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How a patient’s human rights influence the care you give

A human rights approach to healthcare can empower patients and protect nurses

A human rights approach to healthcare can empower patients and protect nurses

  • The Human Rights Act can give nurses a basis for challenging health inequalities and inappropriate service provision for patients
  • This framework helps nurses to ensure people are treated with dignity and respect
  • Human rights features in many new policies and strategies, but is fundamentally about delivering good care and treatment
Picture depicts the medical symbol of a staff with snakes curled round it and scales of justice suspended from it balancing medicine and law books. Nurses are advocates for their patients, service-users, and a human rights approach is essential.
Picture: Alamy

Imagine you are a district nurse with a new patient, an older man who needs regular dressing changes and who is living alone in a rural location. So far, so normal. But what is unusual is that he lives in a stable, sleeping on the floor along with the horses.

Looking around his living quarters, you realise there’s clearly an infection risk if you do the job you’ve come to do, so how do you ensure he gets the care he needs?

    This was a real-life dilemma raised by a participant in a training workshop on applying a human rights approach to healthcare. And the solution, says Jacqui Graves, who led the training, was to use a human rights framework.

    ‘It’s not a nurse’s place to judge’

    ‘The nurse had to look after someone who lived in a stable,’ says Ms Graves, a nurse who is now human rights lead for the Sue Ryder charity. ‘And I don’t mean they were a stablehand and lived above a stable – their home for 25 years had been a stable, where they slept on straw.

    ‘When she was doing the wound dressing, they had to have a conversation about whether or not there was any level of compromise because of wound infection. But ours isn’t to judge whether he should live like that.

    ‘We may have an opinion, but he’s lived like that for 25 years and it’s not our job to say it is unacceptable and we won’t do your wound care because you’re living like this.’ 

    What’s covered by the Human Rights Act

    Taking a human rights approach to healthcare is almost mainstream in 2019. It features in recent strategies, policies and publications designed to improve the way people are cared for in health or social care settings.

    But what does it actually mean? And what impact does it have on nursing practice?

    ‘Human rights are about making sure people are treated with equal dignity and respect, and providing a framework for understanding these values’

    Sanchita Hosali, director of the British Institute of Human Rights

    Essentially, it boils down to the provisions of the 1998 Human Rights Act. The legislation took 16 of the fundamental human rights listed in the European Convention on Human Rights and enshrined them in UK law.

    The areas covered include the right to life, the right to liberty, and the right to family life. Public authorities, including the NHS and local and national government, have a legal duty to comply with the Human Rights Act.

    A legal framework for respectful and dignified care

    Sanchita Hosali, director of the British Institute of Human Rights (BIHR). Nurses are advocates for their patients, service-users, and a human rights approach is essential.
    Sanchita Hosali, director of the
    British Institute of Human Rights

    Why should nurses take an interest in human rights? ‘That’s a good question, particularly as I don’t think it’s always the first place people go to, especially in delivering health and social care,’ says director of the British Institute of Human Rights (BIHR) Sanchita Hosali.

    ‘But when we work directly with nurses and other healthcare professionals and start unpicking what human rights are, and how they work, we find that delivering good care and treatment is what it’s all about.

    ‘Human rights are about making sure people are treated with equal dignity and respect, and providing a framework for understanding these values. Rather than using your own personal or moral compass about what might be dignified or respectful, there’s a legal framework that can support that.

    ‘For front-line staff, particularly nursing staff, who have to make difficult decisions every day and sometimes challenge the decisions of other professionals, it gives them strong backing to be able to say: “I’m not sure that this is the right approach here, can we do something differently?”

    ‘A lot of the nurses we work with say it stops them being seen as a troublemaker and more as a proactive force within the service. It gives them back a bit of power as well.’

    The BIHR works with many organisations, including NHS bodies, to deliver training in human rights. It has also developed resources particularly aimed at nurses, including Nursing and Human Rights: A Practitioner’s Guide, which contains a useful summary of the law and the particular aspects that have most relevance to delivering healthcare, whatever the setting.

    It also contains practical information about when and how nurses should raise concerns if they are worried about a potential breach of the human rights of a patient or service user, or of a healthcare professional.

