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What is dignity anyway? asked our Editor last week. In an ideal world, it should be a matter of common sense and old fashioned good manners.

The fact that undignified treatment of older people has become the intermittent focus of newspaper and television programmes would indicate that dignity needs to be “unpacked” and redefined in a series of manageable programmes designed to both raise awareness and educate.

In the coming issues of the Newsletters, we will be examining some of the elements of dignity in the context of treating our patients. The British Geriatrics Society has chosen as its focus, the fundamental right of every person to be allowed to perform that necessary but most “undignified” of acts - going to the toilet - with as much privacy and dignity as possible. Giving people back control over this most private of functions will enhance their independence and rehabilitation, reduce lengths of stay in hospital and promote continence.
The campaign will disseminate educational leaflets, decision aids, standards and check lists to voluntary groups, patient and carer groups as well as to care staff. It will also make patients aware of what they should expect. We emphasise the importance of the environment, as well as care practices and hope that the campaign will help in the future commissioning of facilities. It will provide commissioners, chief executives and inspectors with a measure of good practice and clinical governance.

Background to the campaign
The recent publication of ‘A New Ambition for Old Age’, by the Department of Health (DoH) describes how some staff still demonstrate deep-rooted negative attitudes and behaviour towards older people. It recommends that each NHS Setting providing care for older people nominate a member of staff to take responsibility for protecting and promoting the dignity of older people. It is recognised that the dignity of older people is infringed every day in many different ways, including:

• visiting at ward rounds
• split back night dresses
• inappropriate hoists
• mixed sex wards on Medical Admissions Units
• patients wearing pads without underwear
• ward curtains or night dresses or smocks which do not fit properly, exposing patients or allowing mooning
• hoisting patients without covers
• patients being referred to as bed blocker, social problems

Prior to the DoH publication, the BGS brought together a multi-agency committee to look at markers of dignity. Despite welcoming the appointment of members of staff to take responsibility for dignity it was thought that these concepts should be developed in a multi-disciplinary fashion. It was agreed that the committee would consist of a partnership between Age Concern England, the BGS, the Department of Geriatric Medicine, Cardiff University, Carers UK, Continence Foundation, Help the Aged, Incontact and the Royal College of Nursing.

It was agreed that “Toilet Access” and “Use” should be used as a marker for this campaign. The Royal College of Physicians National Continence Audit (2005) found that few hospitals appreciate that they need to do better in privacy and dignity in toiletting. The WASH YOUR HANDS campaign has already demonstrated that there is potential to improve clinical practice with a simple campaign.

This campaign has produced:

• the Behind Closed Doors Leaflet
• the Behind Closed Doors Standards
• a decision aid for using the toilet in
  any care setting
• a checklist for use by lay people and
• an action plan for target groups

Behind Closed Doors - Standards

Access
All people, whatever their age and physical ability, should be able to choose and to use the toilet in private. There must be sufficient toilets and equipment available to achieve this.

Timeliness
People who need assistance to use the toilet should be able to request and receive timely and prompt help.
People should not be left on the commode or bed pan for longer than necessary.

Equipment for Transfers and Transit
Essential equipment to assist people to gain access to a toilet should be:

• readily available
• used for transfer onto a transit chair and on / off the toilet.
• used in a way that respects the
  person’s dignity
• used in a way that avoids unwanted exposure.

Safety
People who are unable to use a toilet alone safely, should normally be offered use of a toilet with appropriate safety equipment in place and with supervision if required.

Choice
People’s choice is paramount. Their views should be sought and respected.

Privacy
Privacy and dignity must be preserved. People who are bed bound require special attention.

Cleanliness
All toilets, commodes and bed pans must be clean.

Hygiene
All people in all settings must be enabled to leave the toilet with a clean bottom and washed hands.

Courteous
Discussions with people must be respectful and courteous, especially in regards to episodes of incontinence.

Environmental Audit
All organisations should encourage a lay person to undertake an environmental audit to assess the toilet facilities.

Action Plan for Target Groups
The campaign has identified the following groups of people who might seek to influence change:

• Older people’s fora
• Older people’s champions
• Community Health Councils (Wales)
• Educators in all education and training programmes
• Advocacy and patient support groups
• Carers groups
• Royal Colleges
• Patients’ Association

The campaign aim is to influence policy via:

• The DoH Older Persons’ NSF work programme
• The DoH Dignity Reference Group [NICE Guidelines - Faecal Incontinence (2007); Urinary Incontinence in Women (2006); Dementia (2006)]
• Future national continence audits / research programmes
• The Healthcare Commission’s inspection process

Resources
Leaflets, including the aid to help carers decide on the level of privacy and assistance required for various levels of disability, and a tool to support carers in conducting an environmental audit of toilet facilities, are available in pdf form on the BGS website or in hard copy from the BGS office.

Jackie Morris
James Barrett

Reference:
Jacqueline Morris, David Oliver, David Beaumont. Decent Health Care BMJ Editorial (BMJ, May 2006; 332: 1166 - 1168)