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Monday, April 26, 2010

Personal Privacy Violations Part 2

Part 1 is full. Please continue posting here.
An article discussing what you can do to protest these violations is here.

39 comments:

Joel Sherman said...

A topic that concerns many of you has been revisited in allnurses. Here's a thread about protecting patients' modesty during surgery.
Nearly all the posters were sympathetic to it.
Many passing violations are discussed.

Anonymous said...

A doctor on allnurses writes this:

"The bottom line is that a man without pants is as exposed, in any position, as a woman in stirrups for a pelvic exam, and should be given as much privacy as we accord a woman in that situation. All patients need to be treated as if they are the most modest person on the planet. You won't cause emotional harm if you treat the less modest person with the utmost regard for privacy. But you'll harm a lot if you treat every guy patient based on the myth that "guys don't mind" being seen naked, or "it's no big deal". And speaking of big, the elephant in the room is the issue of penis size in our society. Women do look, and do compare and do talk. As a doc, I can't tell you how often I've heard nursing staff making comments. So it's hypocritical to pretend it shouldn't be a concern for the male patient."

He then goes on to describe a few disturbing male modesty violations that tend to support those who say this happens more often that I have been claiming. Perhaps they're right. You'll find the thread here:

http://allnurses.com/operating-room-nursing/modesty-issues-130341-page7.html#post4283482

MER

Joel Sherman said...

Mer, that post by 'DonMD', #67 is well worth everyone reading. I'd reproduce it here in full if I could (it's copyrighted). The post is much longer than your quote.
It gives several examples of violations that are probably common and that everyone here should be sensitized to. If personnel expose you more than is necessary, you should complain immediately. Unfortunately most people are acutely ill and are taken by surprise by the incident and don't say anything. It happens to both men and women, but almost certainly more so to men.
Having said that, everyone should realize treatment like that is not the rule. It varies greatly depending mostly on the individual involved. Some would never do it; others do it routinely either because they are desensitized to the issue or for other worse reasons.

Joel Sherman said...

This comment was posted to the Organize thread, but it is more on topic here.

My mother is a nursing sister and she says consideration for modesty and privacy varies hospital to hospital. It shouldn't of course, but the individual nurse and doctor and their attitudes makes all the difference.
At one hospital she'd find women stark naked and in stirrups while nurses took their time with drapes and in some cases women stayed like that for 10-15 minutes. (they were unconscious)
This is also negligent as the patient's body temperature drops.
All the while people walking in and out, no one taking responsibility for the patient's privacy. She also saw naked patients in various undignified and exposed positions, male and female.
At another smaller hospital the matron had been a nun and great lengths were taken to preserve modesty. It didn't hold things up, but nurses were shown how to drape and prep with modesty in mind and partitions were used (or someone held up a sheet) while catheters were inserted and shaving took place. Staff were reprimanded for falling short. My mother worked at that hospital for 12 years and loved it...then moved to a larger hospital when my father changed jobs. She found it jarring to be in an environment where no care was taken and people were often treated disrespectfully.
She feels there is no excuse for these violations of people's modesty. She believes people entrust themselves to your care.
She even heard doctors and nurses joking about someone's body, which she always objected too. How would they like people having a good old laugh at them in that position?
Needless to say she was regarded as a party pooper.
My mother now works in a aged care home.
She believes it's the senior nurses and doctors that set the acceptable standard and either train their staff to be observant of modesty and enforce those standards or not.
(They also used female nurses to prep females and male nurses for men years before that became an issue)
Tina


I believe this comment supports what I have always maintained, that privacy violations are highly specific to the institution and individuals involved. In a way that is promising. It means that personnel aren't trained to disregard privacy; they just fall into bad habits caused by the environment in which they work. In most institutions a few complaints brought to the top can reverse this atmosphere of ignoring patient privacy needs. It is important that the complaint get beyond the people who are part of it to reach hospital supervisors and administrators.

Joel Sherman said...

Here's an interesting thread from nurses.com forums. It was started by the lady from patientmodesty.org. Look at her posts (ModestWoman) and especially those by WaspyMD for some interesting reflections on the topic of modesty during deliveries. The thread was started on the topic of male modesty.

Joel Sherman said...

More posts on the allnurses modesty thread from 'DonMD' which are well worth reading. He's one of the best proponents of equal treatment for men and women's modesty issues that I have seen.
I'll also post this on the male modesty thread. Too bad we can't get this physician to contribute here. (They won't let posters include outside links on allnurses.)

Anonymous said...

