Journal of Nursing Management, 2014, 22, 137–139
Editorial Leadership and management challenges in addressing the dignity and respect agenda
This issue focuses on the healthcare leadership and management challenges in promoting and maintaining dignity and respect. People receiving care expect their dignity and respect to be maintained as enshrined within nursing professional codes of conduct. A review undertaken by the World Health Organization across 41 countries, shows that most participants select dignity as the second most important domain from a list of 8, only ‘promptness of care’ was more highly rated (Valentine et al. 2008). The Council of Nurses’ Code of Ethics for Nurses (2012) states that ‘inherent in nursing is respect for human rights. . . including the right to life and choice, to dignity and to be treated with respect’. The Amsterdam Declaration promotes dignity as one of the main rights for patients (World Health Organization, 1994). Developing this edition has made me reflect and think hard about the leadership and management issues relating to dignity and respect. One of the interesting observations is how few papers the journal receives on the dignity and respect agenda that relate to actual patient care. I could have generated several editions of the journal had this been about the dignity and respect agenda for staff. It seems that many authors have studied, and written about the environments in which staff practice. Fewer people are studying and writing about the leadership and management challenges in fostering dignity and respect for patients. Yet this is a significant issue that leaders and managers of nursing and care services spend sleepless nights worrying about and dealing with day to day. Of course many leaders and managers are able to celebrate the care people receive every day, but at times care fails to meet patients’ needs. This puts nurses and nurse leaders at the forefront of the dignity and respect agenda. Much of the care that is provided globally is of the highest standards, delivered by highly educated and attentive staff. Yet I am sure that readers of this journal will be able to identify clear breaches of dignity and respect in their own settings. Some of these ‘breaches’ have become national and international headlines (Francis, 2013), care home abuses in Southern Ontario DOI: 10.1111/jonm.12230 ª 2014 John Wiley & Sons Ltd
(CCTV news, 2013) with some leading centres raising issues of elder abuse (NCEA, 2013). In England, health policy documents increasingly emphasise the importance of compassionate and dignified care. This is largely in response to the Francis Inquiry (2013) that reported significant numbers of examples of patients subjected to gross breaches of their dignity and respect. Partly in response to this inquiry and other significant reports, the National Health Service in England has devised a Constitution (Department of Health 2013a) that includes ‘respect and dignity’ as one of seven NHS values. The contributing authors to this edition collectively provide some important messages. The authors represent nine different countries, and present research across the age ranges, from children’s care to a majority of papers that focus on care for older people. For methodologically inclined readers this edition covers a range of research approaches and includes systematic reviews, quantitative, qualitative and mixed methods studies. No matter what method is used or area is investigated, a resounding message is that promoting dignity and respect requires effective communication at all levels by all involved. The first paper in this edition is by Buchini et al. (pp. 140–150) (Italy) in a descriptive study, capturing the views of staff working in an intensive care ward caring for people in a vegetative state provide an excellent starting point for this edition. They provide clear definitions and state that, ‘when there is dignity people feel under control, valued, confident, capable and able to make decisions. When dignity is absent people feel devalued, out of control and ill at ease’. The authors talk of the need to humanize the hospital, but that this presents a challenge to all nurse leaders and managers thus ‘dignity is often poorly implemented in healthcare facilities’. Baillie (2009) reinforces this by identifying that the physical environment, organisational culture, leadership and healthcare systems are components of the care environment that influence dignity. In this context I would also suggest the work of Ballatt and Campling (2012) on ‘Intelligent Kindness’ as a thought-provoking read. 137
Editorial
