Policy and guidance recognise the importance of dignity in healthcare (Department of Health and Social Care (DHSC), 2015; Dignity in Care, 2019). A quality indicator from the National Institute for Health and Care Excellence (NICE) states that nurses and health professionals should ‘treat patients with respect, kindness, dignity, compassion, understanding, courtesy and honesty’ (NICE, 2012; 2021). However, by noting that dignity is an indicator of quality, there is a danger that it may be viewed as an optional extra, rather than a standard element of care. In practice, caring for patients with dignity is mandated through professional codes of practice for nurses (International Council of Nurses (ICN), 2012; Nursing and Midwifery Council (NMC), 2018), yet dignity remains difficult to define (Social Care Institute for Excellence (SCIE), 2020) and, of course, operationalise.
To date, most empirical explorations of dignity in healthcare settings have been undertaken outside of the community nursing context. Existing studies focus on dignity in acute hospital services (e.g. Zahran et al, 2016) or dying with dignity (e.g. Hemati et al, 2016). There remains a lack of research into dignity experienced by community-based older adults (Black and Dobbs, 2014), although Stevens et al (2021) previously recognised the ‘dignity encounter’ as a helpful concept in community nursing care.
District nursing services are a vital part of NHS care (Maybin et al, 2016) and, as care is delivered in the home, community nurses are well placed to develop close relationships with their patients (Griffith, 2016). It is through these relationships that dignity can manifest in care practices. Respecting patient dignity is a long-established principle of healthcare (Matiti, 2015; Zirak et al, 2017); nonetheless, it has been suggested that patients, families and nurses continue to experience indignity in care settings (Gallagher, 2009).
This paper explores dignity in a community nursing context by considering how a routine community nursing task-dressing parts of the body-offers an opportunity for dignity to manifest. The delivery of wound care is a major element of community nurses' workload and, although the importance of patient dignity in wound care is recognised in the acute clinical environment (National Wound Care Strategy Programme, 2021), it is less well acknowledged in community settings. Here, the authors argue that wound care can offer significant opportunities for acknowledging and validating the dignity of patients in community settings.
Methods
Community nursing is not appreciated outside the professional group (Drew, 2011); therefore, this study adopted an ethnographic methodology, because it offered potential for community nursing culture to be revealed to outsiders. The methodology was also selected because it enabled a means of understanding the ways in which individuals within the system of community nursing (nurses and patients) understand and operationalise the micro-processes and macro-considerations of dignity in community-based care. Data were collected between July and October 2017, in which 470 hours of fieldwork was undertaken in an urban community district nursing team in the north of England. Two research methods were used: observations of clinical interactions (n=62) between 13 nursing staff and 40 patients (aged between 60 and 93 years) and semi-structured interviews with 11 nursing staff and 11 patients. Nurse participants were all clinical staff ranging from a healthcare assistant to the senior nurse within the team.
Iterative thematic data analysis was undertaken in line with qualitative and ethnographic approaches proposed by Braun and Clarke (2006; 2013) using QSR NVivo software. This paper uses both excerpts from interviews and observational descriptions to best illuminate the findings.
Ethical approvals were received from the University of Hull, Faculty of Arts and Social Sciences on 23/6/2016 and Yorkshire and the Humber-South Yorkshire NHS Research Ethics Committee on 13/3/2017 (Ref: 17/YH/0009; IRAS ID: 21677). To maintain confidentiality, all participant information was anonymised at source, and pseudonyms have been used throughout.
Results
Embodiment of dignity through deconstructing dressings
Although there is limited literature exploring embodied experiences of dignity, as bodyworkers, nurses have the potential to both underpin and undermine dignity during physical aspects of care; dignity can thus be considered a profoundly embodied experience.
Dressings are a commonplace task in community nursing practice. In a nursing context, the word ‘dressing’ itself is often used to describe the process of putting something on, specifically describing the act of putting on a bandage which is designed to healing wounds (Dhivya et al, 2015). In this study, nurse participants used the word in a variety of ways, for example, to denote a process (e.g. ‘I'm doing a leg dressing’) or an item (e.g. ‘the dressing covered the wound’), or, in its most reductionist form, it was used to denote the person-effectively distilling them down to a discreet nursing task (e.g. ‘they are a bilateral leg dressing’).
