Quality in Ageing and Older Adults

Right place - wrong person: dignity in the acute care of older people
Win Tadd, Alex Hillman, Sian Calnan, Mike Calnan, Tony Bayer, Simon Read,
Article information:
To cite this document:
Win Tadd, Alex Hillman, Sian Calnan, Mike Calnan, Tony Bayer, Simon Read, (2011) "Right place ‐ wrong person: dignity
in the acute care of older people", Quality in Ageing and Older Adults, Vol. 12 Issue: 1, pp.33-43, https://doi.org/10.5042/
qiaoa.2011.0143
Permanent link to this document:
https://doi.org/10.5042/qiaoa.2011.0143
Downloaded on: 24 February 2018, At: 18:31 (PT)
References: this document contains references to 0 other documents.
To copy this document: permissions@emeraldinsight.com
The fulltext of this document has been downloaded 887 times since 2011*
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)

Users who downloaded this article also downloaded:

(2011),"Improving care for people with dementia in acute hospital: the role of person-centred assessment", Quality
in Ageing and Older Adults, Vol. 12 Iss 2 pp. 86-94 <a href="https://doi.org/10.1108/14717791111144696">https://
doi.org/10.1108/14717791111144696</a>
(2005),"Dignity: The voice of older people", Quality in Ageing and Older Adults, Vol. 6 Iss 1 pp. 22-29 <a href="https://
doi.org/10.1108/14717794200500005">https://doi.org/10.1108/14717794200500005</a>

Access to this document was granted through an Emerald subscription provided by emerald-srm:320271 []
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service
information about how to choose which publication to write for and submission guidelines are available for all. Please
visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of
more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online
products and additional customer resources and services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication
Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation.

*Related content and download information correct at time of download.

 Peer-reviewed article

Right place – wrong person:

dignity in the acute care
of older people
Win Tadd
Reader, Cesagen, School of Social Sciences, Cardiff University, UK
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)

Alex Hillman
Research Fellow, Cesagen, School of Social Sciences, Cardiff University, UK

Sian Calnan
Research Associate, School of Social Policy, Sociology and Social Research, University of Kent, UK

Mike Calnan
Professor of Medical Sociology, School of Social Policy, Sociology and Social Research, University of Kent,
UK

Tony Bayer
School of Medicine, Cardiff University, UK

Simon Read
Research Associate, Cesagen, School of Social Sciences, Cardiff University, UK

Abstract
This paper reports on an ethnographic study to explore the experience of dignity in the acute care of
older people in four acute NHS trusts. It explores the prevalent view that acute care is not the right
place for older people and the failure to acknowledge that the largest group of users are the very
old, the frail and the dependent, which results in environments that are not friendly to older people
generally, and are especially hostile to those with cognitive impairments. Added to this, a culture
that is risk averse and defensive, where care is undervalued and where professional accountability
and discretion are replaced by standardised checklists, pathways and audits, cultivates the attitude
that if an aspect of care can’t be measured it doesn’t matter. Overall, getting the job done appears
to matter more than how the job is done, so that the focus is primarily on the task rather than
seeing the person. It describes how the failure of acute trusts to respond to the needs of the majority
of their users – older people – results in the failure to provide dignified care and the impact of this
on both the quality of care and patient outcomes.

Key words
Dignity; acute care; older people; ethnography; patient outcomes.

