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Improving patients' privacy and dignity on mixed-sex wards

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VOL: 103, ISSUE: 21, PAGE NO: 23

A report by the chief nursing officer for England (CNO, 2007) has highlighted shortcomings in the provision of sing...

A report by the chief nursing officer for England (CNO, 2007) has highlighted shortcomings in the provision of single-sex accommodation in hospitals. The report by Christine Beasley, which was published earlier this month, says that 28 of the 172 acute trusts are still struggling to provide single-sex accommodation for all non-emergency patients (NT News, 15 May 2007, p2).

In the report she states: 'Patients and the public want their privacy and dignity to be respected while in hospital. Single-sex accommodation is a visible affirmation of the NHS's commitment to the subject. It should be the norm in all elective care, and it remains the ideal for all wards and departments.'

The report adds that single-sex accommodation is not the only important feature in ensuring privacy and dignity - on the rare occasions when mixing of the sexes is unavoidable, other factors can turn 'a poor experience into an acceptable one'. This involves paying attention to broader issues such as hospital cleanliness, staff attitudes and hospital food. But the Department of Health report insists that mixed-sex accommodation 'can sometimes be eliminated, can often be reduced, and can always be better managed', adding that 'action is required at all levels'.


The DH commissioned a survey to investigate patient and public views, using focus groups and face-to-face interviews (Ipsos MORI, 2007). This project, involving more than 2,000 people, found that segregation of the sexes is rated behind other aspects of care, in particular cleanliness and good staff attitudes, in delivering high standards of privacy and dignity. Findings from the survey included the following:

- When asked to choose three items from a list of 12 features promoting privacy and dignity, more people chose 'a clean hospital' than any other single factor;

- Human factors such as being kept informed and having thoughtful staff were chosen above 'being in a single-sex ward or bay' and 'having private toilet/washing facilities', which were ranked seventh and eighth;

- Older people, and women in general, were less tolerant of mixing;

- People were less tolerant of mixing for elective admissions, longer stays and gender-specific procedures such as prostatectomy and hysterectomy;

- Single rooms were preferred by around 35% of people, and small, single-sex bays by around 40%.

The report states that these findings mirror those of a Picker Institute study, which asked recent patients to rank the importance of issues covered by the Healthcare Commission adult inpatient survey. Out of a total of 82 features covering all aspects of patient experience, the statement 'I do not have to share a sleeping area with patients of the opposite sex' was ranked 62nd overall (72nd for men and 49th for women). Other privacy-related features were rated more highly, including 'I have privacy when I am being examined or treated by hospital staff (ranked 13th), and 'I am treated with respect and dignity by hospital staff' (ranked 28th).

But the CNO stresses that these insights into patient priorities do 'not mean that we should rein back on our efforts to eliminate mixed-sex accommodation - far from it'. She points out that it helps to understand the complexity of factors at work where respect and dignity are concerned, ensuring that single-sex accommodation is not seen as the only important issue.


The report outlines ways to segregate patients in hospital according to gender, and describes circumstances in which some degree of mixing may be appropriate. It also recommends what actions are to be taken on those occasions when full segregation is not possible, focusing on ways to maximise privacy and dignity (see box, below).

It identifies a distinction between mixed-sex accommodation and mixed-sex wards. The report explains that provided men and women are cared for in separate bays or rooms (a type of single-sex accommodation), and have their own toilet facilities, it may well be appropriate for them to be on the same ward, being cared for by the same team.

For some people and in some situations, having all wards as entirely single-sex will be the best solution, the report says. However, it accepts that this is unlikely to be a realistic goal for all wards, largely because of the need to bring people with the same conditions together. Where patient care requires specialist nursing and medical skills, it may be better for patients to receive their care in the same ward from a single team.

The report concludes that in practice good segregation can be achieved if men and women have separate sleeping areas (such as single-sex bays) and separate toilets and bathrooms that they can reach without having to pass through (or close to) areas in which the opposite sex are accommodated. The DH report states that ward layouts should minimise the risk of inappropriate visual contact and patients being overheard by members of the opposite sex.

Patients and the public accept that, in some circumstances, segregation will be impossible, such as in intensive care units and for emergency admissions. But the CNO insists: 'Nonetheless, some attempt at segregation should always be apparent, as this reassures patients and relatives that all possible steps are being taken.'

Short-stay areas such as day surgery units should normally be segregated, especially in units where an overnight stay is common. Exceptions might be made in the case of very minor procedures where patients do not need to undress or be exposed.


Those groups for whom segregation is especially important are outlined. The report explains that older people, and women generally, find mixed-sex wards particularly difficult. Most elective patients expect single-sex accommodation. Children, and in particular adolescents, need special consideration, the report adds. Under the National Service Framework for Children, segregation by age is a more important issue than segregation by gender, particularly for adolescents, but they also want to be able to choose between being in a single- or a mixed-sex environment.

Two sections of the CNO's report recommend further actions by the NHS and the DH. The NHS section covers three categories: buildings, organisations and people, with practical recommendations at each level. The section covering actions by people/staff explains that the NHS has a generally good record of maintaining privacy and dignity, but adds that relatives and visitors will notice immediately if the accommodation is mixed. It is recommended they should be included in all actions aimed at improving privacy and dignity, so they understand that everything possible is being done.

The report recommends that nurses and healthcare professionals should act in the following manner:

- Give as much control as possible to patients by not passing through closed curtains unannounced; asking patients how they wish to be addressed; and, offering a choice of single-sex room or bay if available;

- Challenge poor practice;

- Consider becoming a dignity champion;

- Apologise for every episode of mixing;

- Give extra personal nursing support to patients in mixed bays, for example by using a separate quiet room for personal conversations; avoiding giving personal care such as toileting in the bay where possible; and allocating extra nursing time to confused patients who may act in an inappropriate manner.


The CNO will publish more detailed good practice guidance later this year, which will include special attention to the needs of mental health service users. The report concludes: 'For some patients, mixed-sex accommodation is not a problem but for many it is a source of real distress. We need to acknowledge this, and work to eliminate it in all but the most unusual of circumstances.'


Human factors:

- Explain and apologise for every episode of mixing;

- Ensure greater staff presence if mixing occurs;

- Reinforce high standards of respect.

Organisational factors:

- Record all episodes of mixing;

- Set and publish local standards on mixing;

- Set and publish local targets for improvement.

Environmental factors:

- Place men and women at opposite ends of rooms;

- Segregate toilet facilities;

- Provide at least some single-sex bays;

- Enhance screening.

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