ENTRAR            

ORIGINALS

Privacy at the Hospital. The experience of patients, their families and nurses*

Joaquín Jesús Blanca Gutiérrez,¹ Rafael Muñoz Segura,² Miguel Ángel Caraballo Núñez,³ María del Carmen Expósito Casado,⁴ Rocío Sáez Naranjo,⁵ María Elena Fernández Díaz^6
1Supervisor de la Unidad Especial-Urgencias. ²Enfermero de Medicina Preventiva. ³Supervisor de Hospitalización. ⁴Enfermera de la Unidad Especial-Urgencias. ⁵Supervisora de Consultas Externas. ⁶Supervisora del Bloque Quirúrgico. Empresa Pública Hospital Alto Guadalquivir, Hospital de Montilla, Córdoba, España

Mail delivery: Joaquín Jesús Blanca Gutiérrez. Avda. de Andalucía, 8-5º C. 23006 Jaén, España

Manuscript received by 7.9.2007
Manuscript accepted by 26.2.2008

Index de Enfermería [Index Enferm] 2008; 18(2): 106-110

*This work has been supported by a research project developed within the program QUID INNOVA from the Public Health System of Andalucía. Funding was provided by the research grants of the public enterprise Hospital Alto Guadalquivir's on their 2006th edition

How to cite this document

Abstract

Introduction. The maintenance of the intimacy inside the Hospital is sometimes forgotten for other more technical aspects. From the juridical point of view it is considered from three different levels: a public sphere, a private sphere and the strictly intimate sphere. Some authors nurses have identified several facets inside it: the physical intimacy, the psychic one, the sociocultural one and the related one to the information and the confidentiality.
Methodology. Qualitative study of descriptive type. The methods to gather the information have been depth interviews and participant observation.
Results. Four big central categories are established: meaning of the intimacy, the relation with the cohabitants in the Hospital, extrinsic factors that determine the experience of the intimacy and intrinsic factors.
Discussion. Few original studies with phenomenological approach that treat the topic. There are studies that approach topics related to the intimacy in the Hospital as the human relations, the physical space, or the family's implication in the care.
Key-words: Qualitative research, intimacy, nurse, patient, familiy.

Introduction

    The care for the persons' privacy is often ignored by the care professionals themselves in favour of more technical elements, whereas it requires focusing on aspects such as the listening attitude, empathy and patient's autonomy. If we want the citizens to benefit from the concept of health understood as the prime of the person's happiness, it is fundamental to educate nurses in these and other ethical aspects and establish health politics based on the respect for autonomy and human dignity. Managers and Institutional Committees for Ethics should warranty nurse cares focused on the care of privacy.¹
    From the legal point of view, legislation considers three different levels of privacy: a public sphere, a private sphere and an intimate sphere (which is the one more related to our present research work) that comprehends the information about the racial origin, sexual life and religious beliefs. Within the framework of Health, there are published rules about the protection of privacy: the Royal Decree 994/1999, the ratification of the Agreement of Oviedo for the protection of the human rights and the dignity of humans related to the application of Medicine and Biology, and the Fundamental Law 15/1999, from the 13^th of December for the Protection of Personal Data.²
    From the Nursing point of view, some authors identify certain very well defined aspects within this concept: the aspects related to physical privacy, those related to the psychic privacy, to socio-cultural privacy, and those aspects related to information and confidentiality. In order to protect the patient's physical privacy, undressing people indiscriminately should be avoided. Only the strictly necessary clothes should be removed, and physical examinations should be done correctly in the sole presence of the professionals involved. Psychic intimacy is related to the individual's psychological dimension. Being it unique for each person, there are multiple ways for this dimension to be experienced or faced. Social and cultural privacy includes the ways in which it is felt by people from other cultures, societies and minorities. The concept of confidentiality implicates privacy when providing or managing the patient's information.³
    Williams made a revision of the existing literature studding the concept of privacy from the viewpoint of the relationship nurse-patient. The researches included in the revision differentiate physic, psychic and emotional-spiritual dimensions. The reviewed authors connect the nurses' high levels of involvement to negative effects on their capability to decide, and to emotional pain, suffering and tension. The author ends up her revision pointing at the need of holding more researches to study in depth the concept of "therapeutic privacy".⁴
    The objective of this work is to analyze the concept of privacy taking into account the experiences of the patients, their family/assistants and the nurses who become part of the structure of characters and interactions that configure the patient's stay in the hospital. We have proposed the following research question: How do the patients, their family/assistants and the nurses involved, experience privacy along their stay in a Hospital?

