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Ensuring patient dignity when accessing and using toilets.

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VOL: 103, ISSUE: 17, PAGE NO: 23

A group of organisations led by the British Geriatrics Society (BGS) has launched a campaign this month to ensure t…


A group of organisations led by the British Geriatrics Society (BGS) has launched a campaign this month to ensure that vulnerable people in care homes and hospitals can use the toilet in private. The campaign, entitled ‘Behind Closed Doors’, includes a best practice toolkit that comprises a decision aid, a tool for lay people to carry out an environmental audit of toilets, key standards, an action plan and leaflets (BGS et al, 2007).



Campaign aims


The aim of the campaign is to raise awareness of the right of people in all care settings, whatever their age and physical ability, to choose to use the toilet in private. It has been endorsed by a range of organisations including Age Concern England, Carers UK, Help the Aged and the RCN. The campaigners say giving people back control over this very private function would enhance independence and rehabilitation, reduce lengths of stay and promote continence.



The initiative emphasises the importance of the environment as well as care practices and will help in the future commissioning of facilities (BGS et al, 2007). The BGS argues that the campaign will provide commissioners, chief executives and inspectors with a measure of good practice and clinical governance. The society says current hospital practice often ‘falls short’ of respecting the dignity and privacy of older patients, some of whom are the most vulnerable in society. It says staff sometimes ignore requests to use the toilet, tell people to wait or use incontinence pads, or leave people who are incontinent wet or soiled.



A case study features the following account from an older person: ‘I don’t know. They do their best but they are short of the most basic equipment such as beds and commodes. There is very little privacy. How can you be treated with dignity lying in a hospital corridor?’ (Dignity and Older Europeans Project, 2007).



Behind Closed Doors is part of a wider BGS ‘Dignity’ campaign that aims to inform older people about their human rights in this area, while educating and influencing care providers and policymakers. Campaigners plan to use access to toilets and the ability to use them behind closed doors as an important benchmark of dignity and human rights among the most vulnerable.



Policy context


The NHS Plan (Department of Health, 2000) reinforced the importance of ‘getting the basics right’ and of improving the patient experience. Essence of Care, launched in 2001 and later revised, provided a tool to help practitioners take a patient-focused and structured approach to sharing and comparing practice (NHS Modernisation Agency, 2003). Patients, carers and professionals worked together to agree and describe good-quality care and best practice. This resulted in benchmarks covering eight areas of care, including continence and bladder and bowel care, and privacy and dignity (NHS Modernisation Agency, 2003).



However, the BGS cites a DH document on implementing the older people’s National Service Framework (Philp and DH, 2006), which argued that while overt age discrimination is rare in the care system, there are still deep-rooted negative attitudes and behaviours towards older people. This document recommended developing identifiable or named practice-based leaders in nursing who would be accountable for ensuring the dignity of older people is respected.



The Royal College of Physicians’ report National Audit of Continence Care for Older People found that those working in healthcare settings felt confident privacy and dignity were well maintained (primary care 94%; hospitals 88%; mental health care 97%; and care homes 99%) (Wagg et al, 2006). However, the authors added it would be interesting to know whether patients/users agreed with this assessment, pointing out it was ‘notable’ that only a minority of services had user group involvement (primary care 27%; hospitals 22%; mental health care 16%; and care homes 24%).



The audit asserted that while most trusts reported they had the ability to manage continence, the reality was that ‘care is well short of desired standards and that poor documentation means most have no way of being aware of the deficiencies’. It stressed there were many isolated examples of good practice and substantial reason to be pleased with the effect of the audit in raising awareness and the standard of care.



Campaign resources


Central to the BGS campaign is a set of 10 standards to ensure people’s privacy and dignity are maintained (see box, p23). The standards cover the following areas: access; timeliness; equipment for transfers and transit; safety; choice; privacy; cleanliness; hygiene; respectful language; and environmental audit.



The toolkit includes a decision aid for using the toilet in private. This outlines six levels of mobility and levels of safety for using the toilet alone, with recommendations for each level of mobility and safety.



For example, for a patient or client who is bed-bound and needs planned bladder and bowel management, the level of safety is specified as ‘unsafe to sit even with support’. For these patients the decision aid recommends using a bedpan or planned rectal evacuations as part of a bladder or bowel management programme, ensuring adequate screening with ‘Do not disturb’ signs.



The decision aid states that use of commodes may be appropriate in a single-occupied room at home or in a care setting provided they are used in private, and that if hoists are to be used then all measures to maintain modesty must be taken.



The tool for lay people to carry out an environmental audit for toilets in any setting covers a range of issues including toilet location, width of doorway, whether the door can be opened and shut easily and locked, assistive equipment and whether the toilet paper is within easy reach when seated on the toilet.



The campaign has devised an action plan for each of the four key target groups: hospital/care home staff; hospital/care home managers; policymakers and regulators; and the public and patients. The key messages for hospital and care home staff are as follows:



- Adopt the Behind Closed Doors standards;



- Review practice against these standards;



- Implement changes in practice to ensure they are achieved;



- Make available leaflets.





Promoting dignity and respect for patients is a fundamental part of good nursing care. This campaign provides useful tools and guidance to help nursing staff improve standards in a range of care settings.



Campaign standards


Access: All people, whatever their age and physical ability, should be able to choose and use the toilet in private, and sufficient equipment must be available to achieve this.



Timeliness: People who need assistance should be able to request and receive timely and prompt help, and should not be left on a commode or bedpan longer than necessary.



Equipment for transfers and transit: Essential equipment for access to a toilet should be readily available and used in a way that respects the dignity of the patient and avoids unwanted exposure.



Safety: People who are unable to use a toilet alone safely should normally be offered use of a toilet with appropriate safety equipment and with supervision if needed.



Choice: Patient/client choice is paramount; their views should be sought and respected.



Privacy: Privacy and dignity must be preserved; people who are bed-bound need special attention.



Cleanliness: All toilets, commodes and bedpans must be clean.



Hygiene: All people in all settings must be enabled to leave the toilet with a clean bottom and washed hands.



Respectful language: Discussions with people must be respectful and courteous, especially regarding episodes of incontinence.



Environmental audit: All organisations should encourage a lay person to carry out an audit to assess toilet facilities.

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