10.5042/qiaoa.2011.0143

Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011 © Pier Professional Ltd 33
 Right place – wrong person: dignity in the acute care of older people
Introduction
Some five years ago, this Journal published a
special edition on the results of the Dignity
and Older Europeans (DOE) study, which
involved partners in six European countries
and some 1,400 older people, health and
social care professionals and middle aged
and young adults (Tadd, 2005a). The study
explored the experience of dignity in the
lives of older people and was important in
progressing theoretical work on the meaning
of dignity (Nordenfelt & Edgar, 2005), and
clearly demonstrated that the experience of
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
dignity is something that is not only important
to older people but can also be threatened by
illness and increasing dependence especially
in the fourth age, as well as by the lack of
social and economic resources that are often a
feature of later life (Bayer et al, 2005).
The study highlighted that the experience
of dignity was dependent upon being:
• able to maintain personal identity and self-
respect
• recognised as an equal human being
• treated with respect by others
• able to exercise control even when
dependent on others.
This paper reports on a further study
undertaken to explore older people’s
experience of dignity in acute care, which
utilises data drawn from direct observation of
practice, as well as individual interviews.
Maintaining the dignity of older people
receiving health care has remained a subject
of concern over recent years (Lothian & Philp,
2001; Tadd & Bayer, 2001; Philp, 2002; Tadd
et al, 2002; Jacelon, 2002; 2003; 2004; Walsh
& Kowanko 2002; Seedhouse & Gallagher,
2002; Woolhead et al, 2004; Tadd, 2005a;
2005b; 2006; Tadd et al, 2010; Woolhead
et al, 2006; Revill et al, 2007; Valentine et
al, 2008) and a number of reports highlight
that dignity remains difficult to translate into
practice (Goodrich & Cornwell, 2008; Patients
Association, 2009; Alzheimer’s Society, 2009).
Why this should be so is not clear, however
it is important to recognise that older people
are the most frequent users of acute health
care. For example, over 70% of patient bed
34 Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
days involve people aged over 60 years. In
addition, 25% of older people on acute wards
are likely to either have dementia or an acute
confusion and older people often have more
than one chronic condition compounding
their acute illness. Yet there are claims that
the acute care system seems incapable of
recognising this, as Rockwood and Hubbard
(2004) identified:
‘Modern health care needs to reconcile
itself to complex patients. There are
many wrong ways to address this, each
of which has the following in common:
instead of getting to grips with how the
service is provided, they want the frail
old people to go away, to some more
appropriate place’ (p429).
This paper will explore the impact of such
thinking on the dignity of acutely ill older
adults.
Study aims
The study reported in this paper sought to:
• identify older people’s and their informal
carers’ views and priorities in relation to
dignified care
• examine health-care practitioners’
behaviours and practices in relation to
dignified care
• identify the occupational, organisational and
cultural factors that impact on dignified care
• develop evidence-based recommendations
and guidance for dignified care.
Methods
The study involved an ethnography of four
acute hospital trusts in England and Wales.
The trusts were purposively selected according
to their organisational characteristics, quality
of care and resource use and involvement
in dignity-related initiatives. Semi-structured
interviews with recently discharged older
people (65 and over) (n=40) and their
relatives/informal carers (n=25) were
undertaken about their experiences and
priorities in relation to dignified care. These
were complemented by evidence from 617
hours of non-participant observation of
© Pier Professional Ltd
 Right place – wrong person: dignity in the acute care of older people
practices and activities in 16 wards across
the four acute NHS trusts. The observation
periods covered 24/7 in each of the 16
wards to identify patterns of practitioner
behaviour. Semi-structured interviews were
also undertaken with a range of frontline
staff (n=79) and with purposive samples
of middle and senior managers (n=32), to
explore the occupational, organisational and
cultural factors that foster or detract from
dignified care.
The data from the observations and
interviews at each site were pooled and
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
analysed using an inductive thematic
approach. Users (older people/carers) were
involved with and informed each stage of the
research process. Four stakeholder workshops
for NHS managers and staff, voluntary
organisations and policy-makers (n=150)
were held throughout the UK as a means of
validation and to determine how the emerging
themes resonated with their experiences.
Findings
The main findings are related to four
overarching themes.
1. Whose interests matter?
2. Right place – wrong patient.
3. Seeing the person.
4. Influences on dignified care.
The notion that acute wards are not the
right place for older people was repeatedly
expressed by ward staff and trust managers:
‘It’s just not the right place for them.’
(Ward staff interview)
‘… in a busy acute hospital because
with the best will in the world... they
[older people] do need to be somewhere
where the staff have some awareness
of the needs of people.’ (Trust manager
interview)
Whose interests matter?
This theme explored the conflict of interests
between the priorities of the trust, the staff
and the patients. The majority of individuals
working in the NHS, are motivated to
Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
represent patients’ interests but these
motivations are frequently compromised by
systemic and organisational factors, including
setting 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 have resulted in older people being
continually moved within the system, which,
together with local ward cultures that have
developed in the context of untenable
staffing levels and the strictly demarcated
and hierarchical division of labour, results in
a struggle to provide not only continuity of
care, but care that protects and promotes the
individual’s dignity.
It is at the point where these various
interests come into conflict that dignified care
may be compromised. Quite rightly, trusts
place a great emphasis on patient safety,
particularly infection control and reducing
falls, while at the same time maintaining high
levels of bed occupancy and increasing the
rationalisation of services. However, each of
these priorities have unintended consequences
that frequently conflict with what is in the
older person’s interest.
De-cluttering to prevent falls and reduce
infection has in some areas been taken to
extreme measures as the following extract
shows:
‘She showed me round the bays
and pointed out that there were no
lockers anymore as they had been
told to remove them as part of the
“de-cluttering” drive… It means now
that patients have to keep everything
on their table, which becomes very
cluttered or in the cupboard in the
wall, which they cannot reach. There is
a real problem with things getting lost
particularly hearing aids, which are
expensive.’ (Observation)
Many participants experienced isolation
through being separated into side rooms with
limited contact with others, often exaggerated
by the restrictions on visiting hours.
© Pier Professional Ltd 35
 Right place – wrong person: dignity in the acute care of older people
Due to safety concerns and risk aversion,
older people were encouraged to remain in
chairs at their bedside and to use bedpans
and commodes rather than being helped to
a toilet. This example taken from a general
medical ward begs the question as to whether
there are some risks worth taking when
balanced with a patient’s dignity.
‘Annie calls out again and Amy the staff
nurse goes to her: “Can I go to the toilet
please?”
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
Amy: “You’ve got a pad on.”
Annie: “Can I have help to the toilet
please?”
Amy: “If you...[she sighs with frustration]
you’ve got low pressure, when you stand
up your blood pressure drops and you’ll
be falling.”’ (Observation)
Perhaps Annie’s risk of falling should have
been balanced against the indignity of
being told to soil herself and the feelings of
degradation that naturally follow.
However, this wasn’t an isolated
experience as some patients described.
Respondent: ‘Somebody would come in
and be desperate for a commode and
they’d say “Don’t worry about it, love,
don’t worry, you’ve got a pad on, use
that and we’ll come and change you
later.”’
Interviewer: ‘Oh no!’
Respondent: ‘Don’t look horrified, my
love, that was done more than once,
that was quite regular.’ (Older person’s
interview)
The drive for 97% bed occupancy leads
inevitably to constant movement of people in
an attempt to get the ‘right patient’ into the
‘right place’. This involves the movement of
patients into and out of wards and into and
out of beds and bays within the ward. People
36 Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
are moved frequently and at all hours of the
day and night:
‘It’s just the case of beds. I would
honestly say that and the pressure of
“We need to get this patient out to get
this patient in”, but you may have
people sat in wet beds you know, but
that isn’t a priority anymore. If you’ve
got people that are breaching down in
A&E because of this four-hour wait,
you know if they’re not seen and put
