VOL: 102, ISSUE: 20, PAGE NO: 29
Diane Wilson, BA, RGN, is education and practice development nurse, University Hospitals of Leicester NHS Trust
An older people’s training and education team was implemented at the University Hospitals of Leicester NHS Trust in October 2004 as part of a government-funded initiative. The team aims to help staff enhance care for people aged over 65 years and to implement the National Service Framework for Older People.
The Department of Health (2001) has stated ‘older people occupy around two-thirds of hospital beds’, so the team works in different areas to ensure staff have the training and support to care for older patients effectively. The team covers three sites, working directly with staff on the wards and departments, and rotates around the different wards every 10 weeks.
Identification and implementation of change to enhance the care of older patients is one of the functions of the team. As part of this remit, many accepted practices are evaluated in the context of enhancing care for older patients, and where appropriate, changes are recommended.
From my experience on the wards, it is accepted practice for patients to wear nightclothes. Standard convention dictates that there is no exception to this rule and the requirements of the individual are not considered. It is a traditional expectation that upon hospital admission patients will be required to change into nightwear. Nightwear is the expected uniform of the inpatient and facilitates differentiation from other people on the ward.
The DH (2001) NSF for Older People states: ‘In hospital if patients choose to wear their own clothes, they are enabled to do so’. In practice, how often is this considered? In my experience, individual circumstances are unlikely to be evaluated with regard to providing this choice, even in cases where the dignity and independence of the individual could be significantly improved as a result.
A lack of dignity and respect for cultural differences may inhibit the patient’s well-being. This is supported by DH policy (1996), which states that ‘you can expect the NHS to respect your privacy, dignity and religious and cultural beliefs at all times and in all places’.
Patients may have preferences or cultural beliefs that influence what they would prefer to wear in hospital. However, it is unlikely that most patients would feel empowered enough to challenge the conventional dress code for inpatients.
Freedom to choose
Clearly, the freedom to choose between day clothes and nightclothes for all inpatients is not right in all circumstances but that does not mean it should be discounted for all. There are a significant number of factors that need to be considered when evaluating the benefits of offering this choice. These include:
- Duration of hospital stay;
- Mobility of the patient;
- Resource impact;
- The provision (by relatives/friends) of suitable/clean daywear;
- The impact on patient well-being;
- Nursing and medical procedures that the patient is likely to undergo during their stay in hospital.
Milner (1982) states that ‘it could be argued that patients wearing their own clothes makes it more difficult for doctors and nurses to carry out examinations and procedures, but it must be remembered that hospitals are supposed to run for the patients’ health - both psychological and physical and not for staff convenience’.
There are some key groups of patients who are more likely to pass this evaluation criteria, including:
- Patients waiting for elective surgery;
- Patients undergoing rehabilitation;
- Patients waiting to leave hospital (especially older patients).
A significant proportion of these patients are mobile, independent, and will remain in hospital for a number of days if not weeks. These patients are also more likely to benefit from the independence afforded to them as a result of being able to wear day clothes. This includes the freedom to leave the ward area, preservation of personal dignity and the suppression of feeling institutionalised.
For older patients the benefits may be more extensive. Wearing day clothes can help uphold self-respect and promote independence, providing a good sense of well-being in preparation for discharge.
To evaluate the benefits of having a choice of what to wear in hospital from both patient and staff perspectives the Odames ward at the Leicester Royal Infirmary agreed to participate in a case study. The scope of the case study was not merely to canvas opinion but also to implement a full trial of offering qualifying patients the choice of wearing their own clothes during their stay on the ward.
This ward is primarily an elective medical day case unit but also cares for up to 18 inpatients. Inpatients are medically fit, but require assessment and intervention to improve their quality of life and promote an effective safe discharge. Patients are transferred from various wards throughout the hospital and are often waiting for alternative accommodation or rehabilitation on specialist units.
The ward’s philosophy is to regard all patients as individuals, treating them at all times with dignity and respect, tailoring their care to meet their own holistic needs from the moment they are admitted to the moment they are discharged. A First Class Service - Quality in the New NHS states that ‘patients in the NHS are entitled to high quality care’ (DH, 1988). The nursing staff endeavour to meet the individualised, holistic care needs of the patient, promoting choice and independence wherever possible. Well-being and a good-quality service are high on the agenda and quality of care for patients is well documented.