Whist preparing this editorial I discovered a recent quote from a leading business thinker, Michael Porter, when referring to health outcomes. He seemingly overlooks patient satisfaction as a desirable outcome to be considered. ‘Whether people were nice to them. . .that’s all good stuff, but it’s not an outcome. The outcome is how the patient does functionally, quality of life, complications, recurrence of disease. . .the actual results’, (West 2014). If this quotation is accurate maybe Professor Porter needs to spend time with nurses and doctors caring for people and review the evidence. Being treated with dignity and being involved in decision-making is associated with positive outcomes (Beach et al. 2005). Experiencing care that ensures dignity and respect is easier to recognise than it is to define or ‘count’. It is more than a set of ‘outcomes’. The next paper Gerasimou-Angelidi et al. (pp. 151– 158) from Greece investigates nursing workload and family satisfaction in an adult intensive care ward. They conclude that family satisfaction should be used as a measure of care quality. This is an important measure especially for vulnerable people that are either afraid or unable to comment on the care they receive. Within England a Friends and Family test has been introduced, (Department of Health 2013b). Patients are asked to rate their response to the question, ‘How likely are you to recommend our ward/ A&E department to friends and family if they needed similar care or treatment?’ Views on this methodology are mixed, however it would be interesting to ask a family member the same question based on their views of the care that their family member experienced. Many papers have been submitted and published by the Journal of Nursing Management on the importance of a supportive climate for nursing staff and its impact on turnover and nurse satisfaction but few papers have examined the impact of nursing workload and its relationship to family satisfaction. Building from this work and looking at the working environment further, Atinga et al. (pp. 159–169) from Ghana explore workplace politics using statistical techniques. They define politics as behaviour strategically designed to maximise the self-interest of individuals or groups in the workplace. The most pertinent finding in relation to this edition of the Journal of Nursing Management is that workplace politics is associated with. . .‘negligent behaviour and improper conduct’. Many papers previously published in this journal clearly identify that the working environment that nurse leaders create is critical to care outcomes. The work of Atigna et al. reinforces this and provides a view from Africa that positive communication is key 138
to improving care. Building on this need for effective communication Cramm et al. (pp. 170–176), (The Netherlands), Aarthun & Akerjordet, (pp. 177–191) (Norway), Rouse & Al-Maqbali (pp. 192–200) (Oman) and Hudson et al. (pp. 201–210) (USA) highlight the importance of communication, shared decision making and user involvement in promoting dignity and respect. They use different methodological techniques and challenge the reader to think differently about care delivery. Rouse &Al-Maqbali examine how effective communication may help to identify nurse manager behaviours that promote dignity and respect. They state that ‘over time, nurses may become socialised to accept a negative work environment that desensitises them to bullying. Rather than passively accept this phenomenon, nurse leaders should work to establish a supportive, encouraging environment that respects the dignity of both patients and nurses’. It is not difficult to hypothesise that those that become desensitised to bullying are less able to identify bullying if it is happening in their environments. Perhaps the famous speech by Elie Wiesel, ‘The Perils of Indifference’ (1999), should be mandatory reading for all those in the caring professions? Hudson et al use the terms ‘Wicked problems’ to explore ‘transitional care’. Transitional care generates a different way of thinking about what many healthcare systems refer to as discharge planning. Wicked problems are characterised by problems that are intractable, inter-related, contradictory, multi-layered and are politically influenced. Indeed this very description defines the working world of most nurse leaders and managers. Reading these three papers provides an opportunity to consider how healthcare can be transformed by adopting different perspectives. One of the common areas of practice presented in this edition relates to care of the older person. Seven papers address this area of practice, this is not surprising given the increasing numbers of older adults. Holm & Severinsson (pp. 211–224) from Norway provide an illuminating systematic review that examines effective nursing leadership and the outcomes of older people in the community. The systematic review in my opinion is undertaken with expertise providing a robust model for others wishing to use this methodology. Six themes emerge from their analysis and a key theme for me is the ability of the leader to change attitudes towards older people. They argue that the medical paradigm enables older people to be seen as objects rather than independent individuals; the consequence being that older people can develop feelings of powerlessness and helplessness. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 137–139