onto a ward or discharged within the
four hours… so they’re on the phone
constantly to us, then we’ve got to, but
then the patient care, where does that…
you know?’ (Ward staff interview)
This constant movement of patients, as well as
being detrimental to older people, is a drain
on trust resources, which does not appear to
have been put into the resource equation as
many hours of staff time are spent packing
patients’ belongings, transporting them, giving
handovers, cleaning vacated beds and bed
areas for the next person – time which equals
money that could be spent in delivering
dignified care as this nurse highlights:
‘I didn’t come into nursing care to
ship patients to different wards, I came
into nursing to care you know and all
the nurses are the same.’ (Ward staff
interview)
So trust priorities and targets can mean a trade
off between competing sets of priorities. In
the following example a ward sister describes
some of the trade-offs between shorter waiting
times and the quality of care, which she
describes as a conveyer belt:
‘No matter how hard you try it’s just
numbers in beds and get them out, get
them out, get the next one in, get the next
one in, get them out, get them out. There’s
no… nothing.’ (Ward staff interview)
The ‘nothing’ that this ward sister is referring
to can sometimes be an older person’s dignity.
© Pier Professional Ltd
 Right place – wrong person: dignity in the acute care of older people
Within health care certainly, it seems that
‘what matters is what is measured’.
We are attempting to measure compassion
– students entering nursing are tested on
compassion and dignity metrics are being
developed (Sturgeon, 2010). Some authors
have termed this the ‘Macdonaldisation’ of
care with wide smiles, and ‘Have a nice day’
tripping glibly from the tongue (Bradshaw,
2009). We might ask why it is so difficult for
people to believe and have confidence in
what they can clearly see, unless they can put
a number or grade on it?
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
What gets measured may well be an
indicator of what’s happening but it cannot
tell us everything. In treating indicators as
targets, they tend to become the standard by
which whole services are judged. This often
means that the experience of care, if it is not
represented in what is measured, is likely to
be neglected.
As many ward staff in this study
commented ‘If it isn’t written down it hasn’t
been done’, which is partly a response to the
blame culture, or at least the perception of
one, in many acute trusts. Of course the flip
side of this mantra is the assumption that if
some aspect of care is written down it has
‘been done’ but often this is not the case. So,
targets and indicators have a price and the
price is sometimes dignity.
The reliance and focus on following
checklists for day-to-day assessment and
observations of patients detracts from the
staff member’s ability to draw on their skills
and experiences in assessing patients more
holistically so that rather than the observations
being part of a person’s assessment, they
become the assessment.
Someone who is not eating or drinking
is put on a food and fluid chart and perhaps
referred to a dietician but the people
recording what that person has had to eat
or drink tend not to talk to the person
about their appetite, how they are feeling in
themselves, or whether there is any physical
problem that may be preventing them from
eating. These processes of recording are not
seen as opportunities to engage with patients
as often staff ask each other what the person
Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
has eaten and leave the bedside with no
interaction with the individual at all.
As Einstein taught us over 60 years ago,
‘Not everything that counts can be counted
and not everything that can be counted,
counts’. This should be a lesson for those who
only believe in what they can measure for,
although dignity doesn’t lend itself to precise
measurement, it does matter greatly to frail
older people.
Right place – wrong patient
Because acute trusts fail to act on the fact
that older people constitute the greatest
users of their services, the hospital and ward
environments fail to meet the needs of older
people.
Designed to disorientate
Wards, bays and corridors look the same in
acute hospitals up and down the UK. There
is a lack of any visual clues as to where
one is, the walls are invariably different
shades of cream, there are few signs or date
boards and where there are clocks, they
are often stopped. Such environments are
disempowering for older people as they
result in disorientation and make it difficult
for individuals, especially those who are
confused, to identify which is their bed, as
this fieldnote shows:
‘Two porters arrive with Mr Dee (bed
10). They ask him if he knows his bed
number – he doesn’t – no one seems
to be able to help and the porters say,
“They’ve given us the wrong ward again
haven’t they?” Mr Dee starts to say it’s
the wrong ward too (all the wards look
very similar). Then the staff nurse comes
out from behind the supper trolley and
says “Oh yes he’s mine – bed 10” and
they wheel him in.’
Designed to dismay
Although bays offer single-sex
accommodation, older people are often
embarrassed as the toilet and washing facilities
are often unisex, which means people have
to walk in their nightwear past, or sometimes
© Pier Professional Ltd 37
 Right place – wrong person: dignity in the acute care of older people
through, bays with people of the opposite
sex. Many of the bays look similar which
increases the potential for embarrassment and
uncomfortable situations as described by this
member of the ward staff:
‘Then you’ve got, you know, the
wanderer, the lady, you know, and she
was wandering in and out of the men’s
bays. The same thing, you know, when
you’ve got gentlemen in there, you know,
they’re confused as well and they’ll
wander and you’ve got nothing, they’ve
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
got nothing on the bottom, you know.’
(Ward staff interview)
Designed to deject
The acute ward is now very focused on caring
for the patient around the bed space. Day
rooms used as day rooms are rare; instead
they have a variety of functions, sometimes
accommodating additional beds, as meeting
rooms, storage space, or as a gym for
physiotherapy sessions. Consequently there
is nowhere for people to go – they must
either be in bed or sitting beside it. There is
nowhere for people to walk to, socialise or
watch television, so they stare at the walls for
hours on end. Both ward staff and patients
see this as detrimental to both physical and
psychological recovery:
‘The staff comment on the lack of a day
room on the ward. They say people have
nowhere to go, they are often on the ward
for a long time and they get depressed
and go downhill. Later I notice John and
William from bay 3 who have come out
of their bay and are sitting talking by the
nurses’ station as there is nowhere else for
them to go.’ (Observation)
‘You know, there’s none of that
[diversionary activity] because... hospitals
are no longer a place for that to happen
and I can understand that, but where
do they go?’ (Ward staff interview)
This aversion to any form of ‘diversionary’
activity, which is seen by some as encouraging
38 Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
patients to stay rather than ‘move on’, means
many nurses no longer see ‘engagement’ as
part of their task. This can lead to depressed,
bored, unmotivated patients who take longer
to recover, especially confused patients who
fare even worse in such environments, as they
are the people who most need stimulation
(Perrin, 1997). As this nurse points out:
‘Just trying to occupy them sometimes
and not just... expecting them to sit
there, you know, in a vegetative state
sort of thing, you know, like a lot of...
places do.’ (Ward staff interview)
The physical environment is therefore not
ideal for the older person who may be
confused. But what about the staff – how well
equipped are they to deal with the patients
they have?
The skills gap
There was an admission among trust managers
that maybe there is something of a skills
gap in caring for older people, particularly
those who are confused, as this manager
commented:
‘I don’t think we do focus on it [older
people’s care and dementia] as much
as we should do really, no. And I
would like to see it being a lot more...
focus on older persons and dementia
care because it is a bigger part and it’s
growing, it’s increasing day by day, year
by year is the older population... But no
I don’t think we focus on it as much as
we should do to be quite truthful.’ (Trust
manager interview)
This was confirmed by the ward staff, very
few of whom had had specific training on
working with older people, or with people
who are confused as in this nurse’s account:
‘Obviously when you train to be a
nurse you go through so many different
placements every year and they normally
do throw in a health care of the elderly
placement. So that’s all the real training
© Pier Professional Ltd
 Right place – wrong person: dignity in the acute care of older people
you get is whether you pick it up while
you’re training as a nurse.’ (Ward staff
interview)
Most staff had to deal with people as they
thought best on a daily basis often using their
own personal experience and without any
particular guidance. Sometimes this resulted in
the same patient being approached in different
ways by different people. One example comes
from observing the way staff looked after a
particular woman who is confused:
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
‘There are different approaches to
looking after Betty. There are those
who go along with Betty and simply
