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Report on Privacy _ Dignity in hospitals_ with particular

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					Report on Privacy & Dignity in healthcare settings, with
recommendations for Addenbrooke’s Hospital – 12th October 2006


Introduction

Many of us can list occasions and situations where the privacy or dignity of individuals has
been compromised. It is harder to recall positive examples. Privacy and dignity are concepts
more noticeable in their absence than when fully respected. Dignity in the context of this
report is fundamentally about feeling and being treated as a valued individual. Privacy is about
the right to have our personal information, bodies and possessions respected.

Many reports of infringements of privacy and dignity relate to older people, or to people who
are particularly vulnerable. People aged over 65 make up more than 40% of emergency
admissions and more than two thirds of hospital patients. It is generally assumed that this
group of people are the least likely to complain about care they receive. Whether or not this
assumption is valid, there are certainly many patients who do not offer feedback to NHS staff.


Background Information

In 2001, the Department of Health published the Essence of Care: Patient-focused
benchmarking for healthcare practitioners. The Essence of Care framework addresses ten
fundamental aspects of care and was developed for use by healthcare personnel to ensure
that patient-centred care is available and evident to all who experience healthcare services.
The Essence of Care Privacy and Dignity Benchmarks state that best practice requires:
 Patients feel that they matter all of the time
 Patients experience care in an environment that actively encompasses individual beliefs,
    values and personal relationships
 Patient‟s personal space is actively promoted by all staff
 Communication between staff and patients takes place in a manner that respects their
    individuality
 Patient information is shared to enable care with their consent
 Patient care actively promotes their privacy and dignity and protects their modesty
 Patients and/or carers can access an area that safely promotes privacy

Balancing the rights of an individual with the needs of others is challenging in a hosptial
setting. Even in a small ward or bay, use of telephones, visits by relatives or walking past
other beds can be intrusive. Closed curtains can feel isolating, but information boards showing
dietary requirements or health issues can make a patient feel vulnerable.

Particular problems for older people include lack of control over medication, exposure of the
body during examination, mixed wards or facilities and lack of appropriate personal care.


Research

The Addenbrooke‟s PPI Forum has collected information and contributions from a wide range
of people and sources. We have invited guest speakers to Forum meetings to discuss areas
such as Care of the Elderly in hospitals and nursing of terminally ill patients in their own
homes. The staff of Addenbrooke‟s Hospital have been helpful and constructive in this area of
the Forum‟s working. Speakers have attended Forum meetings, given insights into their work
and answered members‟ questions. A member of the Forum has also been able to attend the
hospital‟s own Privacy & Dignity Working Group.

The Forum organised a mini-conference on Privacy and Dignity with representatives from
Addenbrooke‟s Hospital, PPI Forums, statutory bodies and voluntary organisations. Focus
groups were given a selection of case studies and discussed:
1) Quality of Patient Experience
2) Obstacles and Opportunities for Voicing Concerns
3) Issues for Staff

Patient and staff surveys were undertaken, and compared with audit results from the
Addenbrooke‟s Privacy & Dignity Working Group.


Focus groups

1) Quality of Experience

The group identified a range of problems and barriers that have the potential to affect quality
of experience of patients. These include:

   failing culture and leadership of ward
   low quality and/or training of staff
   lack of basic care can lead to privacy and dignity issues
   failures in communication (hospital staff not asking about individual problems or do not
    pass information on to other staff)
   ignoring disability problems
   older people who stay longer in hospital need more attention
   lack of knowledge about the profile/background of the patient (e.g. information about
    patient‟s usual carer at home)
   some patients tend not to complain (e.g. older people are “too proud”, others feel
    vulnerable)
   financial constraints
   lack of training of staff in non-clinical, personal aspects
   lack of bed in the right ward

It was agreed that some healthcare providers had made improvements to services with a good
culture on certain wards, and particularly outpatient clinics. The Patient Advice and Liaison
Service (PALS) can have a positive impact, and staff training has started to improve.
Addenbrooke‟s Hospital has been conducting a study on quality of care to improve policy,
including observing practice in individual wards.


2) Obstacles and Opportunities for voicing concerns
Communcation was identified as a potential area for concern. A person who is sick may be
unable or find it very difficult to communicate his/her problems. Anxious family members may
also find it difficult to communicate with staff. The group felt that in these situations, the staff
e.g. doctors should understand and realise the needs of the patients and treat them as human
beings.

All patients should know about PALS - PALS leaflets should be available at every bed, but
additional provision needs to made for people who don‟t read/understand leaflets.
Other areas of communication breakdown discussed included patients being uncertain of
discharge time / day / processes and occasions when inappropriate transport has been sent to
pick up a patient e.g. sending a car to the patient instead of an ambulance.

Balancing the needs of all the patients in a ward or bay can be very difficult. For example if a
patient does not like to sleep then he / she may disturb others patients. Staff need to be
proactive, not dismissive or „helpless‟ in dealing with these situations.