DonMD is sayhing some of the same things I've been saying over the years on both this and Bernstein's blog. As I did, he makes the connection between Abu Ghraib, GitMo and how we treat men's nudity differently than women's. These are strong indicators of our cultural attitudes in this regard.
His are great posts. It's good to see a doctor taking this up -- plus it's good to see allnurses more open to this discussion. Frankly, when a doctor or a nurse brings this subject up, it's taken more seriously by professionals. That's understandable.
MER

Anonymous said...

I've posted a comment on that allnurses site. Let's just see
how long it takes for my post to
get booted off.


PT

Anonymous said...

Good work, PT. Dr. Bernstein and Dr.Sherman have asked us to focus on activism. I strongly believe that getting this topic on various doctor and nurse blogs is a major form of activism. It wont't always work. Sometimes we'll get booted off. But I think that happens less and less these days because this topic is coming out of the closet relative to all the discussion about the Muslim culture and what's called transcultural nursing. Occasionally we'll get posters like DonMD or several nurses on allnurses who advocate for this cause. Non medical professionals can only get so far, but when we get a doctor or nurse advocating for us it makes a big difference. We can all understand how someone within a profession possesses more credibility within that profession that those advocating from without.
So -- let's get on these blogs, let's be respectful and civil -- and I truly believe that this form of activism is one way to get the message out.
MER

Joel Sherman said...

I agree with all of you. Although these blogs have not yet broken through to general awareness, I do believe we've had an effect.
It is important to participate in other blogs and discussions and get our message out.
Comments on allnurses as well as comments on other blogs such as Dr Orrange and Keagirl help get the message out. Keep being activists.

Anonymous said...

I think the closing of the the thread on allnurses and others like it are indicative of why this is a problem. While many express concern about modesty, the want to address it on their terms the way you talk to your patient, using clinical terms. When the discussion comes to what the patient wants, same gender etc. the conversation is often terminated. It seems some take the request as being a personal attack on them instead of a issue for the patient.

Anonymous said...

The thread on allnurses that are
titled as modesty issues I believe
are decieving as to the real problem. Patients that have had
staff take cell phone pics of
their genitals,unprofessional
behavior by staff and privacy
violations don't fall under the
heading of modesty issues.
They are in a category all their
own,yet are lumped in this subject
of modesty. One of the reasons they
(allnurses) dislike these modesty
subjects because they hint at the
notions I've mentioned. These are
the driving forces behind many of
these modesty issues,distrust.

PT

Joel Sherman said...

I find this article surprising and perhaps amusing. It's written by a bioethicist who notes that Canada is apparently experimenting with co-ed hospital rooms mainly to improve the speed of placement of patients from emergency rooms. He's all in favor of it despite admitted objections by some patients and families.
It's easy to tell where this bioethicist is coming from. He's also in favor of co-ed locker rooms, co-ed dorms, and of course co-ed bathrooms. At least he hasn't gotten to co-ed labor and delivery suites. I wonder what Dr Bernstein thinks of his colleague?
On a serious note, co-ed rooms in emergency departments and ICUs are not unheard of in this country.

Anonymous said...

Joel:

I don't find it surprising. I do find it a bit amusing in a pathetic kind of way. It's tone is quite arrogant. There are the civilized, those who are gender neutral; and there are the uncivilized, who worry about gender. The author even at one point equates gender oppressive Arab and Muslim cultures with this issue.
This was tried in UK with tremendous failure. I do agree with the author in one degree -- most of the complaints come from women, and a great fear is not so much modesty but assault by male patients. He does cover that topic quite nicely.
I wouldn't have a problem, in extremely busy ER's, for example, with asking patients if they mind. But then the author later slips in to charging those who do mind an extra fee -- which I don't like at all.
I like the "We" in the article title, as if money won't buy almost any accommodation. The author also falls into that logical trap we commonly see on our blogs, e.g. you can't have both quality medical care and observe patient modesty at the same time. There may be some exceptions, but most of the time the two are not at all inseparable.
MER

Anonymous said...

In many ER's you will find male
and female patients seperated only
by a curtain. I do see a problem
in regards to whats overheard
and certainly when registration
visits you with questions it is
a certain case for hipaa violations.


PT

Joel Sherman said...

Here is a rare follow up to an old story.
One of the high school girls who was accused of abusing nursing home patients in Minnesota has plead guilty to the charges. She was accused both of physical assaults and sexual assaults. The case was shocking because all the accused were high school girls from a small Minnesota town who were working unsupervised in the nursing home. The girls looked more like cheer leaders than sex offenders.
No mention is made in this article of sentencing.