accompany her, whether it’s to look
for a bag or check where her friends
are and there are those who try to
re-orientate her to the hospital ward
and tell her that she is not allowed to
go into others’ rooms rather than simply
trying to distract her with a cup of tea.’
(Observation)
Staff on a number of wards faced many
difficulties in trying to deal with people with
dementia who needed to be ‘occupied’.
Sometimes confused patients were brought
to sit at the nurses’ station as a means of
distracting them while the staff were getting
on with paper work:
‘Jane from bed 11 has been brought to
sit at the nurses’ station – she is very
restless and keeps asking to be taken
to the WC. She sits in her chair at the
nurses’ station for a bit and the staff
nurse who is writing notes talks to her
saying she can be Nurse McDonald and
they will go to her with their problems.
The staff nurse says she can talk to the
visitors for her.’ (Observation)
Even patients commented that staff
experienced difficulties in caring for people
with dementia:
‘A lot of the staff didn’t bother. All
they [confused patients] needed was
Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
somebody to sit and talk and explain,
and OK within five minutes they might
forget and they would have to have it
explained to them again but that’s what
you do isn’t it? You know, that’s just
life when people are confused’ (Older
person interview)
Commission for Healthcare Audit and
Inspection (CHAI), in its report (2007) found
that most of the trusts it inspected find it
difficult to engage with patients with dementia
as the staff do not have adequate knowledge
of their condition. Only one trust in this study
had a ward that specialised in the acute care
of people with dementia.
These concerns raise the question about
whether or not the skills required for older
people generally, and those with dementia
specifically, should be seen as core skills
or specialist skills. The tendency towards
specialism is tempting, however as older
people are the greatest users of inpatient
services and those with dementia constitute
a considerable percentage of the inpatient
population, there is a powerful argument that
these skills should be seen as ‘core’.
Medical training is also be seen as lacking
as Oliver points out:
‘Geriatric medicine does not feature
prominently in the curricula of many
medical schools. Conventional medical
education emphasises “textbook”
presentations of single conditions from
lucid patients, which are amenable to
curative treatment… not your typical
older patient.’ (Oliver, 2008)
Rather than acknowledge and prepare staff to
meet the needs of the vast majority of patients,
it appears that the direction of travel is along
the path of specialisation as this trust manager
emphasises:
‘We have forgotten the generalised
humanity that we have to deal with...
we want to partition everybody into their
“ism” or their “ology”. What I’m trying to
convey is that there are some aspects of
© Pier Professional Ltd 39
 Right place – wrong person: dignity in the acute care of older people
patient need that we’re almost in denial
about because somebody else specialises
in it – but whoever it is, it ain’t [sic] me.’
(Trust manager interview)
This can mean that the older person with
multiple conditions is lost between specialisms
with no one taking an overview of the person
as a whole.
The failure to recognise who constitutes
the majority of patients means that the
workforce is being educated for yesterday or
for some fictional account of what day to day
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
care is like – such that practitioners are not
adequately prepared for the reality of acute
care; as seen below, this too has important
consequences.
Seeing the person
Many staff, especially nurses, spoke in
interviews about the ideals and values
emphasised in their educational programmes
such as patient-centred care and how that is
central to treating people with dignity, yet
they were rarely able to fulfil this commitment.
Care tended to be task based with
someone doing the washes, someone else
doing the observations and another person
doing medications; this wasn’t because of how
staff chose to deliver care, but was all that
could be done with the skill mix available.
Staff frequently felt dissatisfied with the
care they were able to give – they left work
late, they were often in tears and many were
seeking other jobs. In the words of Maben
et al, they were disconnected, disillusioned
and crushed:
‘This disconnection leads to
disillusionment and for some a desire to
leave the profession. In consequence a
greater gap than ever before now exists
between the ideals and values adopted
by students during their education and
those evident in the practice setting.’
(Maben et al, 2007)
Influences on dignified care
Dignity should not be an optional add on, but
should be an integral and essential aspect of
40 Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
caring for older people. This trust manager
clearly identifies one of the problems:
‘Nothing gets equal weighting to targets
and finance regardless of what people
say to you about the NHS. At the end
of the day that is what drives people
because it’s about sustainability. What
is an organisation supposed to do but
concentrate on survival and that’s what
that became to us, it became survival?
Will it ever be survival to us around the
quality of care that people get? If you
look at Mid Staffs, what they were doing
there, they were struggling to survive
with their finances and their four-hour
targets, and dignity and respect got lost.
I always feel that my responsibility at
the board is about bringing people back
to the primary focus of our existence –
what about the patient in this?’ (Trust
manager interview)
Another suggests where attention should be
focused:
‘What we can’t do is we can’t make
them any younger and sometimes sadly
we can’t make them better but we can
make them comfortable and we can...
we can embrace them properly with
conversation, stimulus, a meal, a clean
environment and an environment that
makes it easier to co-exist on a ward
with others.’ (Trust manager interview)
Conclusion
The view that acute care is not the right place
for older people or the failure to acknowledge
that the largest group of users are the very
old, the frail and the dependent, results in
environments that are not friendly to older
people generally, and are especially hostile to
those with cognitive impairments.
It also results in a culture that is risk
averse and often defensive, where care is
undervalued; a culture where professional
accountability and discretion is replaced by
standardised checklists, pathways and audits
resulting in the view that if an aspect of care
© Pier Professional Ltd
 Right place – wrong person: dignity in the acute care of older people
can’t be measured it doesn’t matter; a culture
where getting the job done matters more
than how the job is done, so that the focus is
primarily on the tasks rather than seeing the
people who matter.
It should be emphasised that the majority
of staff work very hard to deliver care in
extremely difficult circumstances. Most
of them choose their career for altruistic
reasons; many are worn out, disillusioned
and looking for new jobs. Very rarely did
we see members of staff treating people in
an undignified manner because they were
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
callous or uncaring.
Instead the failures are largely system
failures, which Youngson argues are so great
that acute health care is on the point of
collapse:
‘Health care is facing a major crisis
that I call “peak-medicine” – the
moment when accelerating health care
demand, consequent on proliferating
technology, ever-increasing
specialisation and rising consumer
expectations, overwhelms the resources
available to care for a rapidly ageing
population.’ (Youngson, 2010)
‘Peak-medicine’ with its emphasis on
technocratic, consumer business models
and productivity ideologies demands a huge
price. That price is the comodification of
care and services, which can result in people
being treated as objects to do things to, from
which it is but a short step to treating them
without respect (Lown, 2007).
In terms of patient outcomes, there is
evidence that positive health and social
outcomes result when people feel valued
and respected, are involved in care decisions,
maintain a positive self-regard and can
exercise direction over their lives (Kenny,
1990; Bensink et al, 1992; Brillhart & Johnson,
1997, Ranzin et al, 1998, Tadd et al, 2002;
Walsh & Kowanko, 2002). Patients who
experience dignified care are more likely to
comply with treatment and report a higher
satisfaction with care (Beach et al, 2005;
Glendinning et al, 2006).
Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
If dignity had been at the forefront of
organisations described as ‘failing’ and
perhaps most notably in Mid Staffordshire,
things might not have gone so far wrong,
as Sir Stephen Moss and Antony Sumara (Dr
Foster Limited, 2010) state:
‘The human impact of what we do
as a board is at the heart of our
responsibilities. The board focuses on
what it means to patients and families
when our actions cause problems...
Our board has learned that a patient’s
experience is influenced predominantly
by how well we meet their fundamental
needs. We need to be aware how long
it is taking for nurses to respond to call
bells, and how well we are assessing a
patient’s nutritional state and acting on
it.’ (pp14–15)
All this suggests that dignity is much more
than a mere nicety and that the perception
of older people as possessors of dignity is of
the utmost importance – so considerations
of dignity should be a central element not