Editorial
Two papers in this edition Kuo et al. (pp. 225–233) (Taiwan) and Chenoweth et al. (pp. 234–247) (Australia) identify the impact of turnover and retention, the first paper presents an overview in Taiwan and the second focuses on attracting and retaining nurses to work in aged and dementia care. They both identify the importance of a supportive organisational environment as a key factor in reducing turnover and attracting staff. These studies illuminate the work of West (2013) who has clearly demonstrated that staff satisfaction is aligned to patient satisfaction and improved organisational outcomes. The concluding paper in this edition Hardacker et al. (pp. 257–266) (USA) presents an the evaluation of an educational initiative designed to improve the attitudes of carers towards older person that are part of Lesbian, Gay, Bisexual and Transgender cultures (LGBT). It is worrying that they cite a study that states ‘over half of LGBT elders express little confidence that health-care professionals would treat them with dignity and respect’. The final paper on LGBT elderly will be published just as the LGBT history month (Feb 2014) is globally celebrated. Drawing on the first paper in this edition it is critical that nurse leaders and managers support others and are themselves supported, to promote dignity and respect to ensure that all patients and family feel in control, confident and capable to make decisions that affect them. Mike Cook
EDD, MSC (Quality Management), MSC (Education
Management), DIP. N (LOND), CERT ED, RN, RNT, FHEA
Editor, Professor of Healthcare Leadership and Management, Faculty of Health and Social Sciences, University of Bedfordshire, Luton, UK, E-mail: [email protected]
References Baillie L. (2009) Patient dignity in an acute hospital setting: a case study. International Journal of Nursing Studies 46, 22–36. Ballatt J. & Campling P. (2012) Intelligent Kindness: Reforming the Culture of Healthcare. RCPsych Publications, London. Beach C., Sugarman J., Johnson R., et al. (2005) Do patients treated with dignity report higher satisfaction, adherence and
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 137–139
receipt of preventive care. Annals of Family Medicine 3 (4), 331–338. Care home abuses in Southern Ontario, (CCTV news). (2013) Available at: http://www.ctvnews.ca/canada/nursing-homeabuse-incident-not-isolated-say-experts-1.1290010, accessed 1 February 2014. Department of Health. (2013a) NHS Constitution. Available at: http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/the-nhs-constitution-for-england-2013.pdf, accessed 1 February 2014 Department of Health. (2013b) The NHS Friends and Family Test Publication Guidance, Available at: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/ 214941/Friends-and-Family-Test-Publication-Guidance-v2FOR-PUBLIC_E2_80_A6.pdf, accessed 1 February 2014. Francis R. (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. Final Report. Available at: http://www. midstaffspublicinquiry.com/news/2013/02/publication-inquiryfinal-report, accessed 12 February 2014. International Council of Nurses. (2012) The ICN Code of Ethics for Nurses. Available at: http://www.icn.ch/about-icn/ code-of-ethics-for-nurses/codigo-deontologico-del-cie-629.html, accessed 1 February 2014. National Center on Elder Abuse. (2013), Abuse of Residents of Long Term Care Facilities, Research Brief. Available at: http://www.ncea.aoa.gov/Resources/Publication/docs/ NCEA_LTCF_ResearchBrief_2013.pdf, accessed 1 February 2014. Valentine N., Darby C. & Bonsel G.J. (2008) Which aspects of quality of care are most important? Results from WHO’s general population surveys of ‘health system responsiveness’ in 41 countries Social Science and Medicine 66, 1939–1950. Weisel E. (1999) The perils of indifference, seventh white house millennium evening, Washington, In Speeches that Changed the World, (2006) (S. Montefiore ed), pp. 215–219. Quercus Publishing Ltd, USA. West D. (2014) Micromanagement won’t deliver value says business guru. Health Service Journal, Available at: http:// www.hsj.co.uk/news/acute-care/micromanagement-wont-delivervalue-says-business-guru/5066985.article, accessed 12 February 2014. West M. (2013) Developing Cultures of High Quality Care, Available at: http://www.kingsfund.org.uk/audio-video/ michael-west-developing-cultures-high-quality-care, accessed 1 June 2013. World Health Organization. (1994) A Declaration on the Promotion of Patients’ Rights in Europe. European Consultation on the Rights of Patients Amsterdam 28 - 30 march 1994. Available at: http://hospicecare.com/uploads/2011/8/WHO% 20Europe_declaration1994.pdf, accessed 12 February 2014.
