In order to ensure that health care delivery is of the highest possible standard, the
This essay will address the perspectives and aims of the ‘privacy and dignity’ benchmark, as outlined in the Department of Health’s Essence of Care (2001b, 2003) document, taking into account its strengths, shortcomings and implications for ‘best practice’. First, the content of the benchmark factors themselves will be examined, both in relation to other key benchmarks and in light of my own experiences on clinical placement. Second, some of the problems associated with the definition of the concepts of ‘privacy’ and ‘dignity’ will be considered, with a view to clarifying their vital importance for the nursing profession.
Of the eight areas of care featured in the first edition of the Essence of Care (2001) the ‘privacy and dignity’ benchmark stands in marked contrast to most others (e.g. ‘pressure ulcers’ and ‘continence and bladder and bowel care’), because it is relatively vague. Moreover, although ‘privacy’ and ‘dignity’ are, broadly speaking, ‘taken-for-granted’ ideas there is little doubt that such terms can have little explanatory power when isolated as abstract concepts. Nonetheless, the Department of Health’s ‘toolkit for benchmarking the fundamentals of care’ aims to go some way towards indicating how these important principles can be made concrete in the delivery of healthcare.The Essence of Care benchmark for privacy and dignity is constructed around seven key factors and benchmarks of best practice, which can be summarised as follows: personal identity; personal boundaries; communication; confidentiality; availability of private areas; and attitudes and behaviour (of staff). The nebulous quality of some of the preliminary indicators of ‘best practice’ seem to reinforce the impression that, at the point of publication, privacy and dignity policies were underdeveloped. For instance, regarding the ‘attitudes and behaviours’ (of staff) the benchmark of best practice announces that ‘patients [should] feel that they matter all of the time’. It is surely easy to see how such an imperative might be considered glib and patronising. Research shows (and this author’s experience confirms) that, just as patients ‘expose themselves to hospital staff, and possibly other patients, to a degree that would not be acceptable in normal life’, they also accept that there is, necessarily, a system of priorities in healthcare that dictates that some cases ‘matter’ more than others at certain times (Malcolm 2005: 12; Scott et al. 2000: 566).
These doubts aside, of the remaining introductory summaries the majority of the benchmarks appear, on first reading at least, to be placed on surer foundations. Thus, in relation to ‘privacy of patient-confidentiality of client information’ (a topic to which this essay will return) the benchmark demands that ‘patient information is shared to enable care, with their consent.’ Similarly, the guidelines insist that ‘patients’ care actively promotes their privacy and dignity, and protects their modesty.’ In addition, together with the making available of ‘an area for complete privacy’, the above advice on ‘privacy, dignity and modesty’ is linked to the question of ‘personal boundaries and space.’ Here, in between uncontentious references to personal contact/touch and disturbing/interrupting patients, attention is drawn to the question of segregated/single-sex facilities. However, this author’s experience on placement, in conjunction with literature on the subject, confirms that there is a notable mismatch between many of the ideals promoted in Department of Health’s official guidelines ‘and the soft messy ground of practice’ (Manthey 2001: 5).
In addition to addressing the conflict between patient dignity and staff safety in the moving and handling of patients, Scott (1997, 2004) has highlighted the practical (not to mention financial) problems of implementing single-sex bays in hospitals. She points out, for instance, that ‘a partition designed to restrict patients’ view will restrict nurses’ view and may impede the delivery of safe patient care’. Unfortunately, the Essence of Care privacy and dignity benchmark does not properly tackle this tension between privacy and dignity, on the one hand, and safety, on the other. An attempt to confront the problem is made in the benchmark ‘safety of clients with mental health needs’ (specifically, in terms of ‘balancing observation and privacy in a safe environment’). Yet, perhaps surprisingly, it is an earlier publication, Safety, privacy and dignity in mental health units: guidance on mixed sex accommodation for mental health services (NHS 2000), that provides a more detailed and honest appraisal of the relationship between privacy and safety; and it is one that matches this author’s experiences and observations during clinical placement at an EMI (Elderly Mental Illness) ward.
The ward in question, a mixed-sex ward with single sex corridors, conforms to the guidelines on privacy and safety outlined in the aforementioned NHS document. Consequently, while the single rooms on the ward ensure a degree of privacy, a ‘fail safe system for entry into rooms if staff are concerned about patients’ security’ is also in operation (NHS Executive 2000). Similarly, assessments of the patients’ susceptibility to self-harm (or suicide) are undertaken prior to the allocation of individual rooms; and the ward layout guarantees access to segregated toilet and bathroom facilities, without members of one sex having to pass through areas designated for the opposite sex.