Joel Sherman said...

This was posted to Part 1 and I have moved it here.

Anonymous said...

i want to know if the doctors and nurses start a confrontation with the patient then force him or her to the bed while he or shes out of control then use four point restraints on the patient then leave for 2hrs then come back and use medicne to calm that paitent down while the paitent is still in four point restraints would that be considrded illegal
August 22, 2010 12:33 AM

Joel Sherman said...

Anon,
Medical personnel would be very unlikely to start a confrontation with patients so that they can put them in restraints. The use of restraints is strictly regulated by JCAHO regulations and causes the staff extra work. Most institutions keep their use to a minimum.

Anonymous said...

Hi Dr Sherman,

What I found most distressing when I had to have 2 hysteroscopies under a general anesthetic, though I tried asking the specialist whether I could have it under a local anesthetic (he refused, saying we don't want you to move), was that they would do the 'prepping and positioning' while I was unconscious. I had never had a general anesthetic and was very afraid of it. I had the first one in Nov 09 and the second one ten days ago. I keep reliving the whole scary traumatic experience over and over and have frequent crying bouts. I've finally figured out my symptoms align neatly with post-traumatic stress disorder. Great.

What distresses me is that I have no way of knowing what they did while I was unconscious (ie did they at all respect my dignity and privacy of my body), though, obviously, they had to wrangle my unconscious body into stirrups, and disinfect the pelvic area, given the procedure I was having. I know what they're supposed to do but I don't have any trust that they did it that way, like who would rat them out - me, the unconscious, unaware patient?

Despite the better overall experience with the team who did my recent, second surgery, I am still profoundly distressed about the 'black void' ie the time during which I was unconscious and whether the staff were respectful of my dignity and didn't expose me unecessarily. I had even more 'spectators' the second time, 2 male anesthetists and 4 (!) nurses, plus the surgeon. I just shudder thinking of all these strangers seeing me exposed (and it doesn't make me feel better at all that they are medical staff and 'see this everyday bla bla' - I don't do this everyday!)

So you see, Dr Sherman, here's my dilemma - I can't complain about being exposed more than necessary or anything at all as I was unconscious. If I ever have to have another procedure with a general anesthetic I am going to ask them if they can do all the prep/draping etc while I'm awake. Though I doubt they would agree, I truly get the feeling that they do it this way ie with the patient unconscious because it's more convenient for them. If they think it makes it less traumatic for the patient, well, in my case, it made it far more traumatic. They may be professionals but they are still people and I shudder to think what comments they might have made about my appearance.

Is there any reason they can't let the patient be awake through the positioning and draping? Surely it makes more sense as the patient can state whether they are comfortable or not. I have a bad low back and neck and with me unconscious, how could they know whether the way they positioned me caused problems in those areas? I did have a severe pain in my neck for several days following the recent surgery.

I wish medical staff would understand that some of us are just not comfortable with having our bodies exposed when unconscious and that it DOES matter to us and it does NOT make it easier on us to have all that happen when we're unconscious and helpless. My comfort level stopped the moment I had to remove my clothes and put that awful hospital gown on, with those always inadequate ties in the back.

Joel Sherman said...

Anon, I can't think off hand of any medical reason why they wouldn't let you be conscious for prepping and draping. My guess is that the majority of patients would rather be unconscious or don't care, so they probably just don't give the matter any thought.
But if you explained your anxieties and preferences to the physician ahead of time, your request might well have been granted. Try it next time.

Anonymous said...

Anon:
This is where upfront patient communication might help. How about saying something like this to the OR team, surgeon and/or circulating nurse:
"I have no reason to believe that you won't look out for my modesty and privacy while I'm knocked out. I have no real reason to believe that you won't drape me properly and avoid inappropriate remarks that I won't be able to hear. But it makes me feel better to hear you say to me now that you will protect my modesty and privacy, drape me properly, and not make any comments that you wouldn't ordinarily make if I were awake. I'm very concerned about these things. Please talk with me."
Give them a chance to respond and see what happens. You may be surprised at their response, and it may make you feel better. On the other hand, if they dismiss your heartfelt comments, that also tells you where you stand. But I think they're more sensitive to this than you may think.
MER/Doug

Anonymous said...