    What is a human rights approach?

    Sanchita Hosali, director of the British Institute of Human Rights, explains the fundamentals of human rights in healthcare and a human rights approach:

    • Our human rights are the basic rights and freedoms we have because we are human
    • A human rights-based approach provides a legal framework that nurses can proactively use to share decision-making with their patients
    • It is an approach that moves beyond risk management to positively embed and promote the autonomy, freedom and dignity of our service users
    • Human rights is not just about values, it is underpinned by law. The Human Rights Act places a legal duty on public officials – including nurses – to uphold these standards by respecting our human rights in everything they do
    • These include ensuring that patients are free from serious harm, abuse or neglect, and respecting their private life by giving them choice and control over what happens to them

     

    Nicky Philips, head of care at Stagenhoe Neurological Care Centre, a Sue Ryder facility. Nurses are advocates for their patients, service-users, and a human rights approach is essential.
    Nicky Philips: ‘I had reservations
    at first about human rights training’

    ‘Human rights training is about involving people in their care’

    Nicky Philips, head of care at a Sue Ryder facility in Hitchin, Hertfordshire, was one of the first to complete training on a human rights approach to end of life care developed by the BIHR and Sue Ryder and offered free to healthcare workers across the UK.

    Although she was sceptical at first about whether the course would add anything to her practice at Stagenhoe Neurological Care Centre, she was soon won over and believes it is applicable to all areas of healthcare, not just the end of life.

    ‘I did have some reservations,’ says Ms Philips. ‘There’s been lots of information in the news about human rights, but for me it was how it was going to work in a service like ours where all our care is already person-centred, which is the foundation of human rights. It was about what information I could gain to support our residents even further.

    ‘A human rights approach is essential – it’s fundamental to everything we do on a daily basis’

    Nicky Philips, head of care at a Sue Ryder facility

    ‘But it was interesting. Talking through some scenarios and case studies brought home how important it is that we involve people in their care, and that rather than “do to” we “do with”, so they are involved and supported through all conversations and decisions. Together we are a bigger force.’

    Case study: Challenging unsanitary housing conditions of service user

    A district nurse was concerned about the living conditions of a man with learning disabilities. He lived in a small, single room and his shower wasn’t working, meaning he had to use just a hand towel and bowl for washing. The toilet was also close to the bed.

    Ensuring access to proper washing facilities should have been a high priority for his housing provider, as he often soiled himself. The man was paying for his accommodation with some assistance from a support package arranged by social services. The nurse raised her concerns with them first but they refused to accept there was anything wrong with his living arrangements.

    A district nurse used a human rights approach to challenge the living conditions of a client with learning disabilities
    Picture: iStock

    Nurse consulted the equalities team

    The nurse talked to the equalities team at her local NHS trust. The trust had been working with the British Institute of Human Rights, which explained that the Human Rights Act might be relevant.

    It suggested that the man’s living arrangements could be infringing his human rights, specifically his right to respect for private life (Article 8) and his right not to be treated in an inhuman and degrading way (Article 3).

    It explained that his right to private life might be compromised by the cramped and unsanitary state of his room. The fact that he often had to spend long periods of time covered in his own faeces, with no suitable way of washing himself, also meant he was potentially experiencing inhuman and degrading treatment.

    Using human rights language changed the conversation

    With some concrete information about the man’s human rights and the local authority’s duty under the Human Rights Act to respect them, the district nurse was able to return to social services and take her concerns to the housing provider. She suggested that the man’s rights were at risk due to his living arrangements, and that both services had a duty to protect his dignity.

    Framing the situation using human rights language changed the conversation in this case. Social services reconsidered its initial response to the concerns and found new accommodation that was more suited to his needs. He now has more space and proper washing facilities, and his quality of life has improved.

    Source: British Institute of Human Rights

     

    Taking a restrictive view of someone’s care can be a human rights violation

    Proportionality and an informed attitude to risk is an important part of a human rights approach. Taking a restrictive view of someone’s care can be a human rights violation, no matter how well-intentioned it is.

    This can include blanket policies of giving every resident with a neurological condition a DNAR (do not attempt resuscitation) form, regardless of individual wishes – although this hasn’t been the norm for a number of years – or insisting that all residents have CCTV in their room.

