by Thomas E. Serena, MD, FACS, FACHM, FAPWCA
"Oh, keep the dog far hence that's friend to man."
-T.S. Eliot, The Waste Land
Perspective of Nursing Care from Past to Future by Matron Marley
by Margaret Heale, RN, MSc, CWOCN
People can be open with few secrets and little to hide but even then there are behaviors, memories, hopes, fears and desires that are not revealed. We have a right to be in control of this part of ourselves and the flesh that encompasses it. Such control is part of the freedom we covet as a nation.
As I watch and help out at the nursing home near where my granddaughter works, I have noticed how there is a tendency for this to erode as we coddle and help people move through the closing chapters of their lives. I am reminded also of how it disintegrates as we become immersed in being cared for in any setting. What is ‘it’, well I guess privacy would cover most of ‘it’. As a Matron in England in the 1970s I would quite often remind those in my charge of this important right. Why has this reared its head today? I have a smartphone and this eye keeps popping up and then something happened that sparked a few memories.
I was asked to take a valuables book down to one of the rooms. It was a new resident I did not know. The door wasn’t fully closed so I walked in with just a rudimentary ‘knock, knock’. Well, I have never seen anything like it. What a vision to behold. There were a couple of student nurses putting on this woman’s stockings, one holding up each leg, as the ‘nurse’ (so called) was washing the residents chest. The lady was completely naked and as I fumbled to retreat the nurse called, “don’t go, we are just washing her up. Can you get me that towel?” Stupidly, it seems, I thought the towel was to cover her up but apparently not as it was hurriedly rubbed over the resident’s chest.
I retrieved a sheet from the top of the pile of discarded linen on the floor (a crime from my matronly days, punishable with a strict reprimand) and covered the body cold and naked before me. As I did so it squeaked a thank you. I could ‘go off on one’ and tell you how the scene would never have happened in my day, but I won’t because of course it probably did. That is why I had the job of matron, and what I had just witnessed is why I tell you now that we need someone to fulfill such a role. There was no apology to the resident from any of those present in the room. When I asked the nurse if I should mention to the students’ tutor their lack of concern for the privacy of the resident, she just said they were in a hurry to get her ready for the day and the students had to learn to work more quickly.
When those in health care talk of privacy we think of HIPAA and not nudity or how awkward a patient may feel during a procedure when a colleague enters the room and starts discussing something that has nothing at all to do with the patient. We are all taught to keep people covered as much as possible, but we do not continue to practice this simple act. Patients have told me that they leave ideas of privacy with their dignity outside the hospital walls. Isn’t that appalling?
Dignity is a high ideal, defined online as “a state or quality of being worthy of honor or respect.” As nurses, our primary role is one of advocacy for people under our care, and we are failing if we do not protect their dignity.
Some of the people who reside at this skilled nursing facility wear absorbent products to assist with maintaining their dignity. There can be nothing as undignified as "wetting yourself in public", so wearing an absorbent product definitely has the potential for maintaining dignity. If these items are called diapers, suddenly their use becomes demeaning and dignity goes out the window. Indiscriminate use changes the product from being discreet, protective and useful to being damaging. Such use includes putting the product on and not incorporating use into a plan of care. This changes use from preserving dignity to promoting incontinence.
The type of containment device that is more like a pair of absorbent briefs is much better as residents can still have a continence plan and manage alone in the bathroom. The problem then becomes different. People have started to refer to the pull up type absorbent briefs as hospital underwear! This might seem okay and even appropriate until it is evident that the use of the brief allows staff to ignore the need for regular toileting opportunities.
It is possible for the rehab residents in the facility where I work to have a brief put on at 7:00am and helped with breakfast so as they are ready for speech therapy at 8:00am. This is followed by PT at 9:00am-10:30am and OT from 10:30am to 11:30am. They will probably be whisked off to chat and chew at lunchtime. Nipping quickly to the bathroom isn’t an option because the definition of nipping quickly does not match the speed at which they can move, remove clothing, transfer, sit, perform, re-dress, transfer, wash hands. Please remember: some are taking diuretics too.
On occasions the rate of falls at our facility increases. Recently when this occurred there was an edict that went out stating that when staff assist residents to the bathroom they must stay in the bathroom with the patient. I am quite positive I would not allow someone to stay with me while doing my business but mostly the residents just tolerated it.
There is no doubt that many falls occur when there are continence issues but is it really necessary to stay in the bathroom? If I was worried someone might get up unaided I’d put a pillow on their lap while they sat on the toilet in addition to reminding them about calling and showing them how, and never had a problem for all of my 55 years of nursing. When I suggested this, no one had ever heard of it (no evidence, no go).
When I was matron we still had Nightingale wards and I think because of the hustle and bustle there was much more privacy than in a two bedded room. I have always been surprised that men would just use the urinal under the covers without asking for the curtain to be drawn. A single room of course doesn’t necessarily offer privacy. I was really surprised when I realized an elderly lady was on the bed pan with all of her extended family in the room (maybe eight men, women and children) all around the bed. I was checking on her and asked if she was comfortable, “well not really could you get me off the pan.”
I was at a loss for words, my only comfort was that it was for the most part her choice, she could have asked them to wait a moment, and she certainly didn’t seem bothered by it.
There is one incident that comes to mind that left me slightly more embarrassed and definitely lost for words. I was rounding on an orthopedic ward that had six bedded bays. I was looking for the charge nurse and thought she might be behind the curtains of a quite newly admitted young man with a fractured femur on skeletal traction (a three month hospital sentence in those days). I did a rudimentary knock, knock on the curtain and to this day cannot quite work out exactly where all the pulley’s ropes and weights were in relationship to him and his fiancé. I was just a little flustered as I recoiled but had the sudden realization that turning the TV up might be a worthwhile venture. When I found the nurse we had little idea of how to proceed but were relieved to see the young lady scooting off down the corridor. We left the curtains for someone else to draw!
I am quite sure we all carry different concepts and needs about privacy and so I suspect health care professionals are bound to get it wrong on occasions, but it is safest to assume that patients value their privacy.
We are in extreme and intimate contact with patients, and our attitude, demeanor and professionalism makes a difference.
Avoiding exposure, keeping people covered, being thorough but efficient all help to maintain our composure and the patient's dignity. Taking staples out with the door of the room open? Not acceptable. Allowing a resident to be unnecessarily exposed? Not acceptable. Washing a resident while they are sitting on the toilet? Not acceptable. Writing Jerry was here on the abdomen of an anesthetized colleague who was having her appendix out emergently? Not at all acceptable (but actually it was very funny when I was 23 and the anesthesiologist was a character. I will always remember him with affection. I am pleased to this day that he didn’t get into the trouble he could have for the prank and know that the young lady concerned still talks of the incident with a laugh in her belly).
So what of the future and privacy, a scary thought as the eye peeks at me from my (very un-smart) phone and I see the cameras gnawing away at my rights at the entrance where I work and the elevator hallway. I am quite certain there are no dental offices anymore that have doors on their treatment rooms so maybe this will extend to doctor’s offices next.
People deserve the opportunity for privacy and we must nurture dignity whenever we are able. As nurses we have always done this. Currently it has become more difficult, but we are the future so please work at this for tomorrow.
About The Author
Based on her extensive nursing experience Margaret Heale, Wound, Ostomy and Continence Nurse, takes us into the blog journal of a fictitious matron, "Perspective of Nursing Care from Past to Future by Matron Marley."
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.