An example of the need for good understanding of risk management and health & safety was
discussed. A patient who needed assistance had been asked to go to the toilet alone,
apparently in relation to a Health and Safety regulation. The risk of a patient falling or
collapsing in a bathroom or toilet needs to be assessed and balanced against other risks. An
assessment of the needs of the patient should be made; particularly with the needs of
disabled and older people. Another area of difficulty for people with disabilities was being
unable to park in the parking spaces for disabled people. This can cause a great deal of stress
for patients.


3) Issues for Staff

Many members of staff have good intentions and show compassion. Staff are often aware of
issues around Privacy and Dignity, but may need training in dealing with particular situations.
It was recognised that some staff members come from cultures where families are primarily
responsible for caring (e.g. Philippines), and may need to adjust to a different regime in UK
hospitals. Members of the focus group felt that there is less concern about training on wards
than in the past.

Miscommunication related to language or understanding can cause problems. It was felt
important that staff should not make assumptions about what was understood. One area of
difficulty for staff was the question of when it is permissible to talk to relatives rather than to
the patient.

Time and training were identified as problem areas. More time is needed for staff to get to
know patients. Volunteers can be a useful addition to staff , but need training to be able to
help patients appropriately. Electronic systems have the potential to increase efficiency in, for
example, managing discharge or ordering meals, but with one computer system for all, access
can be difficult.

Prioritisation can also be difficult for staff – which patient or situation should be dealt with first?
If a ward is short staffed, backlogs can build up. Staff members may face verbal and physical
aggression. It was considered inportant that the general population should be educated
regarding the operation of wards, infection control, and the limitations in resources facing
hospitals, wards and staff members.


Hospital Audits & Surveys

Addenbrooke‟s Hospital has a Privacy & Dignity Working Group, which is multi-professional,
with representatives from various staff groups and clinical specialities within the trust. There
are also representatives from the audit department and practice development. The group
meets every two months. An objective of the group is to develop and audit trustwide standards
for privacy and dignity based on the Essence of Care benchmarks.
The Privacy & Dignity Working Group conducted an audit of 35 wards in January 2006. A total
of 202 patients completed surveys, some with help from a carer, relative or nurse. Areas for
further investigation indicated by the raw audit data include:
 High percentage of patients not offered same sex chaperones while undergoing
    examination (Q17)
 High percentage of patients not asked to get undressed prior to to a physical examination
    before the doctor arrived (Q18a)
 Lack of access to private area for discussion of confidential matters (Q20)
 Lack of access to a private or quiet area for personal use (Q22)
 Problems with noise in the day or at night (Q30 & Q31)
 Disturbance due to lights at night (Q32)
 Lack of review of personal circumstances / needs during stay (Q35)
 Security of valuables (Q38)
 Difficulty of holding confidential conversations (Q40)

Ward Manager surveys were also completed on 35 wards. Potential issues for patients
highlighted by these survey results include:
 Intrusion into cubical space while personal or private procedures are being performed (Q2)
 Mixed sex washing areas and toilet facilities (Q3 & Q4)
 Lack of wet wipes & toilet fresheners (Q5a & 5b)
 Clothing for patients (Q8a & Q8b)
 Chaperoning during examination (Q9a, Q9c, Q9d & Q9e)
 Security of valuables (Q15)
 Access to patient notes (Q18)
 Patient handovers (Q20)

The Addenbrooke‟s PPI Forum also completed a small survey of patients and staff during
June & July 2006. As expected, patients were almost unanimous regarding excellent staff and
treatment. Minor criticisms were expressed on elderly people requiring more help than was
available, food choice, communication and understanding of treatment. Other comments
included worries about hand gels not being clearly marked, staff moving between patients
without using gels or washing hands, phone cards and parking. Bearing in mind that patients
may feel vulnerable whilst in hospital, the Forum would be interested to know how answers to
the Addenbrooke‟s survey and our own would vary after discharge.

During ward surveys, Forum members also noted that in some cases toilets for people with
disabilities are not user-friendly, for example, toilet roll holders are sited behind the user and
therefore difficult to use. In addition, some wards were very short of commodes and others
had problems with sluices.

Our survey of staff revealed widespread dissatisfaction with the lack of staff changing facilities,
shortage of uniform items, and the lack of private rooms in which to talk with patients and
relatives. Lines of communication seemed well understood – 90% of staff would refer
problems to the ward sister. Many staff on the wards felt that doctors needed communication
training.