only in the provision of high-quality care,
but also in promoting health and well-being
in later life.
Acknowledgements
We would like to thank all of the older
people, their families, frontline staff and
trust managers who generously gave their
time to be interviewed. We are particularly
indebted to the four acute trusts who agreed
to participate and who openly welcomed us
into their organisations.
This study is independent research
commissioned and funded by the National
Institute for Health Research Service Delivery
and Organisation (NIHR-SDO) and adopted
by Department of Health and Comic Relief
under the PANICOA initiative. The research
team wish to gratefully acknowledge
this support. The views expressed in this
publication are those of the author(s)
and not necessarily those of the NHS, the
National Institute for Health Research or the
Department of Health.
© Pier Professional Ltd 41
 Right place – wrong person: dignity in the acute care of older people
Implications for policy
and practice
• Older people are the most frequent users of
acute hospital services and ageist attitudes
that result in comments such as ‘they
shouldn’t be here’ are inappropriate. This
key message must be clearly understood.
• The education of all healthcare professionals
needs to be reassessed to ensure that it
is in line with the needs of the majority
of patients in acute hospital trusts – older
people. This reappraisal should include a
better understanding and appreciation of
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
co-morbidities, the nature and management
of dementia and delirium and the
complexities of older people’s needs.
• Commissioners must ensure that all older
people with complex needs complicating
acute illness are seen by a geriatrician in order
to advise colleagues on management and that
liaison services with old age psychiatry (or
other specialist services for dementia/delirium)
are provided in all acute settings.
• Trust boards must give attention to
environmental design and enable patients
to participate in redesign/refurbishment
projects. They should understand the
need to design and operate its acute
services to explicitly meet the needs of
frail older people. Such services will also
meet the needs of other users. All hospital
refurbishments and new builds must
incorporate dementia-friendly design as
standard for all areas. This should include
safe walking space and the helpful use of
colour, lighting and signage to help orientate
those with dementia or delirium. The value
of communal spaces on acute wards in terms
of social engagement and activities must
be recognised as a means of preventing
deterioration and promoting recovery.
• Targets and clinical governance directives
can create an over-emphasis on checklist-
based audit and measurement, which may
fail to ‘see the person’ and be detrimental
to patient care and experience. Broader
approaches to determine the quality
of patient care should include regular
observation of care by middle and trust
board managers.
42 Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
• Middle managers must develop ward leaders
giving them more autonomy and support to
manage their staff.
• Ward managers must support staff in the
delivery of dignified care and be willing to
speak for them to ensure that resources are
in place to enable the delivery of care of an
appropriate standard.
• Ward managers must challenge
inappropriate or poor practices and take
necessary actions to ensure they do not
reoccur.
• All staff must engage with organisational
policies and strategies designed to deliver
person-centred care and recognise and
respect every individual’s need to be treated
with dignity.
• All staff must reflect on the impact of their
own actions on patients’ experience of
dignity.
Address for correspondence
Dr Win Tadd
School of Social Sciences
Cardiff University
6 Museum Place
Cardiff
CF10 3BG
UK
Email: taddw@cardiff.ac.uk
References
Alzheimer’s Society (2009) Counting the Cost:
Caring for people with dementia on hospital wards.
London: Alzheimer’s Society.
Bayer A, Tadd W & Krajcik S (2005) Dignity: the
voice of older people. Quality in Ageing 6 (1)
22–29.
Beach MC, Sugarman J, Johnson RL, Arbelaez JJ,
Duggan PS & Cooper A (2005) Do patients treated
with dignity report higher satisfaction, adherence
and receipt of preventive care? Annals of Family
Medicine 3 (4) 331–338.
Bensink GW, Godbey KL, Marshall MJ & Yarandi
HN (1992) Institutionalized elderly: relaxation, locus
of control, self-esteem. Journal of Gerontological
Nursing 18 (1) 30–38.
Bradshaw A (2009) Measuring nursing care and
compassion: the McDonaldised nurse? Journal of
Medical Ethics 35 (8) 465–468.
© Pier Professional Ltd
 Right place – wrong person: dignity in the acute care of older people
Brillhart B & Johnson K (1997) Motivation and
the coping process of adults with disabilities: a
qualitative study. Rehabilitation Nursing 22 (5)
249–52 and 255–6.
Commission for Healthcare Audit and Inspection
(2007) Caring for dignity: A national report on
dignity in care for older people while in hospital.
London: Her Majesty’s Stationery Office.
Dr Foster Limited (2010) The Intelligent Board 2010:
Patient Experience. London: Dr Foster Limited.
Glendinning C, Clarke S, Hare P, Kotchetkova I,
Maddison J & Newbronner L (2006) Outcomes-
focused Services for Older People. London: Social
Care Institute for Excellence.
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)
Goodrich J & Cornwell J (2008) Seeing the Person in
the Patient: Point of care review paper. London: The
King’s Fund.
Jacelon CS (2002) Attitudes and behaviours of
hospital staff towards elders in an acute care
setting. Applied Nursing Research 15 227–234.
Jacelon CS (2003) The Dignity of Elders in an Acute
Care Hospital. Qualitative Health Research 13 (4)
543–556.
Jacelon CS (2004) Managing personal integrity: the
process of hospitalization for elders. Journal of
Advanced Nursing 46 549–557.
Kenny T (1990) Erosion of individuality in care of
elderly people in hospital: an alternative approach.
Journal of Advanced Nursing 15 571–576.
Lothian K & Philp I (2001) Maintaining the dignity
and autonomy of older people in the healthcare
setting. British Medical Journal 322 (7287) 668–670.
Lown B (2007) The Commodification of Health
Care (online). Available from: www.pnhp.org/
publications/the_commodification_of_health_care.
php (accessed February 2011).
Maben J, Latter S & Macleod-Clark J (2007) The
sustainability of ideals, values and the nursing
mandate: evidence from a longitudinal qualitative
study. Nursing Inquiry 14 (2) 99–113.
Nordenfelt L & Edgar A (2005) The Four Notions of
Dignity. Quality in Aging 6 (1) 17–21.
Oliver D (2008) ‘Acopia’ and ‘social admission’ are
not diagnoses: why older people deserve better.
Journal Royal Society of Medicine 101 (4) 168–74.
Patients Association (2009) Patients not Numbers,
People not Statistics. London: Patients Association.
Perrin T (1997) Occupational need in severe
dementia: a descriptive study. Journal of Advanced
Nursing 25 (5) 934–941.
Philp I (2002) Developing a national service
framework for older people. Journal of
Epidemiology and Community Health 56 (11)
841–842.
Quality in Ageing and Older Adults • Volume 12 Issue 1 • March 2011
Ranzijn R, Keeves J, Luszcz M & Feather NT
(1998) The role of self-perceived usefulness and
competence in the self-esteem of elderly adults:
confirmatory factor analysis of the Bachman
Revision of Rosenberg’s self-esteem scale. Journal
of Gerontology 53B (1) 96–104.
Revill J, Campbell D & Hill A (2007) 700,000
Elderly People ‘Are Being Abused’ (online). Available
from: www.guardian.co.uk/society/2007/jun/10/
longtermcare.uknews (accessed February 2011).
Rockwood K & Hubbard R (2004) Frailty and the
geriatrician. Age and Ageing 33 (5) 429–430.
Seedhouse D & Gallagher A (2002) Undignifying
institutions. Journal of Medical Ethics 28 (5) 368–337.
Sturgeon D (2010) ‘Have a nice day’: consumerism,
compassion and health care. British Journal of
Nursing 19 (16) 1047–1051.
Tadd W (2005a) Dignity and older Europeans
(editorial). Quality in Ageing 6 (1) 2–5.
Tadd W (2005b) Dignity and older Europeans
(editorial). Quality in Ageing 6 (2) 2–3.
Tadd W (2006) Dignity and older Europeans. In: J
Gunning & S Holm (Eds) Ethics, Law and Society
(volume 3) (pp73–92). London: Ashgate.
Tadd W & Bayer AJ (2001) Dignity as a feature
of complaints made by elderly people. Age and
Ageing 30 (S2) 40.
Tadd W, Dieppe P & Bayer T (2002) Dignity in
health care: reality or rhetoric. Reviews in Clinical
Gerontology 2 1–4.
Tadd W, Vanlaere L & Gastmans C (2010) Clarifying
the concept of human dignity in the care of
the elderly: a dialogue between empirical and
philosophical approaches. Ethical Perspectives 17
(1) 259–287.
Valentine N, Darby C & Bonsel G (2008) Which
aspects of non clinical quality care are most
important? Results from WHO’s general population
survey of health systems responsiveness in 41
countries. Social Science and Medicine 66 (9)
1939–1950.
Walsh K & Kowanko I (2002) Nurses’ and patients’
perceptions of dignity. International Journal of
Nursing Practice 8 (3) 143–151.
Woolhead G, Calnan M, Dieppe P & Tadd W (2004)
Dignity in older age: what do older people in the
United Kingdom think? Age and Ageing 33 (2)
165–170.
Woolhead G, Tadd W, Boix-Ferrier J, Krajcik S,
Schmid-Pfahler B, Spj- Stratton B & Dieppe P (2006)
‘Tu’ or ‘Vous?’ A European qualitative study of
dignity and communication with older people in
health and social care settings. Patient Education
and Counselling 61 (3) 363–371.
Youngson R (2010) The Role and Interactions of
Caregivers. Keynote presentation at Dignity for the
Frail Old. 2–5 September in Solstrand, Norway.
© Pier Professional Ltd 43
 This article has been cited by:

1. Joanna Latimer. 2018. Afterword: materialities, care, ‘ordinary affects’, power and politics. Sociology of Health & Illness 40:2,
379-391. [Crossref]
2. Juping Yu, Roiyah Saltus, Paul Jarvis. 2017. Perceived inequalities in care and support for older women from Black and
minority ethnic backgrounds in Wales: findings from a survey exploring dignity from service providers’ perspectives. Ethnicity
& Health 9, 1-21. [Crossref]
3. Jennifer Baumbusch, Maureen Shaw, Marie-Eve Leblanc, Mary Kjorven, Jae-Yung Kwon, Lorraine Blackburn, Barb Lawrie,
Marilyn Shamatutu, Angela C. Wolff. 2017. Workplace continuing education for nurses caring for hospitalised older people.
International Journal of Older People Nursing 13. . [Crossref]
4. Juping Yu, Roiyah Saltus, Paul Jarvis. 2017. A survey of service providers' views on care and support provision for older
women from Black and minority ethnic backgrounds in Wales: Implications for policy and practice. Health Care for Women
International 38:7, 715-731. [Crossref]
5. Simon Read, Sara MacBride-Stewart. 2017. The ?good death? and reduced capacity: a literature review. Mortality 13, 1-15.
[Crossref]
6. Thomas A. Jackson, John R. F. Gladman, Rowan H. Harwood, Alasdair M. J. MacLullich, Elizabeth L. Sampson, Bart
Sheehan, Daniel H. J. Davis. 2017. Challenges and opportunities in understanding dementia and delirium in the acute hospital.
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)