In this author’s view, despite the conditions under which patients can be sectioned under the Mental Health Act (HMG 1983), and notwithstanding the way in which the above account of NHS policy and clinical practice highlights the manner in which patients are sometimes monitored in mental health facilities, there is no good reason to believe that principles of privacy and dignity are not generally adhered to. The point to emphasise is that, rather than being absolute, the principle of dignity is open to adaptation, especially where the issue of individual safety arises. Indeed, paradoxically perhaps, such modification may even provide a fuller scope to the exercise of dignity, because it is predicated on the well-being of the individual or individuals concerned.
To return to the Essence of Care guidelines, the document includes a range of other benchmarks and factors that relate closely, and appropriately, to privacy and dignity. Among these are: ‘assistance to eat and drink’ (‘food and nutrition’); ‘a physical and social environment conducive to continence and a healthy bladder and bowel’ (‘continence and bladder and bowel care’); and ‘environment within which oral and personal hygiene needs are met’ (‘personal and oral hygiene’). But it is the benchmark ‘communication between patients, carers and health care personnel’ – first included in the second edition of Essence of Care (DH 2003) – that is of particular relevance here, largely because much of it dovetails with an indispensable factor within the privacy and dignity benchmark: ‘privacy of patient-confidentiality of client information’.
With this in mind, this essay now turns to an opportunity this author had to reflect upon the implementation of confidentiality policy, at a local level, during time spent on a general adult nursing placement. Whilst on the ward in question, the policy document Information and Technology: Information Security and Confidentiality Policy (UHNS 2000) was made available to me. Emphasising the security of information in patient-care areas, the document stresses that the ‘[d]isclosure of patient-identifiable information [name, age, gender, address, patient’s diagnosis, current state of health etc.]… is a breach of confidentiality and can have serious consequences for the Trust’ (UHNS 2000). Notwithstanding the short duration of the placement, it was possible to evaluate routine practice on the ward against the recommendations of the policy. What was impressive was the continuity between the professional guidelines and the nature of nursing practice on the unit. Indeed great emphasis was placed on the fundamental importance of following the protocols laid out in official confidentiality policies.
The procedures pertaining to ‘telephone enquiries from patients’ relatives and friends (UHNS 2000)’ were among those singled out by the staff for consideration. The advice given was in accordance with the confidentiality directive, which states that ‘information should not be given unless the staff member is certain of the caller’s identity (UHNS 2000)’. Further attention was drawn to matters of confidentiality when staff nurses explained the importance of using password-protected electronic record-keeping in patient-care areas. They noted in particular that, when unattended, computer screens should be kept clear of sensitive information. Significantly, however, important qualifications were highlighted in relation to confidentiality, qualifications that are consistent with the BMA’s advice that, just as unrestricted access to patient-identifiable data by health professionals should be prevented, ‘[p]atients should be made aware that health teams need to share essential, relevant information in order to ensure that the safety and effectiveness of treatment are maximised’ (BMA 1999).
Despite research that has found standards in the NHS wanting (not least in relation to the privacy and dignity benchmark) experiences of clinical placements, so far, have given this author little cause to doubt the commitment of nursing professionals to matters of confidentiality in particular (Woogara 2004). Nonetheless, to enable a clearer understanding of the issues at stake in the discussion surrounding privacy and dignity it will be helpful to clarify some of the concepts underpinning (and the relationships between) both terms. As Woogara (2005: 34) observes, ‘the terms ‘privacy of the person’ and ‘dignity’ are interrelated’, in so far as dignity implies ‘respect for the person, privacy of the body, privacy of one’s space and territory, and having control and choice of one’s surroundings.’ Similarly, the multidimensional character of privacy (physical, psychological, social, informational) also implies (as does dignity) autonomy, or self-government (Scott et al. 2003; Burgoon 1982). And the desire to cultivate a climate of autonomous decision-making is of course especially pertinent to the modern healthcare environment, where the right to privacy is broadly recognised to be essential to maintaining patients’ independence (DH 2005).
