An audit revealed single sex accommodation in an acute medicine unit greatly improves patient satisfaction
In this article…
- Single-sex accommodation standards for acute medical units
- AMU patients’ opinions of being cared for in mixed-sex bays
- An action plan to eliminate mixed-sex accommodation
Liz Lees, is consultant nurse and clinical dean, acute medicine; Grainne Buggy is matron, acute medicine; both at Heart of England Foundation Trust, Birmingham
Lees L, Buggy G (2010) Promoting single sex acute units. Nursing Times; 107: 4, early online publication.
This article discusses the findings of an audit conducted to explore patients’ experiences of being nursed in mixed-sex accommodation on an acute medicine unit.
It outlines achievements resulting from the audit, which include staff awareness of the effect on patients of admission to mixed-sex accommodation and changing the organisation culture within the unit to embrace single-sex-accommodation.
Keywords: Acute medicine units, Patient experience, Privacy, Dignity, Single-sex accommodation
- This article has been double-blind peer reviewed
5 key points
- Mixed-sex bays can undermine privacy and dignity
- All staff should be aware of the single-sex accommodation standards
- Ward leaders should be able to make patient placement decisions that promote single-sex accommodation
- Single-sex accommodation can be achieved even in areas with high patient throughput
- Staff support is crucial to succeeding in eliminating mixed-sex accommodation
This article discusses the results of an audit conducted to explore patients’ experiences of being nursed in mixed-sex accommodation on an acute medicine unit (AMU). It describes the feelings expressed by patients and indicates why patients should be nursed in single-sex accommodation.
The baseline audit revealed comments from patients highlighting major concerns. In contrast, the follow-up audit showed that the issues had been resolved when single-sex accommodation (segregated bays) were successfully introduced or maintained on the AMU.
The main achievements resulting from the audit were:
- Staff awareness of the effect on patients of being admitted to mixed-sex accommodation was raised;
- Staff learnt about the single-sex standard (Department of Health, 2009b);
- The organisation culture within the AMU changed to embrace single-sex accommodation.
This work has succeeded in changing nurses’ perceptions that single-sex accommodation cannot be achieved within an AMU. In conducting this audit we built on previous evidence from corporate and quality improvement work (Hunt, et al, 2010; Maxwell, and Sigsworth, 2009) by developing a local AMU standard, guidelines, and a bespoke survey designed to extrapolate patient-centred concerns. The lessons learned can be transferred to all hospital admission and assessment areas, such as clinical decision units, surgical assessment units and day case units.
The Heart of England Foundation Trust has undertaken a series of initiatives to enable the gradual elimination of mixed-sex hospital accommodation and improve patient dignity and privacy in ward areas (Department of Health, 2009; NHS Institute, 2007). This includes building work to improve bathroom facilities, erect partitions and increase toilet facilities.
While this work concentrates on the physical environment and compliance, we felt it was important to also understand patients’ experiences of acute medical admissions in order to bring about patient-centred improvements.
Acute medical units are specialist areas in acute hospitals, which comprise of two parts; assessment and short-stay admission beds (RCP, 2007). They differ considerably from traditional wards in staffing, skills and organisational processes, and have a large patient throughput – at our trust this is 1,500 patients a month.
Since AMUs do not have a fixed number of male and female beds they need a flexible approach to designating beds and bays of accommodation, according to the volume or sex of patients referred for assessment or admission during any particular shift. For this reason AMUs are always labelled as mixed-sex units, with designated male and female single-sex bays to separate patients’ sleeping areas.
Delivering single-sex accommodation in AMUs requires expert coordination of patients referred for assessment, admissions, transfers to other areas of the hospital and discharges. It is crucial that staff across the whole emergency pathway work as a team, otherwise single-sex sleeping bays cannot be accommodated in an AMU.
Nurses working in areas treating a high volume of patients should consider individual patients’ anticipated journey before they are transferred - it is preferable to place them in the right place, first time (RCP, 2007). For example, moving patients from ward to ward to locate single-sex accommodation is counterproductive on both an organisational and clinical level. From an organisational perspective, each time a patient is moved a range of resources are used including porters, bed cleaning, escorts and bed management.