The process of preparing for and undertaking leg dressings offers important insights into the ways in which dignity can be co-created in the context of this everyday nursing task.
When bandaging the legs, nurses seated themselves at the feet of their patients, a low body position which, perhaps, constitutes a physical marker of submission (something that would be far less evident when nursing in a hospital setting). In preparation to re-dress legs, nurses were observed laying out a sterile field often on the floor, but sometimes on nearby furniture before they commenced unwrapping the previous dressing and washing patients' feet and legs. This presented opportunities to engage patients in conversation, and it was often during these mundane moments that nurses were able to lay the essential foundations for dignity to manifest in relational aspects of care.
‘I look forward to them coming cos we have a little chat, you know, while they're tending my leg … we have a little chat.’
(Judy, age 93 years)
‘I go put kettle on, [saying] “we'll put kettle on, we'll do your dressing, and I'll make you a cup of tea.” That means the world to somebody. And we are a nation of, “oh a cup of tea, cup of coffee” solves everything … and it's that chat while you're doing a dressing.’
(Denise, nurse)
Denise's quote demonstrated one of the wider caring actions that nurses can undertake, but also suggested that she perceives that making a drink for patients is important, as it reflects their shared understanding and cultural assumptions. Both these participant quotes illustrate the importance of non-clinical elements of community nurses' work in creating a positive climate for dignity to thrive and the significance of interpersonal engagement that contributes to ensuring clinical care is given and received with dignity.
For nurse participants, the dressing process was perceived as a routine undertaking, imbued with clinical and professional meaning; however, for many patient participants in this study it was simultaneously a potential source of both pleasure and pain.
‘[Nurses] get the cream out, you see, and they start rubbing it on my leg and rubbing it under me foot and, ooh, it's so lovely. So lovely. And erm, they do it a bit more when you say it's nice [laughs].’
(Antonia, age 83 years)
‘I wash down every morning and, course, I can't wash that [bandaged leg] … oh, it feels lovely when they [nurses] put the warm water on it.’
(Judy, age 93 years)
In daily life, the primary purpose of washing may be to maintain cleanliness and hygiene, but a secondary outcome, which is reflected in Antonia and Judy's quotes, is sensory/human pleasures resulting from the process. During observational visits, community nurses stopped washing once they were satisfied, rather than consulting with their patients to negotiate when it would end. This contributed to making washing a medicalised process that was directed by clinicians, distancing the action from an activity that was recognised as offering pleasure to patients.
When washing, nurse participants were observed to touch their patients gently, although when the cleaning process involved descaling dead skin, their touch became firmer and more focused. They described this as ‘picking’, and while some nurses gained satisfaction from this, others simply endured it as part of the job but gained no pleasure from the task. If they enjoyed this process, nurses labelled themselves ‘pickers’, also describing the descaled skin as ‘cornflakes’ or ‘cornflakes in milk’ when emollients were applied. Mary revealed that some patients also picked their legs, and, although it involved the same physical act, this was not ‘clinical picking’ to promote healing. She stated that it was undertaken to actively slow the healing process, thereby sustaining patients' contact with nurses for longer and avoiding discharge. Hence, ‘picking’ served multiple purposes at different times. It was professionalised when undertaken by nurses as a means of promoting healing, yet, when patients engaged in the same activity, the nurses viewed this as a means to demand their attention and sustain contact. ‘Picking’ offered patients the opportunity to reassert some control over their body and potentially reduce their loneliness if this ensured they received additional time and attention from nurses. ‘The things people will do to stop being lonely …,’ Mary explained.
‘I've had patients in the past that are lonely and they don't want their wounds to heal, and … you might go one day, and you'll be like, “it's nearly healed-great! We'll be able to discharge you soon”, and then you'll go the next week and it'll be as bad as ever. You'll get the ones that'll actually like sabotage their wounds, do you know, because they don't want the district nurse to stop coming.’
(Sheila, nurse)
As described by Mary and Sheila, there may be occasions where patients sabotage their physical health to retain contact with community nurses. In these circumstances, there are inherent dangers for dignity, as nurses appeared focused on elements of physical health (i.e. healing the wound), rather than recognising or addressing the dignity disruptions that may be occurring through their patients' potentially harmful behaviours.
