Issue 36 / 29 September 2014

PATIENTS being obliged to wear gowns that barely cover the backside and genital area is just one example of several unnecessarily dehumanising aspects of the hospital stay in need of reform, experts say.

Associate Professor Eleanor Milligan, academic lead in medical ethics and professional practice at the Griffith University School of Medicine, suggested that many of the indignities suffered by hospital patients went unquestioned because “that’s the way we’ve always done things”.

Other examples were accommodating male and female patients side-by-side in mixed wards, ending visiting hours at arbitrary set times, and using exclusive language and acronyms that prevented patient understanding of their care, she said.

Professor Milligan was commenting after publication of a research letter in JAMA Internal Medicine which found that most patients admitted to acute medical units in Canada did not wear lower-body attire, even though there was no medical reason for them to be exposed in such a way. (1)

The authors wrote that their study demonstrated that most of the patients admitted to acute medical units did not wear lower-body attire.

“This situation occurs despite more than half of them being deemed eligible to do so, despite most of those patients surveyed being interested in doing so, and despite encouragement to wear home clothing …”, they wrote.

The small study included 127 patients admitted on the same calendar day to five hospitals. Attending physicians were asked whether they would agree to allow patient to wear pants if they requested it.

Reasons given for not agreeing included that the patient had a medical problem, wound, line, or catheter precluding their wearing lower-body garments or that the patient was too immobile, too incontinent, too confused, or too ill to wear such attire, given the available nursing resources.

Only 11% of patients in the study were wearing lower-body garments, even though 56% were deemed eligible to do so.

The authors concluded that eligible patients should be encouraged to wear lower-body garments when full home attire was not feasible. They recommended that “functional fashions” be developed to allow those who could not wear or did not have access to their home attire “something more dignified than a one-size-fits-all-open-backed patient gown”.

“Although patient attire can be graduated from an open-backed gown, at one end of the spectrum, to full home dress at the other, we suggest that the absence of lower-body attire that leave the backside and genital areas unnecessarily exposed has an important effect on dignity”, they wrote.

Professor Milligan said another alienating aspect of the hospital stay was regimented timetabling of everything from meals to showering times, which meant that “even something as simple as having a cup of tea is beyond your control”.

“To some degree the logistics of running a hospital does require some structure but I think we could definitely be more creative and responsive to patients’ human needs”, she said.

Dr Michael Kennedy, a consultant cardiologist in Manly, has been a vocal critic of the “appalling practice” of placing male and female patients in the same room in general wards, writing a letter about the issue to the MJA. (2)

The practice was singled out in the 2008 final report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals as something which should “cease forthwith”. (3)

However, Dr Kennedy said that 6 years later patients were still suffering the same indignity.

“An elderly female patient of mine was horrified at having to sleep in a bed next to a male patient in a major metropolitan hospital this year, but was not prepared to make a fuss because of fear it would go on her notes”, Dr Kennedy said.

“This is totally unacceptable. Even in [developing countries] they don’t mix men and women on wards like this. There’s no reason to do it … It causes a degrading attitude towards people.”

A NSW Ministry of Health spokesperson told MJA InSight it had issued a policy directive in January 2010 to ensure that male and female patients staying overnight in NSW public hospitals did not have to sleep in the same room or ward bay, use mixed bathroom facilities or pass through opposite sex areas to reach their own facilities, except when considered clinically appropriate.

However, the spokesperson said it was the responsibility of local health districts to ensure compliance with the policy.

“There are no exemptions from the need to ensure that the privacy and dignity of all NSW Health patients is respected at all times during their health care experience”, the spokesperson said.

However, there were some “exceptional circumstances” such as when patients needed very specialised or urgent care “where providing rapid safe effective care may take priority over ensuring same gender rooms or ward bays”.

 

1. JAMA Intern Med 2014; Online 22 September
2. MJA 2009; 190: 516
3. Final Report of the Special Commission of Inquiry Acute Care Services in NSW Public Hospitals 2008

(Photo: Cristina Pedrazzini / Science Photo Library)


Poll

Should hospitals do more to ensure the dignity of patients?
  • Yes – it’s essential (87%, 114 Votes)
  • Yes – but not always possible (12%, 16 Votes)
  • No – rules are already in place (1%, 1 Votes)

Total Voters: 131

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15 thoughts on “Patients still endure indignities

  1. randal williams says:

    Never understood the hospital gown thing–why not have a simple gown like a dressing gown closed at the back and wrap -around at the front with a belt. Easy to don, and no tricky knots at the back.

