Mixed-sex rooms--invading patients' privacy? Mixed-sex rooms in hospital wards have provoked little debate in New Zealand. But in the United Kingdom they are seen as an invasion of patients' privacy.

MIXED-SEX ROOMING (MSR) in hospitals has attracted little public comment in Aotearoa/New Zealand. Mixed-sex rooming refers to situations where patient of both sexes are placed in adjacent and/or neighbouring beds without structural partitions separating them.

Since the health reforms of the early 1990s, rooming of men and women together occurs in medical, surgical, orthopaedic and other general admitting wards of some hospitals. This article discusses mixing the sexes in general wards; it does not refer to intensive care nursing or high dependency areas where specialised care patients are nursed side by side.

Occasionally complaints have appeared in the media about the stress and embarrassment MSR can cause patients. Newspaper headlines capture these responses: "Mixed-sex wards 'appal'," (1) "Room with men angers gynaecology patient", (2) "Hospital complaint", (3) "Former psychiatric patient in fear after attack". (4)

The New Zealand Nurses Organisation has represented nurses to hospital administration, expressing the "problem" of "mixed-flatting". (5) In response to media coverage, hospital managers have stated their case about pressure to use beds.

In New Zealand the health professions, including nursing, have largely not entered public discussion of the topic. A literature search found that MSR has attracted ongoing debate in the United Kingdom (UK) and sporadic comment in Australia. North American and European countries do not mix the sexes as a rule. Holland has some mixed facilities but careful processes guarantee patients consent to sharing. The UK literature offers patients', patient advocates', staff and policy makers' perspectives. This article reviews the issues debated in the UK as a starting point for reflecting on the situation in New Zealand.

Mixed-sex warding has had a chequered history in the UK, due to crowded ancient hospitals, the drive to modernise, and changing social attitudes. Debate has raged since the late 1970s. Discussion culminated in a commitment from Tony Blair's first Labour Government to end mixed-sex warding in the National Health Service (NHS) by the year 2000. Although this was not achieved, on going auditing of hospitals will assess their movement towards that goal. (6)

The Patients' Charter, produced by Britain's Department of Health, sets standards providers are expected to observe. The charter requires that patients be informed before admission, if it is intended to room anyone in mixed-sex wards. Patients may state a preference for single sex accommodation, and "in all cases patients can expect single sex washing and toileting facilities". (7) The emphasis is on patients' rights to privacy and dignity. One way health authorities have enacted these standards is within guidelines for best practice. An example is the North West Regional Health Authority's principles for best practice, whose mixed-sex provision states: Patient preferences must be taken seriously. Staff need to demonstrate willingness to adjust the system to the patient's needs, rather than being resigned to there being no alternative or pressurising patients into accepting what is on offer. (8)

The Royal College of Nurses has moved from a 1978 position widely interpreted as supportive of mixed provision, to guidelines that set parameters intended to limit occurrences. These guidelines highlighted patients' need for privacy and dignity. They stopped short of outright opposition but stressed patients' right to choice. (9) The Nursing Times ran several articles over the 1990s to highlight the issue, and in 1994 published findings of a readers' survey on mixed-sex wards. (10) The survey concluded the majority of staff and patients strongly objected to mixed provision. These articles cited erosion of individual rights, and undermining of patients' privacy and dignity, as issues. The results also revealed that patients complained to family members but did not complain formally as inpatients. Formal complaints were lodged after discharge.

Patient and consumer responses

The Nursing Times survey involved 967 interviews with people aged 15 years and above. In response to a hypothetical question, 41 percent of respondents said they would not be happy to be nursed in mixed sex wards. (10) AUK consumer group, the Patients' Association, has persistently campaigned against mixing the sexes, reporting that mixed-sex wards featured among the ten most common complaints to their organisation. (7) In 1995, The Greater London Association of Health Councils commissioned a report on "policies, practices and preferences on mixed sex hospital wards". The report's title, "Sacrificing Dignity for Efficiency", encapsulates the findings that many patients reported a loss of dignity and intrusion of privacy. (11) Shared toilet and bathroom facilities were consistently condemned. In the UK then, the tide has turned against MSR, which is now viewed as unhelpful for patients. In 1998 a large-scale audit of 260 hospitals reviewed progress toward the goal to end mixed warding along with other quality factors. (7)

The New Zealand situation

No definitive policy statement on rooming of patients exists at a national level in this country. Health care providers are obliged to reflect the various Acts governing patient rights and health care service delivery. Policy is formed at district health board (DHB) level and therefore varies, with some hospitals and nurses displaying more effort than others to minimise MSR.