Managing the ‘leaky’ body
Personal body maintenance is a social obligation and, generally, a necessary prerequisite for engagement in the wider world. When bodies fail or escape their customary boundaries (through leakages, for example), nurses aim to heal by undertaking necessary bodywork to manage and control leakage. Embodied identities can become disrupted when previously healthy bodies become ill, and a lack of bodily control, often associated with an ill body, fails to outwardly reflect internal dignity, making the management of bodily leakage an important dignity consideration. Further, leaky bodies often smell, and the successful concealment of leaky or ill-bodies was, understandably, commonly identified by patient participants as critical for the maintenance of dignity.
‘When I had that … erm … thing on my foot [exposed tendon] what she's taken off now … it was rotting, you see. I just thought, [whispering] “oh my God, is that what the nurses have to smell everyday?”’
(Antonia, age 83 years)
‘I get a bit embarrassed … I always think people can smell it, are you with me? So, I'm always spraying. That's all, all I seem to do is spray, spray, spray.’
(Barbara, age 77 years)
With regular bodywork from nurses, bandaging can promote healing, but dignity can simultaneously be stabilised through the successful containment of any malodour. To preserve their patients' dignity, nurses recognised that, even when smells were present, it was important that they themselves did not overtly display any discomfort, which illustrates the emotional labour involved in their work.
‘Sometimes, you see things and you wanna vomit or … it makes you gurge [sic] … like the smell of wounds or like certain things. But you've just got to keep it hidden.’
(Sapphire, nurse)
‘You just think, “urgh!” Like I'm there, trying to act like it's normal … because it's normal to them, but like if it smells.’
(Chloe, nurse)
‘Cancer was kind of eating away his abdomen, and it was really smelly.’
(Daisy, nurse)
These honest reflections illustrate the nurses' implicit disgust, but explicit acceptance in scenarios in which bodily odours become a potential threat to dignified care delivery. Nurses concealed their revulsion, and, at times, preferred to simply deny the presence of smells to their patients, which may have avoided a difficult conversation, although this did not go unnoticed.
‘When they're unwrapping me leg and I'll say, “oh my God [it smells]”, and they'll say, “We don't smell it. We don't notice it.” It calms me down a bit cos I think it is bad … but they never, ever refer to anything.’
(Antonia, age 83 years)
For 18 months, Antonia had received daily nursing visits for a leg dressing. In one observation, Antonia revealed, ‘I am really conscious of smelling’. Her pained expression slowly softened as her nurse Sapphire reassured her that there was no smell. The observer (ES) was seated significantly further away but could smell, and almost taste, the necrosis from Antonia's leg. When Sapphire denied the presence of smell, dignity could remain intact through their joint complicity in avoiding the acknowledgement of malodour.
There was only one observation in which a nurse participant acknowledged bodily odours to a patient. In this observation, nurse Rina unwrapped a patient-Michelle's-leg dressing and remarked that it smelled a bit. ‘Don't say that!’ Michelle hastily retorted, and the conversation was over. The atmosphere immediately became frosty, and Michelle's tensed muscles and rigid frame visibly demonstrated her embodied reaction. The nurse had unwittingly made a statement that destroyed the image of an odour-free scene, which disrupted, if not shattered, her patient's dignity. In this scenario, it was the verbal recognition of bodily malodour and not necessarily the presence of smell itself that hindered the dignified delivery of care. Therefore, careful acknowledgement, discussion and management of bodily odours are crucial in ensuring that community nursing care is received with dignity.
For dignity to manifest, nurses must ensure their patients retain autonomy and agency when they are managing the ‘leaky’ body. Antonia was confident in informing her nurses how she liked her dressing done, and, during the observations of her care, each nurse readily obliged. It was important to Antonia that the nurses allowed her to direct them, demonstrating her agency and enabling her to retain control over her body, which is evidently important for ill bodies that are, ostensibly, out of control.
‘I could quite easily wrap me leg up meself cos I've got all the equipment, and I know exactly what they do [laughs] but, er, and I would if it was absolutely necessary.’
(Antonia, age 83 years)
Reinforcing her sense of agency, Antonia explained how one time, a ‘blunt’ nurse did not take kindly to her explaining how she liked things done.