The framework for the case study was as follows:
- Survey pre-introduction of daywear;
- Introduction of the choice to wear day clothes;
- Survey post-introduction of daywear.
An informal patient survey was carried out to canvass patient opinion.
This was specifically targeted to provide evidence that patients would like to wear daywear given the opportunity and to identify the perceived benefits and difficulties that may be experienced as a result.
As part of the introduction of the trial a number of activities were completed to support its implementation. Ward literature was introduced in the form of leaflets and posters. These were primarily targeted at the patient’s relatives and friends on whom a regular supply of laundered day clothes would depend.
Care plans for personal care were updated to include the option of wearing day clothes where appropriate. A standard letter was produced for distribution (before the patient’s admission) to residential and nursing homes requesting that a patient’s day clothes be provided.
Staff were surveyed to determine the impact that patients wearing day clothes had on their day-to-day activities and also to gauge their opinion of any change in patients’ overall well-being. Patients were surveyed again to find out if their perceived benefits or concerns identified in the initial survey were realised.
At the time of the study the ward had 15 permanent members of staff consisting of eight registered nurses and seven auxiliaries. Students and bank staff also contributed to the staffing levels. A representative cross-section of staff was included in the pre and post surveys with a sample size of 11.
Random samples of 10 male and female patients from diverse backgrounds were selected for the initial survey prior to any change. A slightly larger sample of 13 patients were questioned in the post-change survey. The survey was completed over a four-week period and six patients were discharged within this time frame.
Review of possible outcomes
The first and perhaps most significant outcome to consider is whether or not patients on the ward believe that the choice to wear day clothes is a valuable option to have. Clearly if patients do not feel inclined to break with tradition and do not recognise any of the probable benefits, then associated theories of enhanced well-being, independence and preservation of dignity all fall by the wayside. To achieve a positive outcome and for acknowledgement of the possible benefits the change has to be something that is actively desired by the patient.
There are likely to be some practical concerns for both ward staff and patients with the introduction of the change. Patients may worry about the practicalities of changing between day and night wear and ensuring a good supply of freshly laundered clothes. They may feel that it is an unfair imposition on friends and relatives on whom they depend.
Patients may also consider that they are placing an additional burden on the staff who are required to assist with dressing and undressing. Staff may question the wisdom of the change, may be apathetic in its implementation and may also have concerns over the additional workload that could be generated.
The change could contribute to social disharmony on the ward, creating a two-tier hierarchy of patients, those able to wear day clothes who can benefit from the freedom and independence this brings and those confined to the ward areas because they are constrained by wearing nightclothes.
Hygiene issues could also arise with patients who choose to wear day clothes who do not have adequate support to maintain a fresh supply of clothes. This in turn can add pressure to the staff who find themselves having to police the cleanliness of daywear.
Positive outcomes could include a boost to the patients’ well-being. Contributory factors are independence achieved by freedom to move around the hospital, and preservation of individuality, personality and dignity. Wearing nightclothes, especially among complete strangers, can contribute to an increased feeling of vulnerability that is not apparent in people who have the familiarity of wearing their own day clothes.
The findings of the patient surveys undertaken before the introduction of daywear are reported in Box 1 (p29) and those post-introduction in Box 2.
It is interesting to note that many patients thought that wearing day clothes would give them the freedom to leave the ward. However, the post-introduction survey showed that day clothes actually had little effect on this and the staff survey results confirm this (Box 3).
The survey results from staff and patients showed that staff on the ward agreed that offering the choice of wearing day clothes and assistance with dressing and undressing was not a problem.
Almost all staff (90%) thought that wearing day clothes had a positive effect on patients’ sense of well-being and all staff said that they were committed to achieving the objective of enabling patients to wear their day clothes.
This study highlighted the importance of practical considerations when implementing change and how likely these are to affect the outcome.
Ward staff implemented this change with enthusiasm and professionalism. Staff feedback was both constructive and positive, with the overall consensus being that the change was good for the patients.
For the patients who chose to wear day clothes, the benefits appear to be encouraging but the full significance of this is not easily quantifiable.
A change to patient dress code is not appropriate for all patients. Of those who could benefit and are given the choice, many will choose not to take advantage of it. Those who do elect to wear day clothes could benefit from a positive contribution to their overall sense of well-being and at the very least day clothes will provide them with individuality, familiarity and comfort on the ward.