Methodology

     The present work constitutes a qualitative descriptive analysis. The reason to choose a qualitative methodology is the will to approach and understand a series of experiences lived by the people during their stay at the Hospital. The work has been done in the Hospital de Montilla (Córdoba, España) This Hospital gives coverage to a reference population of 60000 inhabitants (districts of Montilla, Aguilar de la Frontera, Fernán Núñez, La Rambla, Montemayor and Montalbán). It counts on a total of 50 hospitalization beds, 18 beds for special cares, a surgical area with 3 operating rooms and birthing room, 5 beds for day cares and 24 rooms for External Consultations. The average number of people taken care of daily at the emergency department is 119 patients per day.
    The tools used for the data compilation are the in-depth interview and the field notebook. In order to process the information gathered, interviews were coded and literally transcribed. A series of also coded categories and sub-categories for those interviews were established based on sets of properties and dimensions. Interviews were completely open at the beginning but started to become semi-structured according to the emerging categories and first codification steps.⁵ The activities notebook contains the notes taken during our participative observation (in fact we were both participants and observers as the authors of this work do live professionally immersed in the scenario used to compile data).⁶
    In order to select reporters, we have chosen two types of sampling: a theoretical sampling ("go to places, contact people and analyze events maximising the opportunities to discover variations of the existing concepts and therefore building more compact categories"),⁷ and an intentional sampling (we looked for those patients, relatives and professionals with whom the authors had a previous fluid communicative relationship, those who spoke Spanish fluently and those who had gone through processes or events interesting for our research). Interviews were done and notes were taken until information flood was reached within each category analyzed. 24 interviews were done: patients and relative involved in diverse processes of assistance (long stays with periods within the Intensive Care Unit and Hospitalization, birthgivings, surgical interventions...), not only Spanish but also foreign reporters (from Russia, Romania, Morocco, Brazil) and health professionals (nurses and auxiliary nurses).
    In order to warranty the methodological rigour of our analysis, it has been based on criteria of credibility, confirmation possibilities, contextualized meaning, recurrent patterns, and information flooding and transfer possibilities.⁸

Results

     Four central categories have been defined based on observations and testimonies. Results will be exposed on the basis of those four categories: meaning of privacy, extrinsic facts not related to patient-family determining the experience of privacy, intrinsic family-patient facts determining the experience of privacy, patient-family relationships with the rest of people coexisting in the room and professionals.

Meaning of privacy. Two sub-categories are established within this main category. The first one is the one defining the participants of the experience of privacy: the patient, his/her family (husband or wife, brothers, sons and daughters, mother and father), visitors (friends, neighbours, distant relatives), the people coexisting in the room (other patient and his/her respective relatives), health professionals, and strangers (maintenance staff, health professionals not involved in our patient-family's process..). The second sub-category within this block deals with the characteristics of the private atmosphere. There are positive easing features (respect, confidence, pleasant interactions, privateness, freedom of action, support, comfort, protection, calmness and confidentiality), and there are non-favouring features (nakedness, noises, nuisances, anxiety, lack of knowledge, lack of control and fear). These concepts can be dimensioned: the range of values admitted by the feature "respect" goes from "a very respectful ambiance" to a very "un-respectful ambiance" -that would make this feature a non-favouring feature instead.
    Privacy needs a physical space considered as the own space to take place. This space is considered as a private space and reporters always compare it to their own home space. The participants related to this private space are the partners, relatives, or the friend who goes along the process with the patient during the whole stay at the hospital [figure 1].
    The experience of privacy inside this personal space does not only depend on "who" stays in the private space, but also on "how" the person is introduced in that space. The concepts of permitted privacy and imposed privacy (both of them are 'in vivo' codes) are introduced in order to explain this situation. Permitted privacy is the situation in which people unconnected to the patient/family stay in their private space having been voluntarily accepted inside the privacy core ("in vivo" code), punctually or in a continuous way. On the contrary, imposed privacy is defined as the situation in which people unconnected to the patient/family remain within his private space without consent. With regard to the environment features, this space experienced as private is supported by a net built with the favouring features as materials. Non-favouring features are identified as located outside this environment [figure 1].