139
Editorial Leadership and management challenges in addressing the dignity and respect agenda
This issue focuses on the healthcare leadership and management challenges in promoting and maintaining dignity and respect. People receiving care expect their dignity and respect to be maintained as enshrined within nursing professional codes of conduct. A review undertaken by the World Health Organization across 41 countries, shows that most participants select dignity as the second most important domain from a list of 8, only ‘promptness of care’ was more highly rated (Valentine et al. 2008). The Council of Nurses’ Code of Ethics for Nurses (2012) states that ‘inherent in nursing is respect for human rights. . . including the right to life and choice, to dignity and to be treated with respect’. The Amsterdam Declaration promotes dignity as one of the main rights for patients (World Health Organization, 1994). Developing this edition has made me reflect and think hard about the leadership and management issues relating to dignity and respect. One of the interesting observations is how few papers the journal receives on the dignity and respect agenda that relate to actual patient care. I could have generated several editions of the journal had this been about the dignity and respect agenda for staff. It seems that many authors have studied, and written about the environments in which staff practice. Fewer people are studying and writing about the leadership and management challenges in fostering dignity and respect for patients. Yet this is a significant issue that leaders and managers of nursing and care services spend sleepless nights worrying about and dealing with day to day. Of course many leaders and managers are able to celebrate the care people receive every day, but at times care fails to meet patients’ needs. This puts nurses and nurse leaders at the forefront of the dignity and respect agenda. Much of the care that is provided globally is of the highest standards, delivered by highly educated and attentive staff. Yet I am sure that readers of this journal will be able to identify clear breaches of dignity and respect in their own settings. Some of these ‘breaches’ have become national and international headlines (Francis, 2013), care home abuses in Southern Ontario DOI: 10.1111/jonm.12230 ª 2014 John Wiley & Sons Ltd
(CCTV news, 2013) with some leading centres raising issues of elder abuse (NCEA, 2013). In England, health policy documents increasingly emphasise the importance of compassionate and dignified care. This is largely in response to the Francis Inquiry (2013) that reported significant numbers of examples of patients subjected to gross breaches of their dignity and respect. Partly in response to this inquiry and other significant reports, the National Health Service in England has devised a Constitution (Department of Health 2013a) that includes ‘respect and dignity’ as one of seven NHS values. The contributing authors to this edition collectively provide some important messages. The authors represent nine different countries, and present research across the age ranges, from children’s care to a majority of papers that focus on care for older people. For methodologically inclined readers this edition covers a range of research approaches and includes systematic reviews, quantitative, qualitative and mixed methods studies. No matter what method is used or area is investigated, a resounding message is that promoting dignity and respect requires effective communication at all levels by all involved. The first paper in this edition is by Buchini et al. (pp. 140–150) (Italy) in a descriptive study, capturing the views of staff working in an intensive care ward caring for people in a vegetative state provide an excellent starting point for this edition. They provide clear definitions and state that, ‘when there is dignity people feel under control, valued, confident, capable and able to make decisions. When dignity is absent people feel devalued, out of control and ill at ease’. The authors talk of the need to humanize the hospital, but that this presents a challenge to all nurse leaders and managers thus ‘dignity is often poorly implemented in healthcare facilities’. Baillie (2009) reinforces this by identifying that the physical environment, organisational culture, leadership and healthcare systems are components of the care environment that influence dignity. In this context I would also suggest the work of Ballatt and Campling (2012) on ‘Intelligent Kindness’ as a thought-provoking read. 137
Editorial