Clinically, patient transfers increase the likely morbidity or length of stay and the potential for mistakes in the transfer details.
However, if the single-sex standard is adhered to from the moment patients enter the emergency care pathway, our audit indicates that it is possible to achieve single-sex accommodation in designated (Bonner, 2009). Patient flow and placement is challenging, but if single-sex accommodation is accomplished in the AMU it sets a precedent for all other areas of the hospital (RCP, 2007).
Our aim was to audit compliance against the national single-sex accommodation standard. We also wanted to look at patient perspectives of being nursed in mixed-sex accommodation on an AMU and how that affected their dignity and privacy.
The consultant nurse, matron and senior sisters devised local standards for the AMU based on national guidance (DH, 2009a,b,c,d; DH and National Patient Safety Agency, 2009), modified minimally to suit local context. We placed particular emphasis on understanding the environment within an AMU, so we added a standard (2) for clarity, to ensure staff understood patients must be nursed in a single-sex bay regardless of whether they were being assessed or admitted for a short stay (up to 48 hours).
Our standards are:
- All patients being assessed and admitted to the AMU will be segregated into single-sex bays.
- A single-sex bay is applicable to the assessment and the admission area.
- If any patients are admitted to a mixed-sex bay their stay should not exceed 24 hours in the area.
- Patients will be kept informed and moved to a single-sex bay within 24 hours.
- In accordance with the national standard, exceptions are only permissible where patients require a rapid admission, and segregation into a single-sex bay is not possible at the time. All exceptions will be monitored.
The Department of Health guidance has since been superseded (DH, 2010a; 2010b; 2010c), but the main messages remain the same as in the 2009 guidance. These are founded on the principles of eliminating mixed-sex accommodation, choice, information, monitoring and exception for patients requiring rapid admission only.
The audit was conducted prospectively using a semi-structured survey instrument at patients’ bedsides in the first 48 hours of their inpatient stays. We used a prospective design because patients do not spend their whole episode of care on an AMU and we were keen to establish their perceptions of the unit. After 48 hours patients will be transferred to an appropriate ward, which accommodates a longer length of stay. Ultimately this facilitates bed availability for new referrals to be seen in the AMU. After 48 hours, the resources and issues involved in providing single-sex accommodation are beyond the remit of an AMU.
The survey was in two parts. It featured questions to explore compliance to the single-sex standard (whether patients were nursed in a mixed-sex area), and included optional questions to investigate any privacy or dignity issues that might have resulted from being nursed in mixed-sex accommodation. The questions were structured around the process of care that patients experience throughout their stay on the AMU, which is divided into five clinical stages: assessment, examination, treatment, investigations and ward rounds.
A member of the administrative and clerical team on the AMU was briefed to conduct the survey and suggested changes to the original tool after piloting. She then conducted the bedside interviews and administered 108 surveys during both early and late shifts on the AMU. The audit of baseline data and re-audit took place over a six-month period from November 2009 to April 2010.
During December 2009 108 patients were surveyed. Of these, 100 were cared for in a mixed-sex bay; the remaining eight were removed from the audit data at this point as the aim of the audit was to explore perspectives of being nursed in a mixed-sex bay. The survey revealed:
- Fifty-eight of the 100 patients were comfortable with being cared for in a mixed-sex bay, while 42 were not;
- Eighty -two had not been told they would be in a mixed-sex bay;
- Ninety-four were not kept informed of when they would be moved into a single-sex bay;
- Sixty-nine were not moved into single-sex accommodation within 24 hours, while 11 were moved – the remaining 20 were removed from the data for this question as they had only been in hospital 12 hours at the time of the survey;
- Thirty-nine felt their dignity and privacy had been compromised by being nursed in a mixed-sex bay - the 61 who felt their dignity and privacy was not affected were removed from the data for the remaining questions as they questions would be irrelevant to these patients.
The 39 patients who were affected by being cared for in mixed-sex accommodation were asked to complete the second part of the survey exploring which part of the process within the AMU had caused them concern. Graphs of the responses were made to demonstrate satisfaction or dissatisfaction in each area of the ranking scale.