Extrinsic facts not related to patient-family determining the experience of privacy. Three sub-categories have been established: (a) Physical barriers: they are split into minor physical barriers (curtain, screen, sheets, dark windows, blinds) and mayor physical barriers (door, walls). (b) Tools to make the Hospital's room as similar as possible to the home: TV, DVD, newspapers, books, children pictures, letters, nice words written, posters, hammocks, folding chairs. (c) The third sub-category is the Hospital's policy of visits: null (no visits at all), close visits (only close relatives and from time to time), half-open (the spouse can stay as companion) and open (spouse as companion, added to visits of relatives and friends).
    Two types of spaces can be built to capture the experience of privacy at the Hospital based on these three sub-categories: a positive space for privacy and a non-positive space for privacy. The non-positive space contains situations of imposed privacy. It coincides in time with the first period of stay at the Hospital, when aggressive therapeutic interventions predominate due to the severity of the patient's process. The concrete physical spaces could be the box of an Intensive Care Unit, the operating room, and the rooms for diagnostic tests. The patient finds himself in a space surrounded by professionals which participate assisting him. But, around them, the patient finds as well other professionals not related to his process, other patients, and even some people which are totally unconnected to him. He can only separate himself from them using what we have called minor physical barriers. Family stays in the background, outside the patient's physical space due to a restrictive policy of visits. [Figure 2]. The second type of space is the space positive for privacy where the situations of permitted privacy predominate. In terms of time, these kinds of spaces are linked to the patient's recovery periods, when the process severity is lower. In physical terms, these spaces correspond to the rooms of the hospital's Hospitalization Unit. The policy of visits is then open. The patient has his spouse as companion (parents, brothers/sisters, sons and daughters as well) added to the sporadic visits of relatives and friends. Health professionals enter the patient's own space but, they do it occasionally and within a situation of consented privacy. The space is completed with a series of tools-objects brought from home by the patient-family in order to make the room as comfortable as possible. There might be another patient-family living together with them in the same room. Minor physical barriers exist to maintain certain separation among both groups. Mayor physical barriers avoid the presence of strangers in the personal space [Figure 3].

Intrinsic family-patient facts determining the experience of privacy. Sub-categories: patient's level of dependency-independency, family's level of involvement in the cares, and patient-family's previous hospitalization experiences.
    Patient's level of dependency-independency: the bigger the patient's dependency is, the higher quantity and quality of cares is needed. For this reason, in such case there will be more professionals, and during a longer time, moving inside the patient's privacy core. Patients with a high level of dependency will need support for the most of their basic needs. In that case, the factor determining the patient's privacy won't be the physical space configuration, but the professional's immersion in his personal core within an atmosphere of consented privacy.
    Family's level of involvement in the cares: a previous phase of training done by Care professionals is needed in order to involve the family. This phase and the subsequent participation ease a more fluent communication added to a closer relation with the professionals. Interaction within the consented privacy is strengthened as a consequence. When the family is involved in the cares process, the set patient-family achieves a level of independence higher than the one achieved individually by the patient.
    Patient-family's previous hospitalization experiences: previous experiences related to the Hospital environment lived by the patient and his family will have a direct influence on the establishment of relations with the professionals and people sharing the space. They will also determine their management of the physical spaces taking them in. Previous experiences proportionate a background easing the development of personal interactions inside the hospital, and increase the level of control of the environment (visits, adaptation to the room...).

Patient-family relationship with the rest of people coexisting in the room and professionals. The patient-family relationship with the rest of professionals and people coexisting in the room can be classified into three correlative levels: (a) Distant (the length of the stay is some hours). Properties: shame, fear, anxiety, pity, situations of imposed privacy. (b) Warm (the length of the stay is some hours-days). Properties: communication on superficial topics, kindness, reciprocity, tasks sharing, entertainment sharing, consented privacy vs. imposed privacy. (c) Familiar (the length of the stay is of days-weeks). Properties: friendship, communication on personal topics, confidence, relax, inclusion within the privacy core, consented privacy. The relationship with the people coexisting in the room is defined by the coexistence in a common physical environment. This implies sharing essential aspects of daily life like eating, drinking, using the same toilet, sleeping together in the space... This such close life together is complemented with situations of reciprocity, mutual help and respect established between both sets of patients-families. The relationship with the Health professionals is based on the provision of cares and on the training of the patients-families tending to self-care. The features that constitute this relationship are the exchange of information, confidence, sincerity, support-help, personalization and respect. The relationships' development makes the three groups (the patient-family, the patient-family coexisting in the room, and the professionals) constitute a wider privacy core with the consented privacy as predominant [Figure 4].

Discussion

     The works referenced by Williams' state of the art cited in this article's introduction analyze privacy from the point of view of the relationships nurse-patient, focusing on the professional's emotional involvement and its potential consequences.⁴ Several original research works have been found, some of them having also a phenomenological approach,⁹ but they are more related to this type of interaction nurse-patient, than to privacy as such. Dowling focuses again his work on this type of interaction (relationship nurse-patient) and uses as well the bibliographic revision to contribute with a series of explanations from the viewpoint of sociology.¹⁰ Excluding the work of Nieto Poyatos, who captures the experience of intimacy of the hemodialyzed patient¹¹ via participative observation, there are no analyses of the intimacy at the Hospital with a phenomelogical or ethnographical orientation within the Latin American scientific context. This type of analyses are only found regarding the experiences of patient and family within that environment, facing topics connected to those studied in our current work: physical space, human relations, family's involvement in cares, etc.
    Within his works about family caretakers at the Hospital Quero Rufian points out the influence of the Hospital's physical space on the patient-family, and on their way to adapt to this environment considered as hostile. He also studies the human relations nurse-caretaker concluding with the need of a "new framework for relations between professionals and caretakers".^6,12 Celma Vicente deals again the relation informal caretaker-nurse to conclude underlining the necessity of a pattern of relations collaboration-training between both groups.¹³
    The analysis of Portillo Vega et al. brings us closer together to the experiences of the carers of patients with stroke, related to the citizens' participation. Their work established "the need for the normal citizens and patients to receive information and education about this process, its medical treatment and rehabilitation. This should be done through a continuous process of advice and education".¹⁴ Flores et al. analyze in their work the subject of quality of life for the patients' companions at the Hospital. They point at three determinant factors for their quality of life at the Hospital, which are also decisive for their experience of privacy as was shown in this work's results section: the relationship nurse-patient-companion (we added the interaction with the rest of people living in the same room to this parameter), the adaptation to the environment, and the illness degree of seriousness (we have analyzed this factor in terms of dependency-independency).¹⁵