Anecdotally, it appears mixing the sexes is the exception rather than the rule. It is not the first choice for patient placement. For example, page three of the Otago DHB's pre-admissions patient information booklet includes a section on room sharing which states: "When you are admitted to hospital, every effort will be made to place you in a room with members of your own sex--this is [our] ... policy. From time to time there are circumstances when we are forced to place men and women in the same room. If this happens to you, we will move you to a room with a member of your own sex as soon as possible. In special care or intensive care units, mixing of men and women is necessary for intensive monitoring. Please talk to your nurse if you have any concerns." (12)

Here, single sex rooming is viewed as an optimal condition and a social norm of separation of the sexes is clearly acknowledged. Mixed-sex rooming is recognised a compromise, an expedient measure and contrary to the ideal of single--sex room allocation. The statement implies that discretion is available to staff. The onus is on the patient to "express concern" (read complain) rather than a choice being offered at the outset. Where a patient does not formally express concern, one wonders whether this might be interpreted as consent, when in actuality the patient's needs are being silenced or ignored.

Logically, two issues arise from this policy. Firstly, if nurses can remedy something by way of a complaint, then it is misleading to imply that the hospital is "forced" to mixed-sex room. Secondly even though patients are invited to express concerns, their failure to do so does not imply consent, since patients are never asked to agree that they will complain.

Quality of care is an aim of health care providers. Ministry of Health documents state that quality includes "freedom from preventable harm to an individual's physical and non-physical wellbeing after a consumer has gained access to hospital services". (13) Statutory obligations about patient care are outlined in the Privacy Act 1993 and the Code of Health and Disability Services Consumers' Rights, a regulation under the Health and Disability Commissioner Act, 1994. Under the latter Act, a Health and Disability Commissioner is appointed whose role includes resolving complaints about infringement of patient rights under the code. One provision relates to the establishment of a consumer advocacy service. Another concerns the Code. Clause two of the Code details ten rights of consumers and the duties of providers:

1) the right to be treated with respect

2) the right to freedom from discrimination, coercion, harassment, and exploitation

3) the right to dignity and independence

4) the right to services of an appropriate standard

5) the right to effective communication

6) the right to be fully informed

7) the right to make an informed choice and give informed consent

8) the right to support

9) rights in respect of teaching or research

10) the right to complain. (14)

These rights set regulatory boundaries for professional practice and sit alongside codes of practice of individual health professions and their respective registration and regulatory mechanisms. In addition, nurses will be also responsible under the competence-based practising certificate provisions in The Health Professionals Competence Assurance Bill.

Insights concerning how New Zealand patients respond to mixed-sex rooming are provided by a research project that used in-depth interviewing. (15) A qualitative study of eight women who had experienced mixed-sex rooming for at least a one-night stay in a general hospital ward was undertaken. Intensive care and high dependency units were excluded. Participants responded to advertisements placed in newspapers throughout the country. All participants had also experienced single-sex rooming so could identify the things that were unique to MSR, for them. Recruiting participants by this method is likely to attract women who have strong feelings about the topic. Concerns about mixed-sex rooming documented in the UK were reflected in the findings. Negative feelings were expressed about intrusion of privacy and dignity, embarrassment, and a reluctance of patients to complain.

For some women, routine nursing care exposed them to the view of male roommates. For example, four interviewees had intravenous (IV) therapy and were mobile and wore clothing to accommodate the IV lines. They reported feeling self-conscious and distressed by being partially clothed in the company of male patients. Bed rest conditions meant toileting and washing was carried out in mixed company. Odours and noise drew attention to intimate bodily processes and this caused excruciating embarrassment to some. Participants mentioned considerable concern about shared toilet and bathroom facilities and about the dirty condition of some of the ensuites.

Admission for two women involved investigation of specifically female anatomy. One woman was an acute admission for investigation of abdonimo-pelvic pain and questions about her reproductive and sexual history formed part of the assessment. The discussion between staff and the patient took place in the mixed-sex room. This caused the patient extreme indignation, as she was acutely aware the male patients could overhear. She felt this was a serious breach of her privacy in the mixed setting.

Embarrassment and anger arose for another woman who had undergone reconstructive surgery after breast cancer. Post operatively, staff discussed the shape and symmetry of her new prostheses and that a distinct cleavage had been achieved, in the hearing of male room-mates.

The participants described efforts they made to gain privacy, such as drawing the curtains around themselves 24 hours a day. Others roamed the corridors, despite needing rest, avoiding their mixed room and sought out toilets that were for women only, finding it uncomfortable to share with men. Two of the women sought early discharge for the express reason of escaping mixed-sex rooming. Two participants said that the presence of male patients in the room when they were consulted by health professionals prevented them from asking all the questions about their condition and care they wished to ask, thus denying them full information.

