An audit that collected the views of patients and nursing staff highlighted key points to improve patients’ privacy and dignity when they were using the toilet in hospital
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In this article..
- How issues around using the toilet can affect patients’ dignity
- Carrying out an audit to gather views on the issue
- Actions taken to improve privacy and dignity
Karen Logan is nurse consultant and head of continence service, Llanfrechfa Grange Hospital, Cwmbran, Torfaen.
Logan K (2012) Toilet privacy in hospital. Nursing Times; 108: 5, 12-13.
Good practice in toilet management and continence promotion can help hospital patients to maintain their dignity.
This article reports on an audit that highlighted the issues important to patients and nurses in terms of improving privacy and dignity for inpatients using the toilet.
Keywords: Continence/Toilet use/Privacy/Dignity
- This article has been double-blind peer reviewed
- Download a print-friendly PDF file of this article here
5 key points
- Dignity is about small things that are extremely important
- Concern is growing that inpatients’ expectations are not being met in terms of dignity, particularly for older people
- Without sensitive support, continence care can become undignified and impersonal
- Ensuring patients have privacy and dignity when using the toilet is crucial
- Privacy pegs and signs can help give patients more dignity
Dignity is a complex concept, with a value and philosophy that is central to nursing. In its “Dignity: at the heart of everything we do” campaign, the RCN said dignity should be central to every task nurses are involved in.
Dignity is often about small things that are extremely important, such as maintaining hygiene and personal appearance, having access to the toilet, being offered choices and being involved in decisions.
However, there is mounting concern that hospital patients’ expectations are not being met in relation to dignity, particularly among older people.
Recent media coverage and Care Quality Commission and government reports continue to suggest the NHS is failing patients in this area.
Using the toilet is a private activity and patients are likely to be embarrassed if other people can see or hear them while doing this. An inadequate response to the toilet needs of those who are confined to bed, including poor continence management on wards, needs to be addressed. Without sensitive support, continence care can become undignified and impersonal (Averall, 2010). The Mid Staffordshire Foundation Trust Inquiry (2010) report made numerous references to failings in continence care and toilet use management. The Royal College of Physicians’ (2010) audit highlighted the need for improvements in continence care and privacy when using the toilet.
This audit and various government reports prompted a local internal audit that reviewed the processes at an NHS health board in South Wales to ensure patients were treated with dignity and respect, particularly in terms of toilet issues.
The audit aimed to give us information that would enable us to:
- Improve care for people needing help with using the toilet or who had special continence needs;
- Improve the ward environment to meet patients’ privacy and dignity needs in relation to personal care and to ensure they can use the toilet in private;
- Enable ward nurses to ensure that people’s privacy and dignity is respected while in hospital.
Questionnaires were designed to obtain the views of patients and nursing staff. Permission to conduct the audit and visit wards across different hospitals in the board was sought from the nurse director, and lead divisional nurses were informed that ward visits would be taking place during November and December 2010.
Random wards and departments from different specialties within acute and community hospitals were visited, including urology, stroke and elderly care/rehabilitation areas. Informal interviews were held with patients and nursing staff. Further questionnaires were distributed and left with other nursing staff; these were subsequently posted to the audit department.
Information was collated from mixed wards in two large district general hospitals (DGHs) and from three smaller community hospitals. In total, the views of 78 patients and 79 nursing staff were collected.
Some questionnaires were returned with the ward details and staff grades omitted, which made data analysis and feedback to wards more difficult.
Table 1 shows the patient questionnaire results and Table 2 shows the nursing staff results.
Below is a small selection of comments from patients and staff in each setting.
General remarks from patients in DGH 1:
- Cannot reach call bell, cord too short;
- Toilet not big enough to close the door when using a wheelchair.
Comments from nursing staff in DGH 1:
- Refurbished female toilets is a must; mornings are very busy and extremely difficult for patients and staff to accommodate all patients in such a small area;
- Bed curtains are very poor and difficult to close.
General remarks from patients in DGH 2:
- Have gone to use the toilet and found a lady sitting on the toilet;
- No designated single-sex toilets. Shared washing facilities.
Comments from nursing staff in DGH 2:
- Do not disturb peg/signs for curtains in bay please;
- Need designated room to see patients who do not have a bed to discuss private issues.
General remarks from older patients in three community hospitals:
- Sometimes you have to wait for the commode;
- Had to wait 30 minutes for commode, staff are really busy.
Comments from nursing staff in community hospitals:
- [Need] privacy pegs and signs for no entry;
- [Need] more soap and towels for handwashing.
Action after the audit
The audit results were discussed with the nurse director and presented to the health board’s patient quality and safety committee. The health board has since called for a zero-tolerance approach to poor continence care across the organisation.
An audit action plan and recommendations for improvement at ward level were discussed. Collaboration with divisional lead nurses is planned to implement the agreed actions, develop recommendations and support and monitor ward progress, and a re-audit is planned for 2012.
Key points from the audit
The audit revealed important points that nurses need to consider on the importance of ensuring good practice in toilet use.
Most issues were around the need to improve the environment in terms of better privacy for patients, not only in relation to personal care and toilet use but also when discussing confidential information.
The organisational nursing metrics process (Foulkes, 2011) and “transforming care at the bedside” (Unruh et al, 2011) will help to ensure a more rapid response to call bells. Regularly offering to take patients to the toilet avoids the use of commodes at the bedside where possible.
infection control nurses have been asked to address the problem of failure to offer soap and water for handwashing to patients who have used the toilet at the bedside.
To improve privacy and dignity in wards, the continence service has obtained sponsorship and funding to supply privacy pegs and signs for use on all bed curtains, indicating when personal care should not be disturbed. The audit showed use of these in many areas was limited and nurses asked for more to help maintain privacy. The new pegs and signs will include tips for improving toilet use and promoting continence to remind nurses of best practice.
This audit aimed to improve privacy and dignity in toilet use and promote continence and good practice in ward areas.
It has gone a long way to meet these objectives.
It is also supported by a rolling programme of continence education and, supported by the corporate nursing team, it has helped to drive a culture change towards improved dignity in continence care.
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Averall W (2010) Clinicians must remember that dignity is a private affair. Continence UK; 4: 1, 10.
Foulkes M (2011) Nursing metrics: measuring quality in patient care. Nursing Standard; 25: 42, 40-45.
Mid Staffordshire Foundation Trust Inquiry (2010) Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009. London: DH.
Royal College of Physicians (2010) The National Audit of Continence Care. London: RCP.
Unruh L et al (2011) The business case for transforming care at the bedside among the “TCAB 10” and lessons learned. Nursing Administration Quarterly; 35: 2, 97-109.