‘When they're doing my leg, [the nurse] would go, “ugh, ooh, ugh–don't touch! You'll get infected!” I'm not gonna touch, I'd never touch. I'm just showing you where I want it to be. But that, she always blew up if I tried to do that and erm, then one time I think I told her about something, and she said, “I know what I'm doing”. So, to me, that was a real blunt reply. She didn't want me to be taking part.’
(Antonia, age 83 years)
Antonia's dignity depended on her active participation in these tasks, which normalised the dressing process. Antonia wanted an active role in her care, not passively allowing the bandaging to be done to her; she felt it should be done with her. The ‘blunt’ nurse's attempts at dissuading Antonia from touching illustrated how Antonia's body was no longer entirely under her own control; it had been displaced to the nurse's jurisdiction, which raises issues of who assumes ownership of the body in these scenarios. The nurse had dictated what was appropriate (her own clinical touch) and inappropriate (touch from Antonia, which could result in infection or harm). This nurse had appropriated control of Antonia's body, preferring the patient to keep out of her own bodily business, and, in turn, this disrupted and undermined Antonia's sense of dignity. In this context (much like the earlier example of ‘picking’), when undertaken by clinicians, ‘touch’ became professionalised and legitimate, but the activity was invalidated when undertaken by patients, and this difference in perception is a potential threat to dignity.
Practice recommendations
Dignity is not a universally agreed concept which presents challenges for community nurses who aim to deliver dignified nursing care across a diverse range of patient groups.
It is sometimes the most difficult conversations which can present opportunities for dignity to fully surface in clinical encounters, as this paper has demonstrated in the context of bodily malodour. Thus, a willingness to engage openly and honestly with patients is obviously the starting point for dignified clinical and person-centred care. However, a key issue is the ability and openness to recognise that opportunities to create the conditions for dignity to flourish can appear in what, at first sight, might be unlikely ‘dignified’ situations. These circumstances can arise during clinical tasks (such as dressing wounds), where there is the opportunity reinforce somatic dignity, but, also through relational aspects of care in which good communication, kindness and compassion can ensure that patients experience care with dignity.
Conclusion
This paper has demonstrated how community nursing activities are inherently laden with dignity possibilities, as exemplified by considering the common tasks of undertaking wound dressings. Dressing an ill body involves several stages, including washing and bandaging, but it is in both the clinical and non-clinical (relational) aspects of care delivery that dignity can manifest. Nurses undertake medicalised washing primarily to ensure that the ill body is clean in preparation for dressing, but patients acknowledge that this as an important time to converse with their nurses and to gain sensory pleasures from a part of their body that usually remains untouched, which can reinforce their dignity through positive engagement with their nurses.
Dressings go hand-in-hand with leaky or malodourous ill bodies. In this study, patient participants consistently reported that it was bodily malodour (as a result of their health condition) that presented a specific challenge to the creation and maintenance of their dignity. Consequently, to reinforce dignity, leakages must be hidden, they should not be observable by others, nor should odour accompany any leakage, as nurses can reinforce dignity by stemming the tide.
The intersection between dignity, dressing and malodour becomes apparent during relational aspects of care delivery. This is exemplified by scenarios in which speech identifies the presence of malodour – it is not necessarily the smell per se that diminishes dignity, but it is the verbal recognition of odour that can disrupt dignity and, in these situations, dignity can remain intact if the taboo remains unspoken. Thus, the way spoken language is employed also illuminates the fragility of dignity, when ill-thought words or misconstrued speech and deeds can quickly destroy dignity in nursing relationships. Malodour is an affront to dignity. As smell is invisible, it can potentially remain an unspoken secret, yet it is the nurses' dilemma to consider how to address the presence of malodour with their patients. It is during these interactions that disruptions to dignity may occur, but they simultaneously offer great potential for dignity to thrive.
KEY POINTS
- Experiences of dignity are embodied, in that, they are relative to the individual body that experiences them
- The ill-body does not always behave in a socially acceptable manner, and a lack of bodily control can undermine patients' dignity
- Malodour associated with certain types of wounds is a particular threat to patients' dignity
- Community nurses can reinforce dignity through relational aspects of care
CPD REFLECTIVE QUESTIONS
- How do you support patients' dignity in your practice?
- How can you ensure patients' dignity is maintained when you engage them in conversations about their bodies?
- How can you mentor student nurses to offer care with dignity?