Whist preparing this editorial I discovered a recent quote from a leading business thinker, Michael Porter, when referring to health outcomes. He seemingly overlooks patient satisfaction as a desirable outcome to be considered. ‘Whether people were nice to them. . .that’s all good stuff, but it’s not an outcome. The outcome is how the patient does functionally, quality of life, complications, recurrence of disease. . .the actual results’, (West 2014). If this quotation is accurate maybe Professor Porter needs to spend time with nurses and doctors caring for people and review the evidence. Being treated with dignity and being involved in decision-making is associated with positive outcomes (Beach et al. 2005). Experiencing care that ensures dignity and respect is easier to recognise than it is to define or ‘count’. It is more than a set of ‘outcomes’. The next paper Gerasimou-Angelidi et al. (pp. 151– 158) from Greece investigates nursing workload and family satisfaction in an adult intensive care ward. They conclude that family satisfaction should be used as a measure of care quality. This is an important measure especially for vulnerable people that are either afraid or unable to comment on the care they receive. Within England a Friends and Family test has been introduced, (Department of Health 2013b). Patients are asked to rate their response to the question, ‘How likely are you to recommend our ward/ A&E department to friends and family if they needed similar care or treatment?’ Views on this methodology are mixed, however it would be interesting to ask a family member the same question based on their views of the care that their family member experienced. Many papers have been submitted and published by the Journal of Nursing Management on the importance of a supportive climate for nursing staff and its impact on turnover and nurse satisfaction but few papers have examined the impact of nursing workload and its relationship to family satisfaction. Building from this work and looking at the working environment further, Atinga et al. (pp. 159–169) from Ghana explore workplace politics using statistical techniques. They define politics as behaviour strategically designed to maximise the self-interest of individuals or groups in the workplace. The most pertinent finding in relation to this edition of the Journal of Nursing Management is that workplace politics is associated with. . .‘negligent behaviour and improper conduct’. Many papers previously published in this journal clearly identify that the working environment that nurse leaders create is critical to care outcomes. The work of Atigna et al. reinforces this and provides a view from Africa that positive communication is key 138
to improving care. Building on this need for effective communication Cramm et al. (pp. 170–176), (The Netherlands), Aarthun & Akerjordet, (pp. 177–191) (Norway), Rouse & Al-Maqbali (pp. 192–200) (Oman) and Hudson et al. (pp. 201–210) (USA) highlight the importance of communication, shared decision making and user involvement in promoting dignity and respect. They use different methodological techniques and challenge the reader to think differently about care delivery. Rouse &Al-Maqbali examine how effective communication may help to identify nurse manager behaviours that promote dignity and respect. They state that ‘over time, nurses may become socialised to accept a negative work environment that desensitises them to bullying. Rather than passively accept this phenomenon, nurse leaders should work to establish a supportive, encouraging environment that respects the dignity of both patients and nurses’. It is not difficult to hypothesise that those that become desensitised to bullying are less able to identify bullying if it is happening in their environments. Perhaps the famous speech by Elie Wiesel, ‘The Perils of Indifference’ (1999), should be mandatory reading for all those in the caring professions? Hudson et al use the terms ‘Wicked problems’ to explore ‘transitional care’. Transitional care generates a different way of thinking about what many healthcare systems refer to as discharge planning. Wicked problems are characterised by problems that are intractable, inter-related, contradictory, multi-layered and are politically influenced. Indeed this very description defines the working world of most nurse leaders and managers. Reading these three papers provides an opportunity to consider how healthcare can be transformed by adopting different perspectives. One of the common areas of practice presented in this edition relates to care of the older person. Seven papers address this area of practice, this is not surprising given the increasing numbers of older adults. Holm & Severinsson (pp. 211–224) from Norway provide an illuminating systematic review that examines effective nursing leadership and the outcomes of older people in the community. The systematic review in my opinion is undertaken with expertise providing a robust model for others wishing to use this methodology. Six themes emerge from their analysis and a key theme for me is the ability of the leader to change attitudes towards older people. They argue that the medical paradigm enables older people to be seen as objects rather than independent individuals; the consequence being that older people can develop feelings of powerlessness and helplessness. ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 137–139