In August 2006, Addenbrooke‟s Privacy & Dignity Working Group produced an Audit Summary
mapping adherence to the following agreed standards:

Standard 1: All patients experience care that actively promotes their privacy
Standard 2: All patients experience care that actively promotes their dignity
Standard 3: All patients experience care that actively promotes their modesty
Standard 4: All patients experience care in an environment that actively encompasses respect
for individual needs, values, beliefs and personal relationships
Standard 5: All staff will promote the privacy of confidential patient information
The target for all standards is 100% adherence – initially the earlier audit data has been
divided into areas scoring above 70% or below 70%. Issues have been highlighted against
Standards 2, 3, 4 and 5, and recommendations made with regard to Governance, guidelines
for chaperoning and dealing with vulnerable adults, staff training issues, hygiene, dietary
needs, confidentiality and communication issues.


Conclusions
It is everyone‟s role to look after the National Health Service. We all have rights and
responsibilities. Informing the general public of ways in which they can support healthcare
professionals to do their work efficiently would help. Visitors and family members may be able
to pass on useful information about a patient and their needs or help with patient property,
such as clothing or valuables. If kept informed, they may have better understanding at times
when a ward or clinic is very busy, be more able to be involved in planning, and less likely to
make incorrect assumptions about elderly care.

Hospital managers and service providers should stay alert to examples of good practice from
other hospitals and Trusts. Constructive ways forward include better access to advocacy
services, early identification of problems / issues, raising consciousness of the public and staff
to issues of privacy and dignity, and improved training of staff.

Time is needed to build relationships. When a patient is cared for at home, in community
facilities or in paliative care, the care is often more personal to the individual. In a large and
busy hospital it really is challenging for all staff to be alert to all patient needs all of the time.
Staff should, however, be trained appropriately and be proactive in communicating with
patients. Ward managers should be confident that ward assistants responsible for feeding and
caring for patients have appropriate information about individual needs and know what to do if
a patient is not eating or appears to have a problem. Reliance on volunteers could present
difficulties in the longer term – first because of the necessity to provide appropriate training,
and secondly, as hospitals grow and become more complex „volunteer fatigue‟ may set in.



Recommendations for Addenbrooke’s Hospital

1) The Privacy & Dignity Working Group should have a higher profile, with more staff
   encouraged to attend and contribute.
2) Particularly on wards specialising in care of the elderly, consider employing dedicated
   patient advocates to support patients‟ issues and to take care of patients‟ needs.
3) Draw up chaperoning guidelines for staff undertaking consultations and examinations, and
   ensure appropriate training.
4) Draw up guidelines for staff dealing with vulnerable adults, and ensure appropriate
   training.
5) PALS leaflets are not enough - additional provision needs to be made for people who don‟t
   read/understand leaflets.
6) Patients & visitors should be encouraged to give feedback and suggestions – some people
   will never “complain”.
7) Protect meal times and ensure patients do not miss meals / drinks due to scans or
   examinations.
8) Look at options for flexibility in visiting, such as shorter visitng times, but more often.
9) Encourage staff to be proactive, not dismissive or „helpless‟ in dealing with situations
   where privacy or dignity is infringed.
10) Address the privacy & dignity issues of staff (uniforms, changing facilities, private areas for
    discussion) – staff who feel respected may feel more able to be proactive in promoting the
    privacy & dignity of others.
11) Consultation around architecture and the use of space to provide more flexibility in wards
    to balance the needs of individual patients and to combat inappropriate storage of
    equipment, lack of space for staff facilities, and particularly, lack of private space for
    consultation and discussion.
12) Ensure all staff and volunteers have disability discrimination awareness training, and feel
    able to address the needs of people with disabilities.
13) Ensure all staff have training in communication.
14) Ensure good symptom control and adequate pain relief.
15) Respect the autonomy of individuals, and ensure they have the information to make
    decisions.
16) Be advocates for patients and contribute to support groups.
17) Ensure social dignity is maintained.
18) Continue to take the patient stories, and make the difference.
19) Conduct “follow-up” surveys of patient satifaction after discharge when patients may feel
    less vulnerable in answering.
20) Stay alert to examples of good practice from other hospitals and Trusts – (for example:
    http://www.cgsupport.nhs.uk/Resources/Eurekas/Essence_of_Care/default.asp)



References

1) Privacy & Dignity Powerpoint presentation, 7th March 2006, Jo Birrell & Claire Nicholl
2) The Essence of Care: Patient-focused benchmarking for healthcare practitioners,
   Department of Health, 2001. Updated by The Essence of Care: Patient-focused
   benchmarks for clinical governance, 2003
3) Focus Group reports form 7th March 2006 on
       a)     Quality of Experience
       b)     Obstacles and Opportunities for Voicing Concerns
       c)     Issues for Staff
4) Essence of Care: Addenbrooke‟s Standards for Privacy & Dignity, Audit Report, Project
   leads: Lyn McIntyre & Nicola Woodruff, April 2006
5) Essence of Care: Addenbrooke‟s Standards for Privacy & Dignity, Audit Summary, Project
   leads: Lyn McIntyre & Nicola Woodruff, August 2006

				
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