PLOS Medicine 14:3, e1002247. [Crossref]

7. Kate O’Loughlin, Hal Kendig. Attitudes to Ageing 29-45. [Crossref]
8. Caroline Nicholson, Elizabeth M. Morrow, Allan Hicks, Joanne Fitzpatrick. 2017. Supportive care for older people with
frailty in hospital: An integrative review. International Journal of Nursing Studies 66, 60-71. [Crossref]
9. Lucy Ellen Selman, Barbara A. Daveson, Melinda Smith, Bridget Johnston, Karen Ryan, R. Sean Morrison, Caty Pannell,
Regina McQuillan, Suzanne de Wolf-Linder, Steven Z. Pantilat, Lara Klass, Diane Meier, Charles Normand, Irene J.
Higginson. 2016. How empowering is hospital care for older people with advanced disease? Barriers and facilitators from a
cross-national ethnography in England, Ireland and the USA. Age and Ageing . [Crossref]
10. Nicola Mackintosh, Jane Sandall. The Social Practice of Rescue: The Safety Implications of Acute Illness Trajectories and
Patient Categorisation in Medical and Maternity Settings 69-86. [Crossref]
11. Kay de Vries, Jenny Drury-Ruddlesden, Chris Gaul. 2016. ‘And so I took up residence’: The experiences of family members
of people with dementia during admission to an acute hospital unit. Dementia 47, 147130121665609. [Crossref]
12. Jennifer Baumbusch, Marie-Eve Leblanc, Maureen Shaw, Mary Kjorven. 2016. Factors influencing nurses’ readiness to care
for hospitalised older people. International Journal of Older People Nursing 11:2, 149-159. [Crossref]
13. Veronika Williams, Deborah Kinnear, Christina Victor. 2016. ‘It's the little things that count’: healthcare professionals’ views
on delivering dignified care: a qualitative study. Journal of Advanced Nursing 72:4, 782-790. [Crossref]
14. Kate Furlanetto, Katherine Emond. 2016. “Will I come home incontinent?” A retrospective file review: Incidence of
development of incontinence and correlation with length of stay in acute settings for people with dementia or cognitive
impairment aged 65 years and over. Collegian 23:1, 79-86. [Crossref]
15. Nicola Mackintosh, Jane Sandall. 2016. The social practice of rescue: the safety implications of acute illness trajectories and
patient categorisation in medical and maternity settings. Sociology of Health & Illness 38:2, 252-269. [Crossref]
16. Zainab Zahran, Marcelle Tauber, Holly Howe Watson, Phoebe Coghlan, Sarah White, Sue Procter, Gulen Addis, Christine
Norton. 2016. Systematic review: what interventions improve dignity for older patients in hospital?. Journal of Clinical Nursing
25:3-4, 311-321. [Crossref]
17. Frederick Graham. 2015. A New Frontier. JONA: The Journal of Nursing Administration 45:12, 589-591. [Crossref]
18. Jackie Bridges, Alison Fuller. 2015. Creating learning environments for compassionate care: a programme to promote
compassionate care by health and social care teams. International Journal of Older People Nursing 10:1, 48-58. [Crossref]
19. Ellen Tullo, Tien K. Khoo, Andrew Teodorczuk. 2015. Preparing to meet the needs of an ageing population – A challenge
to medical educators globally. Medical Teacher 37:2, 105-107. [Crossref]
20. DAVINA POROCK, PHILIP CLISSETT, ROWAN H. HARWOOD, JOHN R. F. GLADMAN. 2015. Disruption, control
and coping: responses of and to the person with dementia in hospital. Ageing and Society 35:01, 37-63. [Crossref]
21. Kathy H. Whittamore, Sarah E. Goldberg, Lucy E. Bradshaw, Rowan H. Harwood. 2014. Factors Associated with Family
Caregiver Dissatisfaction with Acute Hospital Care of Older Cognitively Impaired Relatives. Journal of the American Geriatrics
Society 62:12, 2252-2260. [Crossref]
22. Karen Spencer, Pippa E. R. Foster, Kathy H. Whittamore, Sarah E. Goldberg, Rowan H. Harwood. 2014. Staff confidence,
morale and attitudes in a specialist unit for general hospital patients with dementia and delirium-a qualitative study.
International Journal of Geriatric Psychiatry 29:12, 1315-1317. [Crossref]
 23. Tessa E. Watts, Ruth Davies. 2014. Tensions and ambiguities: A qualitative study of final year adult field nursing students'
experiences of caring for people affected by advanced dementia in Wales, UK. Nurse Education Today 34:8, 1149-1154.
[Crossref]
24. Philip Clissett, Davina Porock, Rowan H Harwood, John RF Gladman. 2014. The responses of healthcare professionals to
the admission of people with cognitive impairment to acute hospital settings: an observational and interview study. Journal
of Clinical Nursing 23:13-14, 1820-1829. [Crossref]
25. Merryn Gott. 2014. Avoidable for whom? Hospital use at the end of life. Palliative Medicine 28:7, 917-918. [Crossref]
26. Tessa Watts. 2014. Final-year nursing undergraduates’ understandings of palliative care: a qualitative study in Wales, UK.
International Journal of Palliative Nursing 20:6, 285-293. [Crossref]
27. Mary R O'Brien, Harriet Preston. 2014. Family carer perspectives of acute hospital care following a diagnosis of motor neuron
disease: a qualitative secondary analysis. BMJ Supportive & Palliative Care bmjspcare-2013-000627. [Crossref]
28. A.W. Ekdahl. 2014. The organisation of hospitals and the remuneration systems are not adapted to frail old patients giving
them bad quality of care and the staff feelings of guilt and frustration. European Geriatric Medicine 5:1, 35-38. [Crossref]
29. Philip Clissett, Davina Porock, Rowan H. Harwood, John R.F. Gladman. 2013. Experiences of family carers of older people
with mental health problems in the acute general hospital: a qualitative study. Journal of Advanced Nursing 69:12, 2707-2716.
[Crossref]
30. Anita Nilsson, Marie Lindkvist, Birgit H Rasmussen, David Edvardsson. 2013. Measuring levels of person-centeredness in
Downloaded by UNIVERSITY OF NEW ENGLAND (AUS) At 18:31 24 February 2018 (PT)