Analysis of patient comments
Comments from the 39 patients for whom dignity and privacy had caused concern were analysed. Five main themes were evident from the whole content of all responses (Table 1). It would seem that when privacy is threatened patients recall this above all other aspects of the care episode, perhaps because it is such a vivid experience at the time.
Statement 6 from the questionnaire asked patients to rank the comment: “I felt I had enough privacy when I was being examined by the doctors or nurses” (Fig 1). We selected some comments from the patient responses to demonstrate where patients they expressed concern about privacy. We also came up with some interpretations of the possible care issues taking place to prompt such comments.
“The curtains were opened before I was dressed properly and it was very embarrassing with men opposite.” Female patient. Poor organisation of care with on-looking patient of opposite sex.
“Curtains were not always closed properly, especially during the ward rounds and I felt really exposed to all the men in the bay.” Female patient. Indicates a problem with care interactions.
“Nurses were always popping their heads in and out of the curtains and this left me on edge using the bottle in the bay of ladies.” Male patient. Indicates a problem with lack of control for the patient over their environment.
Privacy and dignity
The patients’ comments indicate that not only privacy was being affected but also dignity. Dignity is present when people feel in control, valued or comfortable (Baillie, 2007). Maintaining patient privacy is a pivotal part of the nurse’s role and is inextricably linked to the environment in which care is delivered. However, the environment is much more than the building and unit layout; it also encompasses the culture among the staff and practices (Maxwell and Sigsworth, 2009). Privacy and dignity are inseparable in the context of patient care and undoubtedly heighten patients’ anxieties in the context of mixed-sex bays.
Before the work to eradicate mixed-sex bays on the AMU was undertaken, the practice of closing curtains around beds to segregate male and female patients was widespread. This was based on the assumption that it eliminated potential adverse privacy issues and adequately segregated male and female patients (Burden, 1998). Paradoxically, hospitals are designed to provide optimal layouts for patient visibility, so this is poor practice – particularly since patients nursed in an AMU need to be observed (Carayon and Schoofs-Hundt, 2006). Single-sex bays eliminate the need to have screening to offer privacy from the opposite sex.
The audit was presented to nursing staff at away days, and circulated by email. We drew up an action plan with three main aspects warranting immediate improvement on the AMU and submitted them to audit governance (Table 2).
In March 2010, five months after the first audit cycle, the re-audit of 100 patients took place using the same survey instrument. Over the one-month survey period 96 out of a sample of 100 patients surveyed had been nursed in a single-sex bay during the assessment or admission phase, compared with the first audit, in which 100 out of 108 patients had been nursed in a mixed-sex bay. We had not anticipated there would be such a vast improvement.
Nurses on the AMU have indicated that hospital policy and deciding the organisational process of how male and female patients could be segregated and nursed in single-sex bays had the greatest impact in ensuring the standard was met. Before this, it had been thought that it would be impossible to change practice. The results of the audit and the comments about privacy were also considered in terms of changing the way patients are nursed. It is a matter of thinking ahead – being proactive and organised.
Patients’ comments revealed in the first audit cycle were communicated to the team through meetings and an audit report. Gradually this feedback has had an impact upon care and raised awareness about patients’ perspectives on privacy and dignity if they are nursed in a mixed-sex bay. The audit demonstrated that mixed-sex bays do lead to dignity and privacy issues. We will continue to revisit the issue through surveys so that the quality of care can be improved.
This work demonstrates that it is possible to introduce single-sex bays on an AMU. Setting out staff responsibilities and expectations, supported by a “zero tolerance” trust policy has led to a huge change in the way patients are placed and nursed on the unit (DH, 2010b). The multidisciplinary team responded positively to the change in practice and the nurse coordinators (predominantly sisters) work hard to maintain single-sex bays.
Acute medicine is a notoriously challenging area in which to introduce single-sex accommodation, and will be subject to variances according to hospital capacity. That said, in the words of one sister: “It has made our life a lot easier and it is so much better for the patients.” If staff feel happier this should promote the single-sex standard and make mixed-sex bays for the most part, a thing of the past.
*The survey instrument and the local AMU guidelines are available on request: Liz.firstname.lastname@example.org
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