    Older generations definitely do not like mixed gender wards and bays–avoid at all costs.

    Another thing I have always drummed into junior staff—do not divulge confidential information about patients on communal ward rounds that other patients might be able to hear.

  2. Professor Avni Sali says:

    Why is it that if you are a patient you are generally treated as if you are not a human being in hospitals,especially public hospitals.Given the choice as a traveller as to where you would stay, at the Hilton or at a public hospital in a four bed ward with mixed sexes, there would be no doubt as to which one you would choose. It’s when people are ill that they deserve the best accommodation.       

  3. Ulf Steinvorth says:

    Medical (and nursing) tradition expects patients to give up their autonomy, brains and rights at the hospital door, just as it was expected of junior army (or medical) recruits to unquestioningly obey orders and partake in all ‘ceremonies’ no matter how vicious or violent.

    EBM and the civil rights movement have done a lot to change our approach but there still is ample room left uncovered – no pun intended.

      

  4. Dr. Kevin B. ORR says:

    I have been in a public ward at St. George Hospital on more than one occasion. These are mixed sex wards and are appalling. Most patients leave the curtains around for privacy. On one occasion, in the middle of the night, an elderly lady, having been to the toilet, came back and got into bed with a male patient! Numerous requests to the hospital hieracy have fallen on deaf ears.     

  5. Department of Health Victoria Clinicians Health Channel says:

    There is no place for accomodating man and women in the same room no matter what age or religion. It is just plain wrong. Having to leave the curtains around in a small space adds to creating obstacles for the staff to work in and adds to a claustrophobic environment. As for the cringeworthy gowns, they make a mockery of patient choice and rights…..who would choose to wear them? I look forward to the day there are changes around these two issues, however I fear that “things will remain the same”

  6. Genevieve Freer says:

    Not only are inpatients suffering dehumanising indignities,  breaches of human rights, outpatients are also.

    The question is, who is responsible for patients’ rights ? 

    At a recent first   hospital clinical staff  meeting,   caused by accreditation, staff raised issues of outpatient triage, confidentiality,  privacy, safety, transfer, infection control, after hours , (when the hospital manager/director of nursing is at home in another town ).

    One would think that a patient who presents to an ED has a right to be triaged appropriately, and if  triage category 3 or less has a right to be seen within the designated time frame, when possible,.

    All patients, regardless of triage category, have  rights to privacy, safety, to  transfer according to health policy, and infection control.

    There is little value in nursing staff doing endless training on anything, if there is no auditing of the implementation of this training.

    Sick children do not have BP taken-easily audited on  observation charts, triage categories 2 , 3, evident from the history , observations , ambulance notes,  are called 4  and 5 , to falsify stats, infection control procedures , including masks, are often  ignored., privacy is limited by the facility, and lack of signs.

    Transfer protocols  for children and mental health patients  from small rural hospitals are ignored sometimes by the Base Hospital staff, and often by ambulance officers and ambulance administration:  after hours.

    Complains by rural VMOs and nursing staff  are ignored.by administrators-they are the ones  to blame.

     

     

     

     

     

  7. University of Queensland - Central Library says:

    It couldn’t have been a clinician who made the decision to change from sex-segregated wards to mixed wards.  Everybody except the decision-makers seem to “get” that this is a degrading and repulsive practice.  Maybe it’s time for someone to spell out to them that it is economic irrationalism. 

  8. Sue Ieraci says:

    Mixed-sex wards have occurred due to one reason only – hospital overcrowding. It is no longer considered fincially viable for hospitals to run at less than 90% occupancy (often closer  to 100%), which means that new arrivals bank up in the emergency department. We know that patients requiring hospital admission, who wait hours to days on an ED trolley to get to a ward bed, have worse clincial outcomes. Mixing sexes on wards is one of the solutions for moving these patients out of ED, so the new arrivals can get in, and get access to care. Universally accessible health care involves a long series of compromises. Perhaps we should allow the community to help decide which compromises are preferable, bearing in mind that there is no sex-segregation in ED, and that everyone as the right oaccess care.

  9. Genevieve Freer says:

    Mixed sex wards are a separate situation to mixed sex rooms-as there are only  2 sexes, x and y, it should not be difficult to manage a 90% occupancy with single sex rooms, however this would require the highly -paid bed managers to manage the puzzle.

     Following Sue Ieraci’s excellent  suggestion, regarding compromise, rather than the community deciding on mixed-sex wards, perhaps a patient election form on admission could include the election of either  a single-sex or mixed-sex ward, so that  the patient may  choose a mixed-sex ward over the ED corridor, then only those patients who are more worried about  lying / dying in the ED corridor then having a delirious, disturbed or demented person of the opposite sex crawling into bed with them while they press the call-button for nursing staff could choose mixed-sex wards.