    Stressing the right of individuals to make decisions that involve some risk – such as walking rather than using a wheelchair – is part of the advocacy role. ‘We promote independence for as long as possible,’ says Ms Philips. ‘It’s about positive risk, enabling not disabling people.

    ‘Over half the residents here have Huntington’s disease. It can be quite difficult with this condition because we’re all about promoting independence. When you’ve got a condition with an unsteady gait and involuntary movement, with an extremely high risk of falls, promoting independence is challenging and we do have injuries. 

    ‘Our residents know what they want,’ she adds. ‘So when they fall and go off to hospital, the first thing the hospital does is call in the safeguarding team. We struggle with that sometimes.’

    Case study: Unreliable allegations breach nurse’s rights

    A nurse was accused by healthcare assistants of neglect and ill treatment. She said the allegations were made maliciously, and an investigation found they were unreliable.

    The nurse was interviewed by the police, and the Crown Prosecution Service decided there was insufficient evidence to take action. She resigned, but when she applied for another nursing job her Criminal Record Bureau check disclosed the allegations and she was refused employment.

    The nurse used Article 8 of the human rights legislation to argue that her right to respect for private life had been interfered with by the police’s decision to disclose the allegations. The court said that balancing the interests of patients to be free from ill treatment and negligence against the harm caused to the nurse by the disclosure was particularly sensitive where allegations had not been substantiated and were strongly denied.

    The court found that on balance the disclosure breached the nurse’s Article 8 rights.

    Source: British Institute of Human Rights

     

    Working with the patient to reach the best decision

    So what happened to the man in the stable? Ms Graves says that in the end the nurse negotiated with him to go to the farmhouse to have his dressings done there.

    ‘That’s taking a human rights approach, because you’re saying “I’m not judging you, but I need to care for you in a way that’s not going to make an infection or anything else worse. So how do we, as two human beings, compromise and come to the best decision we can in these circumstances?”.’

    Image shows abstract representation of people dancing in a circle around the figure of a woman. Nurses are advocates for their patients, service-users, and a human rights approach is essential.
    Picture: Alamy

    She adds that a key part of a human rights approach to nursing is leaving our own biases to one side, however right you may believe you are.

    ‘We will all have our own moral and ethical compass. It may come from how we’ve been brought up by our parents, from religious teachings and our faith, culture and spirituality, how we are as a human being – it will be made up of hundreds of components.

    ‘We need to understand our own biases and prejudices and then embrace and support someonewho may have a different framework’

    Jacqui Graves, nurse and human rights lead for charity Sue Ryder 

    ‘But when we’re in a care-giving situation, we almost need to park our own moral and ethical compass in order to understand that someone else may have a different compass. That doesn’t make us right and them wrong, it just means that we need to understand our own biases and prejudices and then embrace and support somebody who may have a different framework.’

    And that, says Ms Philips, is what nursing is all about. ‘I think a human rights approach is essential – it’s fundamental to everything we do on a daily basis. As nurses, we are advocates for our patients, service users and residents. We have to work with them to ensure they get the care they want and need. A human rights framework helps us do that.’

    Case Study: Restraint and a ‘best interests’ decision

    A community learning disability nurse used the Human Rights Act as a framework to help make a ‘best interests’ decision.

    The nurse was supporting a woman with a learning disability who was experiencing severe pain from suspected gallstones but did not want a blood test. The nurse had to make a best interests decision about using restraint to allow the test.

    The nurse said: ‘I’m uncomfortable using restraint as it has been used to control people in the past. But the Human Rights Act gave me the confidence to intervene, knowing that we were taking reasonable steps to protect the patient’s right to life and right to be free from inhumane and degrading treatment, and that we were using restrictions proportionate to the situation.’

    The nurse also challenged hospital staff on their decision to exclude the woman’s family from the best interests meeting, citing her right to private and family life.

    This made a difference because the service user had a close, trusting relationship with her brother and he was able to support her during the interventions, minimising the impact of restrictions on her physically and psychologically.

    Source: British Institute of Human Rights


    Jennifer Trueland is a health journalist


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