Conclusion

     We will remark as conclusion that the meaning of privacy is influenced by the physical space that surrounds the patient and his family, by "those" who become part of that space, and by "how" do they become part. A series of factors extrinsic to the patient-family exist that make the ambience in which they are immersed in at the Hospital to be positive or non positive for privacy. There are also a series of determinant intrinsic factors for the experience: the patient's degree of independence, the family's involvement in the patient's cares, and the previous experiences at the Hospital. The sequential development of the relationship patient-family with the room mates and professionals make the whole group contribute to create a wider privacy core.

References

1. Durán Escribano M. La intimidad del cuidado y el cuidado de la intimidad: una reflexión desde la ética. Rev Rol Enferm. 1999 abr. 22(4): 303-307.
2. García Ortega C y Cózar Murillo V. La intimidad del paciente: novedades legislativas. Med Clínica. 2000 oct. 115(11): 426-427.
3. Jiménez Herrera MF y Nogués Domingo C. Perspectiva enfermera sobre la intimidad en la asistencia prehospitalaria urgente. Metas Enferm. 2002 oct; V(49): 6-9.
4. Williams A. A literature review on the concept of intimacy in nursing. Journal of Advanced Nursing. 2001 Mar; 33(5): 660-7.
5. Blanca Gutiérrez JJ, Muñoz Segura R, Hervás Padilla J, Alba Fernández CM. El padecimiento de los enfermos con Síndrome Coronario Agudo. Index Enferm, 2006; XV(52-53): 20-24.
6. Quero Rufián A. Los cuidados no profesionales en el hospital: la mujer cuidadora. Enferm Clínica 2003; 13(6): 348-356.
7. Strauss A y Corbin J. Bases de la Investigación Cualitativa. Técnicas y procedimientos para desarrollar la Teoría Fundamentada. Facultad de enfermería de la Universidad de Antioquia. Medellín, 2002.
8. Morse JM (Ed.). Asuntos críticos en los métodos de investigación cualitativa. Ed. Facultad de Enfermería de la Universidad de Antioquia. Medellín, 2005.
9. Savage J. Nursing intimacy: an ethnographic approach to nurse patient interaction. Scutari Press, London. 1995.
10. Dowling M. The sociology of intimacy in the nurse-patient relationship. Nursing Standard 2006; 20(23): 48-54.
11. Nieto Poyato RM. La intimidad de la diálisis vista desde un sillón de escay negro. Arch Memoria 2006; 3(1). Disponible en: </memoria/3/n0601.php> [Consultado el 30 de agosto de 2007].
12. Quero Rufián A, Briones Gómez R, Prieto González MA, Pascual Martínez N, Navarro López A, Guerrero Ruiz C. Los cuidadores familiares en el Hospital Universitario de Traumatología y Rehabilitación de Granada. Index de Enfermería 2005; 48-49: 14-17.
13. Celma Vicente M. Cuidadoras informales y enfermeras. Relaciones dentro del hospital. Rev Rol Enferm 2003; 26(3): 22-30.
14. Portillo Vega MC, Wilson-Barnett J, Saracíbar Rázquin MI. Estudio desde la percepción de pacientes y familiares del proceso de participación informal en el cuidado después de un ictus: metodología y primeros resultados. Enferm Clínica 2002; 12(3): 94-103.
15. Flores, ML; Cano-Caballero, MD; Caracuel, A; Castillo, A; Amezcua, M; Osorio, MV; Vegas, S. La calidad de vida de los acompañantes de pacientes hospitalizados de media y larga estancia. Index de Enfermería. 2002; 38: 18-22.

RECURSOS CUIDEN

RECURSOS CIBERINDEX

FUNDACION INDEX

GRUPOS DE INVESTIGACION

¿Quiénes somos?
RICO Red de Centros Colaboradores
Convenios
Casa de Mágina
MINERVA Jóvenes investigadores
Publicaciones
Consultoría