The dignity and privacy of patients
The Healthcare Commission's recent publication on patient dignity has underlined the importance attached to delivering a service underpinned by quality rather than quantity.1 The executive summary implied that the failure to achieve these standards was a reflection of an insensitive culture derived from poor training and monitoring skills in the nursing establishment. My surprise was to find that these nursing skills, previously well embedded in nursing practice, had apparently been forgotten. In order to acquire their data the Commission had to rely on a mixture of patients' complaints, whistle blowing members of staff and spot visits by the Commission's agents. Short of having 24/7 comprehensive CCTV footage of all clinical areas, this was the best available evidence for their report. However, most patients are unaware of the issues being studied and usually would not complain unless there was a persistent problem, nursing staff are wary about whistle blowing for fear of reprisals, and spot checks, even if they are 'unannounced' are never carried out between 22.00 and 08.00 when the pressures on nursing staff may be greatest. In view of the limitations of the methodology employed it is hard to see how they were able to exclude the effects on their conclusions of politically motivated targets such as surgical waiting lists, A&E waiting times and financial solvency. Furthermore the availability of accommodation appropriate to the patient's needs was completely overlooked. Their statement that hospitals were 99% compliant with the delivery of single sex accommodation sounds too good to be true. In emergency medicine most difficulties are encountered in finding a high dependency bed in a gender sensitive bay on a specialty appropriate ward. High dependency relates to the close proximity of nursing staff able to observe and assist seriously ill patients. Low dependency areas can be used for high dependency patients but only when accompanied by an increase in the nursing establishment. Since that usually can not be implemented at a moment's notice, issues of dignity and privacy may be compromised in order to give priority to the seriousness of the patient's medical condition. I cannot remember, when we had same sex (Nightingale) wards, ever having to accommodate a female medical patient on a male ward or visa versa. It did mean that average bed occupancy in those wards was well below the 95% plus average bed occupancy which we have today. Low bed occupancy during the summer months when demand for nursing staff holidays was greatest did mean that wards could be closed for deep cleaning and redecoration in a cost effective way without having to compromise the service to patients. The move to unisex wards with flexible, gender 'specific' bays and a higher percentage of single rooms should have improved the quality of patient accommodation had it not been accompanied by an overall reduction in bed numbers. It is clear that those decisions were made by bean counters and not by the doctors and nurses involved at the coal face. Difficulty in finding the accommodation appropriate to a specific patient's needs and the health and safety of others is the legacy of those decisions to maximize bed occupancy. The standard of accommodation espoused by NHS Estates is rarely available today except in recently built or comprehensively reengineered wards. Their recommendations included four bed bays with en suite toileting facilities and an increase in the proportion of single rooms to 30% or more of the total available beds instead of the usual 20% or less. In contrast to these recommendations, single room accommodation on medical wards in our Trust has fallen from 20% in 1986 to 15% in 2007. Although the report dealt mainly with the process of delivering patient dignity and privacy in a sensitive and caring environment to an elderly population, these issues are not confined to delivering nursing care to the elderly, particularly when the decision to regard a patient as elderly is arbitrary and relates to management directives specific to a particular Trust. Having to release one's emotions or bodily functions in a public arena will cause personal distress and a mixture of stress, annoyance, embarrassment, disgust and fear in one's neighbours. The appropriate application of standards of dignity and privacy to hospital patients should be aimed at avoiding these unpleasant experiences. I would suggest that it is exceptional for nursing staff to have an attitude problem or lack the necessary training regarding issues of dignity and privacy, and that the problem is rather that their managers have failed to acknowledge the deficiencies in the fabric of the environment in which care is being offered. It is incumbent upon managers not to be in denial of the structural inadequacies of their hospital buildings and to seek additional funding so that they can more readily achieve compliance with patient dignity, privacy and sensitivity without exposing their staff to an intolerable level of stress.
Journal of the Royal Society of Medicine