7/11

Gallagher, A., Wainwright, P., Baillie, L. and Ford, P. (2009) The RCN Dignity Survey:implications for leaders. Nursing Management. Vol. 16 Iss. 4. pp. 12-16.

Griffin-Heslin, V. (2005). An analysis of the concept dignity, Accident and Emergency Nursing Vol. 13, Iss 4 pp.251-257.

Harman, H. (2008). The Equality Bill. London: Cabinet Office

Help the Aged (2007) [online] The Challenge of Dignity in Care: Upholding the rights of the individual Available: http://www.helptheaged.org.uk/NR/rdonlyres/30C24F74-6C35-4DF7-95D1-C996142CEFE9/0/dignity_in_care_300708.pdf

Help the Aged (2008) Measuring Dignity in Care for Older People: A research report for Help the Aged. London: Help the Aged.

Hines J (2000) Communication problems of hearing-impaired patients. Nursing Standard. Vol. 14, Iss. 19, pp33-37.

Hudson, A, and Moore, L. (2006) A new way of caring for older people in the community. Nursing Standard. Vol. 20, Iss. 46, pp.41-47.

Human Rights Act (1998) London: Office of Public Sector Information.

Lothian, K and Philp, I. (2001). Maintaining the dignity and autonomy of older people in the healthcare setting. British Medical Journal. Vol. 322 pp. 668-670.

Marks-Maran D, Rose P (1997) Reconstructing Nursing Beyond Art and
Science. Philadelphia:Bailliere Tindall

Matiti M., Cotrel-Gibbons E, and Teasdale K (2007) Promoting patient dignity in healthcare settings. Nursing Standard. Vol. 21, Iss. 45, pp.46-52

Miller, L. (2002) Effective communication with older people. [online] Nursing Standard. Vol. 17. Iss. 9. pp. 45-50. Available: http://nursingstandard.rcnpublishing.co.uk/resources/archive/GetArticleById.asp?ArticleId=3298

National Audit Office (2007). [online] Improving services and support for people with dementia. Available: http://www.nao.org.uk/whats_new/0607/0607604.aspx

Nay, R. (1998). Contradictions between perceptions and practices of caring in long-term care of elderly people. Journal of Clinical Nursing. 7, 5, 401-408.

Nelson, T. (2002). Ageism: Stereotyping and Prejudice against Older People. California: The MIT Press.

Nursing and Midwifery Council (2008) The Code. London: NMC.

Nursing and Midwifery Council (2009) Guidance for the care of older people. Available: http://www.nmc-uk.org/(cxfqsfbeg1izab45vcj2wr45)/aDisplayDocument.aspx?DocumentID=5593

Orem, D (2001) Nursing: Concepts of Practice, 5th Edition. St Louis: CV Mosby.

Richter J, Roberto K, Bottenberg D (1995). Communicating with persons with Alzheimer's disease: experiences of family and formal caregivers. Archives of Psychiatric Nursing. Vol. 9: pp279-285

Roper, N., Logan, W. & Tierney, A, J. (2000) The Roper Logan and Tierney Model of Nursing Based on Activities of Living. Edinburgh: Churchill Livingstone

Royal College of Nursing (2008). Defending Dignity – Challenges and opportunities for nursing. London: Royal College of Nursing

Royal College of Nursing (2009). Small changes make a big difference: how you can influence to deliver dignified care. London: Royal College of Nursing

Rippon, A. (2010). Caring is knowing. Nursing Standard. Vol 24. Iss. 31

Sabat, S and Harre, R (1992) The construction and deconstruction of self in Alzheimer’s disease. Ageing and Society. Vol. 12, Iss. 4, pp.443-461.

Seedhouse, D. (2000) Practical Nursing Philosophy: The Universal Ethical Code.
Chichester: Wiley.

Siviter, B. (2008) The Student Nurse Handbook (Second Edition). London: Bailliere Tindall.

Social Care Institute for Excellence (2009) [online] SCIE Guide 15: Dignity in care Available: http://www.scie.org.uk:80/publications/guides/guide15/index.asp [10/04/10]

Thompson, N. (1995) Age And Dignity: Working with Older People. Aldershot: Avebury.

Wilde, D. (2002) The single assessment process. Primary health care. Vol. 12 Iss. 1. pp. 20-21.

Wilkinson, J and Ferraro K, (2002). Thirty Years of Ageism Research. Ageism: Stereotyping and Prejudice Against Older Persons. Massachusetts: Massachusetts Institute of Technology Press.
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Being involved in Care

Decency

Respect

Making Choices

Forms of address

Communication

Need for Information

Privacy

Confidentiality

Independence

Choice

Choice

Choice

Choice

Choice

Choice

Choice

Choice

Choice

Choice

Control

Control

Control

Control