Others, notably Wainwright (1995, cited in Scott et al. 2000), have sought to condense the idea ‘privacy’ into simply ‘two types’, one pertaining to personal information, the other to the physical aspect of the person. Meanwhile, Westin (1967: 31, cited in Woogara 2001) provides a more compelling, philosophical account of privacy, wherein he identifies (in advanced capitalist societies) four distinctive elements: solitude, intimacy, anonymity, reserve. Taken in turn, the composite aspects of Westin’s explanatory scheme make clear the importance of clarifying the meaning of privacy for the healthcare environment. Thus, ‘solitude’ implies a state in which an individual is separate and free from the observation of others. ‘Intimacy’ points to an individual’s facility to participate in family or friendship units. A third element, ‘anonymity’, arises when an individual is in a public place but wishes to be free from the scrutiny of others. Finally, ‘reserve’ describes an individual’s construction of ‘mental distance’ as part of ‘a psychological barrier against unwanted intrusions’ (Woogara 2001: 239).
If defining ‘privacy’ and its parameters has preoccupied the minds of many contributors to medical, nursing and healthcare journals, then establishing the salience and meaning of ‘dignity’ has proved to been an even more vexed question. In the first instance, however, it should be said that one need not agree with either Macklin’s claim that ‘dignity’ is so vague an idea as to be ‘useless’ or Beckworth’s assertion that dignity is a ‘right’ to recognise the significance of dignity, not least for nurses and their patients (Macklin 2003, cited in Gallagher 2004: 590; Beckworth 2006).
Bradshaw (2000) cites Stuart and Cuff’s Practical Nursing (1899) as an early example of a text emphasising ‘gentleness and dignity’ as an essential characteristic of nursing care. Similarly, at the Florence Nightingale commemoration service in May 2006, no less than the Archbishop of Canterbury reminded us that the founder of modern nursing viewed professionalism as ‘whatever served not only the physical health but the dignity of those being cared for’ (Beckworth 2006). It is clear, then, that dignity has long been deemed been a ‘core value’ for nursing practice. Nonetheless, despite the much-trumpeted claim that modern healthcare is moving away from medical paternalism towards to patient-centredness, dignity remains an under-defined concept in both nursing literature and Department of Health publications (Walsh and Kowanko 2002).
Haddock (1996, cited in Frankin et al. 2006) describes dignity as the quality of feeling valuable in relation to others, and being treated as such when that dignity is threatened. Elsewhere, Gallagher (2004) cites several attempts to define dignity. Mairis, for example, echoing Woogara (2005: 34), states: ‘Dignity exists when an individual is capable of exerting control over his or her behaviour, surroundings and the way in which he or she is treated by others’ (Mairis 1994, cited in Gallagher 2004: 589). No less useful is Shotton and Seedshouse’s ‘negative’ definition (1998, cited in Gallagher 2004: 589). Hence they suggest that ‘we lack [my emphasis] dignity when we find ourselves in inappropriate circumstances, when we are in situations when we feel foolish, incompetent, inadequate or unusually vulnerable.’ But perhaps the most important insight to be gained from the literature on dignity is that derived, in part, from Spiegelberg’s (1970) distinction between ‘intrinsic’ and ‘extrinsic’ dignity.
Dignity is the state or quality of being worthy of esteem and respect; and we earn or expect esteem and respect on the basis of common human values. Consequently, to treat a patient with dignity is to treat him or her with respect, and in the interests of his or her self-esteem. What Spiegelberg did was to distinguish between, on the one hand, our estimation of our own worth (intrinsic dignity) and, on the other, that conferred on us by others (extrinsic dignity). Therefore, where one is said to be able to have dignity, treat (or be treated) with dignity, or bestow dignity what is at stake is self-respect, in as much as valuing the dignity of others ‘requires an appraisal and recognition of one’s own value and worth, both as a human and as a professional’ (Gallagher 2004: 591). It is this acknowledgment of the two-fold character of dignity (respect for ourselves and others) that is conspicuous by its absence from both Department of Health literature and that of the Nursing and Midwifery Council (DH 2001b, 2003; NMC 2004).
As is consistent with reflective practice, where they are able to recognise the multi-faceted nature of privacy and dignity it should be incumbent upon student and registered nurses to adopt a properly critical perspective towards the health policies that they are expected to both implement and comply with. As part of a profession that is, in many respects, subordinate to government diktat, taking issue with, for example, some of the shortcomings of official guidelines is not a straightforward task for nurses to undertake. And yet, as this essay has sought to illustrate, ‘best practice’ will indeed be at its best when nurses set out to achieve it armed with the dignity and respect they owe to themselves and, above all, their patients.
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