Editorial
Two papers in this edition Kuo et al. (pp. 225–233) (Taiwan) and Chenoweth et al. (pp. 234–247) (Australia) identify the impact of turnover and retention, the first paper presents an overview in Taiwan and the second focuses on attracting and retaining nurses to work in aged and dementia care. They both identify the importance of a supportive organisational environment as a key factor in reducing turnover and attracting staff. These studies illuminate the work of West (2013) who has clearly demonstrated that staff satisfaction is aligned to patient satisfaction and improved organisational outcomes. The concluding paper in this edition Hardacker et al. (pp. 257–266) (USA) presents an the evaluation of an educational initiative designed to improve the attitudes of carers towards older person that are part of Lesbian, Gay, Bisexual and Transgender cultures (LGBT). It is worrying that they cite a study that states ‘over half of LGBT elders express little confidence that health-care professionals would treat them with dignity and respect’. The final paper on LGBT elderly will be published just as the LGBT history month (Feb 2014) is globally celebrated. Drawing on the first paper in this edition it is critical that nurse leaders and managers support others and are themselves supported, to promote dignity and respect to ensure that all patients and family feel in control, confident and capable to make decisions that affect them. Mike Cook
EDD, MSC (Quality Management), MSC (Education
Management), DIP. N (LOND), CERT ED, RN, RNT, FHEA
Editor, Professor of Healthcare Leadership and Management, Faculty of Health and Social Sciences, University of Bedfordshire, Luton, UK, E-mail: [email protected]
References Baillie L. (2009) Patient dignity in an acute hospital setting: a case study. International Journal of Nursing Studies 46, 22–36. Ballatt J. & Campling P. (2012) Intelligent Kindness: Reforming the Culture of Healthcare. RCPsych Publications, London. Beach C., Sugarman J., Johnson R., et al. (2005) Do patients treated with dignity report higher satisfaction, adherence and
ª 2014 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 137–139
receipt of preventive care. Annals of Family Medicine 3 (4), 331–338. Care home abuses in Southern Ontario, (CCTV news). (2013) Available at: http://www.ctvnews.ca/canada/nursing-homeabuse-incident-not-isolated-say-experts-1.1290010, accessed 1 February 2014. Department of Health. (2013a) NHS Constitution. Available at: http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/2013/the-nhs-constitution-for-england-2013.pdf, accessed 1 February 2014 Department of Health. (2013b) The NHS Friends and Family Test Publication Guidance, Available at: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/ 214941/Friends-and-Family-Test-Publication-Guidance-v2FOR-PUBLIC_E2_80_A6.pdf, accessed 1 February 2014. Francis R. (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. Final Report. Available at: http://www. midstaffspublicinquiry.com/news/2013/02/publication-inquiryfinal-report, accessed 12 February 2014. International Council of Nurses. (2012) The ICN Code of Ethics for Nurses. Available at: http://www.icn.ch/about-icn/ code-of-ethics-for-nurses/codigo-deontologico-del-cie-629.html, accessed 1 February 2014. National Center on Elder Abuse. (2013), Abuse of Residents of Long Term Care Facilities, Research Brief. Available at: http://www.ncea.aoa.gov/Resources/Publication/docs/ NCEA_LTCF_ResearchBrief_2013.pdf, accessed 1 February 2014. Valentine N., Darby C. & Bonsel G.J. (2008) Which aspects of quality of care are most important? Results from WHO’s general population surveys of ‘health system responsiveness’ in 41 countries Social Science and Medicine 66, 1939–1950. Weisel E. (1999) The perils of indifference, seventh white house millennium evening, Washington, In Speeches that Changed the World, (2006) (S. Montefiore ed), pp. 215–219. Quercus Publishing Ltd, USA. West D. (2014) Micromanagement won’t deliver value says business guru. Health Service Journal, Available at: http:// www.hsj.co.uk/news/acute-care/micromanagement-wont-delivervalue-says-business-guru/5066985.article, accessed 12 February 2014. West M. (2013) Developing Cultures of High Quality Care, Available at: http://www.kingsfund.org.uk/audio-video/ michael-west-developing-cultures-high-quality-care, accessed 1 June 2013. World Health Organization. (1994) A Declaration on the Promotion of Patients’ Rights in Europe. European Consultation on the Rights of Patients Amsterdam 28 - 30 march 1994. Available at: http://hospicecare.com/uploads/2011/8/WHO% 20Europe_declaration1994.pdf, accessed 12 February 2014.
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