I have exactly the same worries anon. I refuse general anesthesia for the same reason. I had an experience when I was a teenager for an elective nose surgery. I was ambushed the morning of the surgery by the nurse telling me I had to be naked under the gown, for a nose surgery! I refused, and my parents backed me up. I told the nurse the surgery would be canceled if I was required to be naked. She threw a hissyfit and left. A few minutes later she came back and told me the doctor relented and I would be allowed to wear scrub pants under the gown. I never thought the nurse would lie to me (being an alleged "professional"), especially in front of my parents, so I agreed. I found out after the surgery that as soon as I was unconscious they stripped me naked and later redressed me. I was so traumatized that ever since that experience I can't sleep unless I'm alone in a room with the door locked.

I vowed that I would never let that happen again no matter what the consequences. I've already accepted the fact that I'm destined to one day commit suicide rather than be put into that position. I will never be able to trust anyone wearing scrubs, particularly the women because I know what liars they are and no matter what they promise me when I'm awake, I know they'll do the opposite after I'm unconscious. "For my own good". I don't worry much about what happens when I'm awake because I am determined enough to always stand up for what I believe and I'm not too shy or embarrassed to keep them from doing anything unethical.

I know one day I'll have a serious condition that requires surgery, or I'll be in so much pain that the only humane thing to do is put me to sleep. I am prepared to take my own life rather than tolerate unethical behavior or endure the terrible pain.

I dare anyone in the medical world to try and convince me that what they do is harmless and it is for my own good. Their careless and unethical behavior has ruined my life and will no doubt send me to hell for eternity because I'll be forced to take my own life. Because of the fact that I will never be able to sleep unless I'm alone with the door locked it will be impossible for me to ever get married. I keep thinking that sooner is better than later so I might as well get it over with before the pain starts.

Joel Sherman said...

Don't know when the incident happened, anon. It's probably less likely to happen nowadays, but it's not impossible. If you should need surgery, you should discuss it with your doctor ahead of time. We have discussed this scenario before somewhere. I certainly think it is reasonable to have some underwear on if preferred.
But beyond that, the level of anger and despair you describe is well beyond what this incident alone could have caused. You should look into undergoing counseling and therapy.

Anonymous said...

How a patients feels and what experiences make them feel that way is for nobody but that person to decide. How can anyone say a single incident couldn't cause a person to distrust all medical professionals and in certain ways destroy his life? Only that person knows how that experience makes him feel.

Anonymous said...

Sorry, Joel. But I take a much stronger stance on this issue -- assuming the incident happened as reported. Apparently, from other stories I've read, this is not an uncommon experience -- people be lied to about OR procedures. That's unethical, if not illegal. It involves issues of informed consent. This is where medicine shoots itself in the foot. When people can no longer trust medical professionals, then they need to get things like this in writing. This kind of responses eventually gets the lawyers involved. Studies have show that many court cases could have been avoided if doctors had simply been upfront with patients, perhaps apologized, but at least told them the truth.
You suggest that this individual discuss this with his doctor. As you know that may or may not mean anything. Doctors who have priviledges at hospitals are not necessarily able to trump hospital policy or even the personal desire of the circulation nurse. Doctors know they have to work with these surgery teams day after day and week after week, and they'd better have a good relationship with them. The doctor may tell the patient one thing and then may be trumped by the OR team or hospital policy.

The issue described here transcends the whole modesty issue and gets into the "secret" culture of medicine that I've discussed before -- the "we know what's best for you" -- the whole paternalistic attitude. This has got to change. Experiences like this cause extreme distrust with the entire medical profession, and eventually cause people to get this stuff in writing. This has got to change.
Doug/MER

Anonymous said...

It happened in the mid-1980s.

Anonymous said...

I do hope Anon seeks therapy. This incident happened in the 80s. That is a long time to suffer. They state they can't marry because pants were removed during surgery and they have since been unable to share a bed. That is a lonely life. This incident happened 20+ years ago. It is time to get professional help.

Anonymous said...

I think an important related issue to modesty violations is how empowered nurses are(doctors, too,, but esp. nurses)in reporting these violations. If the "system" or the management punishes them, they won't report.The clinic or hospital culture must support the reporting of these violations. Read this recent article out of the UK:

"Will greater protection for whistleblowers change anything?"
(24 October, 2010)
by Dr Graham Pink who reflects on what’s changed since he became nursing’s best known whistleblower in the 1980s.
Make sure you read the comments after the article, especially the first one which contains a good example of the kind of modesty violation we're talking about on blogs like this. Here's the URL:
http://www.nursingtimes.net/opinion/the-image-of-nursing-the-unskilled-nurse/5020797.article
Doug/MER

Joel Sherman said...