    Personally, I would rather take my chances in the ED corridor. 

    The problem is that when  x and y change with new admissions, patients may have to be moved from one room to another, which would require changing the linen and hopefully cleaning the room, which is outside the duties of the after-hours bed manager, who is not actually in the hospital, but on a mobile telephone. 

    One solution is for the bed-manager to occupy a bed in the (mixed-sex) ED, so that she /he may readily jump out of bed with each admission, rush to the wards, and change the linen . If this duty becomes too onerous for one bed-manager, perhaps the health service managers could be second on-call to trouble-shoot the ward room sex puzzle. One could ask whether the health service manager would be happy to share a room in the ED with a bed-manager of the opposite sex.

     , 

  10. Department of Health and Human Services Tasmania says:

    I agree with everything said, except the comment that “Even in [developing countries] they don’t mix men and women on wards like this”. 

    I have worked in hospitals in Cambodia, Vanuatu and Belize, PNG, the Solomons and visited hospitals  in other developing countries.  In most of these the wards were mixed gender and very crowded – beds lined up practically next to each other. There are no curtains and no privacy.  Doctors expose patients for examination in full view of the rest of the ward.  I don’t agree with it, but to say it doesn’t happen is incorrect. I would post a photo if I could.

  11. Sue Ieraci says:

    Rose – you say ” I would rather take my chances in the ED corridor.” but is that what you would want for an elderly relative? The ED corridor not only has zero privacy and no curtains, but no oxygen or suction should anything medically go wrong. ED overcrowding has been shown to cost lives. Mixed-sex wards might not be the best solution, but it is much more humane to both the patient and the incoming ED patients than stacking everyone in ED until the right bed is available. If not mixed-sex wards, then some other inpatient solution is needed.

  12. Jan Bowman says:

    I have both looked after patients in mixed wards and been one. Many years ago I was in a surgical ward in a private hospital, and I had a 17 year old boy in the next bed. The surgical gown did not quite meet at the back, and as I am tall it barely covered my pubic region. I remember trying to walk up the ward to the toilet with the gap at the back pulled a little to one side. I was very worried about the wash the nurses gave me when I came back from theatre half asleep – we all know how curtains have a habit of drifting apart. Although I remember all this, I cannot remember what the operation was – so it must have bothered me a lot! And I think it is happening more often now, despite the fact that we have more people from cultures from overseas who would be even more horrified by the practice.

  13. Ruth Armstrong says:

    ED overcrowding is a real issue and stable patients need to be moved to a ward to make way for others. But isn’t there a middle way? Surely patients could start off in a mixed-sex room if needed, and be moved to a same-sex part of the ward when there is availability. The blanket rule of “we don’t care if you’re a man or a woman or 18 or 80 — we’ll put you wherever is expedent” seems deliberately designed to keep patients in their place. Sue is right — another solution is needed — involving more advanced logistics and a bit of empathy.

     

  14. Genevieve Freer says:

    Sue-if I need oxygen presumably  I should have it in the ED , the trolley to the ward, and in the ward on arrival, or at home.. ( My elderly relatives died at home , never attending any public ED )

    If  I deteriorate in the ED corridor, requiring suction (I must now be less than conscious ) then oxygen,  I should not  be in the ED corridor-I have should  be in Resus .

    If I was fine in the ED corridor, then needed suction (again less than conscious)  in the ward, I should not have been sent to the ward, where I would probably die unnoticed. 

    So while ED overcrowding may cost lives, if the patient is unstable enough to die or deteriorate  in the ED, I doubt that transferring unstable patients to any  ward other than ICU, CCU, HDU , telemetry beds, or theatre is not likely to reduce mortality., 

     I have not seen any evidence that mixed-sex wards improve outcomes, nor reduce mortality/morbidity. 

    ED overcrowding  is caused by too many patients, not enough staff,,  not enough ED beds,  not enough  of all beds- including  palliaitive care, nursing home, rehabilitation beds,  representations due to inappropriate early discharge, not enough theatre time,  etc-none of these problems will be solved by mixed-sex wards.

     

     

     

  15. angie gittus says:

    does anyone have a link to the policy directive apparently realeased by nsw health in 2010 ensuring male and female patients did not share rooms o/night?

    i would really love to see the exact wording of the document and whether it’s helpful in attempting to provide more dignified care at our facility.

    thanks, angie 

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