acute care of older people with cognitive impairment: evaluation of the POPAC scale. BMC Health Services Research 13:1. .
[Crossref]
31. Philip Clissett, Davina Porock, Rowan H. Harwood, John R.F. Gladman. 2013. The challenges of achieving person-centred
care in acute hospitals: A qualitative study of people with dementia and their families. International Journal of Nursing Studies
50:11, 1495-1503. [Crossref]
32. Alexandra Hillman, Win Tadd, Sian Calnan, Michael Calnan, Antony Bayer, Simon Read. 2013. Risk, governance and the
experience of care. Sociology of Health & Illness 35:6, 939-955. [Crossref]
33. Anita Nilsson, Birgit H Rasmussen, David Edvardsson. 2013. Falling behind: a substantive theory of care for older people
with cognitive impairment in acute settings. Journal of Clinical Nursing 22:11-12, 1682-1691. [Crossref]
34. Alison Orrell, Kevin McKee, Judith Torrington, Sarah Barnes, Robin Darton, Ann Netten, Alan Lewis. 2013. The
relationship between building design and residents’ quality of life in extra care housing schemes. Health & Place 21, 52-64.
[Crossref]
35. Roiyah Saltus, Elizabeth Folkes. 2013. Understanding dignity and care: an exploratory qualitative study on the views of older
people of African and African‐Caribbean descent. Quality in Ageing and Older Adults 14:1, 36-46. [Abstract] [Full Text] [PDF]
36. Fiona J Jurgens, Philip Clissett, John RF Gladman, Rowan H Harwood. 2012. Why are family carers of people with dementia
dissatisfied with general hospital care? a qualitative study. BMC Geriatrics 12:1. . [Crossref]
37. ANITA NILSSON, MARIE LINDKVIST, BIRGIT H. RASMUSSEN, DAVID EDVARDSSON. 2012. Staff attitudes
towards older patients with cognitive impairment: need for improvements in acute care. Journal of Nursing Management 20:5,
640-647. [Crossref]
38. Jackie Bridges, Peter Griffiths, Catherine Pope, Ruth Bartlett. 2012. Editorial: Failure to rescue: improving nursing care for
older people. International Journal of Older People Nursing 7:1, 1-2. [Crossref]