Here's another follow up to the startling case in Albert Lea, Minnesota where two high school girls working as CNAs in a nursing home were charged with egregious abuse of elderly defenseless residents, both physical and sexual abuse. There were 4 other girls not charged because they were minors. The two have now both publicly pleaded no contest. The first of these has been sentenced to 6 months of jail time. The second is still awaiting sentencing.
The jail sentence is well deserved, but still surprising. This may be the first case of its kind where high school girls were sentenced to jail for abusing patients while working as CNAs.

Anonymous said...

"4 other girls not charged because they were minors."

That fact is revealing and frightening, isn't it. Why were these immature, undereducated, insensitive "minors" allowed to do this kind of work in the first place? Is there no respect for the elderly? Is it all about cheap labor?
MER/Doug

Joel Sherman said...

Doug,
We have talked a little about this in the past. It is not unusual for hospitals to run programs introducing high school students to health care vocational opportunities. In my area, both hospitals do it. Believe they may do some clinical work, but under supervision is the key. The fault of this nursing home was that no one was supervising these kids and knew there were assaults going on.

Anonymous said...

Joel:

Personally, I think it goes beyond mere supervision -- although that is essential. Minors shouldn't be doing clinical work in any nursing home without specific up front permission from the patients or their advocates. Even then I question the whole practice. How do you determine the cutoff age. If 17 is okay,why not 16? Why not 15? And, like the "group think" topic we're discussion on another thread -- the danger comes when you put a few of these immature female cna's together, espl. if the supervision is minimal. Same would be true with immature male minors -- so I'm not being sexist. We've moved from the "Candy Striper" who just helped out nonclinically to the "Candy Striper" who is being used now to replace adult cnas because of staff shortages.
MER/Doug

Anonymous said...

Minors shouldn't be involved with direct patient care or observation as students. While I understand why hospitals want to encourage minors to enter the field it should be done in the actual classroom not where students get access to actual patients. It should also be noted that minors whether they be students or employees can't enter into a binding contract nor can they be held liable if they break one.

Dr. Lisa

Joel Sherman said...

Dr Lisa,
I mostly agree with your comment. I am not comfortable with high school students giving any clinical care. I don't think it is uncommon though throughout the country. And indeed they cannot be held accountable. Their signature to uphold patient privacy for example is worthless. But I can see it IF the patient is asked about the presence of a high school student, the patient willingly agrees and there is full supervision. I wouldn't permit a high school student to witness any intimate care being given to me, but I'd agree to their general presence if the illness wasn't a sensitive one, that is a diagnosis that I wouldn't be concerned about if everyone in town knew.
Dr, I understand you're a female urologist. If so would you please consider giving your thoughts on the patient gender preferences thread, either on this blog or on the companion article blog. Input from physicians on this subject is sorely lacking.

Anonymous said...

Thanks for your comments, Dr. Lisa. As Joel said, we would sure appreciate your perspective on this issue, regardless of your position.

Joel, you wrote: " And indeed they cannot be held accountable. Their signature to uphold patient privacy for example is worthless."

That's the key. If a patient is asked permission to have a 16 or 17 year old take part in his/her care in any shape or form, to achieve true informed consent, you'd have to tell the patient that the student was under no legal obligation to protect the patient's privacy. And their promise or signature would be worthless. How many patients would then agree to a minor if they knew that? Few, I think.
Doug/MER

Doug Capra said...

I just had to post this link from allnurses. It represents a horrible example of lack of communication and patient modesty violations in the ER. And people wonder why and how some patients become traumatized in medical situations? And by the way, this is an example of one of the good things allnurses does -- by revealing violations like this and admitting to this tendency. Here's the URL:
http://allnurses.com/general-nursing-discussion/seriously-518865.html
Doug/MER

Joel Sherman said...

Yes Doug, that example from an ER almost qualifies as being elder abuse, a criminal offense in many states.
Note the responses up to now. Everyone suggested that the friend file formal complaints. That's what we repeatedly stress here too.

Anonymous said...

I have a friend, Brett Gyllenskog, that is the best basketball player in this area. He should be playing point guard for the Arizona Wildcats right now, but he protests the unethical treatment of athletes at the University. If given the chance, he will play in the NBA. But he won't put up with certain practices used at the U of A. That's the only University he'll except. If he can't play there he wants to try to go straight to the draft, but I find that would be impossible. What can he do to compromise with the healthcare people at the University of Arizona without breaking his own morals? Anyone have any ideas?
L Olson

Joel Sherman MD said...

L, you have to give us a few more details as to what kind of problems your friend has had.

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