Some women said they felt the male patients also found sharing awkward. One woman roomed with an elderly Samoan gentleman whom she believed was "visibly distressed", and a youth who "appeared uncomfortable".

Judging from both the literature and the New Zealand study, complaining or expressing concern is something patients are reluctant to do. One reason patients resist criticising is a fear their care might be affected. As most of the women in this study had not been offered a choice about mixed rooming, they found it difficult to raise questions about it when the staff behaved as if it were a matter of course.

One woman recounted her observation that several rooms in the ward were mixed and speculated that potential therefore existed to reallocate some as single sex rooms should patients choose. The option is not available if the nurses who place patients on admission do not offer it.

Individual nursing care

It appears that patients who object to mixed-sex rooming most often do so on grounds of erosion of individual rights. Intrusion of privacy and undermining of dignity are recurring themes in research and commentary on MSR. Nurses using blanket formulae to allocate beds are likely to compromise some patients' rights, unless individual preferences are sought and respected.

Cultural safety is another perspective we need to consider. The social norms and behaviours surrounding intimacy, privacy, nudity and sex segregation form a significant part of cultural understandings. As cultural safety architect Irihapeti Ramsden has stated: "Cultural safety is not about patients; it is about nurses, their behaviour and attitudes towards patients, and their ability or otherwise to create trust." (16) It is only patients themselves who can acknowledge a nurse as culturally safe. The onus is on nurses to meet these standards of care.

We are responsible, as nurses, for the environment patients inhabit. Tension exists between blanket policy, when patients are mixed-sex roomed regardless of preference, and nurses' professional responsibility toward individuals. The Code of Rights and cultural safety policy cover individual patient entitlements. It is not good enough to compromise patients by offering "choices" which exclude that possibility. Safe individual care depends upon patients being informed about any possibility of being mixed-sex roomed, before being placed in a hospital room, and being given the opportunity to state their preference. If nurses deny patients the right to choose, we are in danger of foreclosing their options and making it difficult for them to express concern about conditions that work against their getting well. It is up to nurses to monitor that their conduct is ethical and culturally safe and that

patients' environments promote trust and communication. Despite the stress of crowded hospitals and juggling competing needs, New Zealand nurses can and must exercise the discretion available to them to ensure that patients are not mixed sex roomed unless by explicit agreement.

I would like to acknowledge the support of the Research and Scholarship committee, Faculty of Health and Community, Otago Polytechnic for assistance during 2002 in the production of this article.

REFERENCES

1) Topham-Kindley, L. (1992) Otago Daily Times, December.

2) Benn, R. (1995) Otago Daily Times, January 28.

3) Letter to the Editor, (1999) The Daily Tel egraph, Napier, May 1.

4) Hartley, S. (1999) Otago Daily Times, April 1.

5) Cannan, D. (1998) Patients' safety al risk, nurses say. Otago Daily Times, August 6.

6) Snell, J. (1997) Mixed is no match. Health Services Journal; 2, October, 26-29.

7) Warner, L, and R. Ford. (1998) Conditions for women in in-patient psychiatric units: The Mental Health Act Commission 1996 national visit. Mental Health Care; 1: 7, 225-228.

8)) Cole, A. (1995) No mixed sex, please. Nursing Times; 21: 29, 44-46.

9) Royal College of Nursing. (1994) Mixed-sex wards: the choice of patients? Nursing Standard; 8: 33, 32-33.

10) Burgess, L. (1994) Mixed-sex wards--the NT survey results. Nursing Times; 90: 31, 35-38.

11) Joule, N. (1995) Sacrificing Dignity for Efficiency. A report on a survey Of policies, practices and preferences on mixed sex hospital wants. Lon don: Greater London Association of Community Health Councils.

12) Otago District Health Board. Pre-Admission Patient Information Booklet. Dunedin: Otago District Health Board.

13) Ministry of Health. (1998) Purchasing for your health 1996/1997: A performance report on the fourth year of the Regional Health Authorities. Wellington: Ministry of Health, 101.

14) Office of the Health and Disability Commissioner. (1994) Code of Health and Disabilty Services Consumers' Rights. Wellington: Office of the Health and Disability Commissioner.

15) Burrell, B. (2000) Gender, power and practices in tension: Mixed-sex rooming in hospital. Unpublished Masters Thesis, Massey University, Palmerston North.

16) Manchester, A. (2002) Challenging and changing the culture of nursing. Kai Tiaki Nursing New Zealand; 8: 1, 20-21.

Beverley Burrell, RGON, BA, MA, Dip T (Tertiary), is a senior lecturer at the Centre for Postgraduate Nursing Studies, Christchurch School of Medicine.