Clinical review

Privacy: a key nursing concept

Sally Glen, Sheila Jownally
This article discusses
how intrusion of
territory and
personal space
produces anxiety
and feelings of
depersonalisation in
hospitalised clients.
The implications of
privacy as applied to
nursing contexts are
also examined.
Finally, there is a
brief discussion of
the use of space by
staff in terms of
status and function.

^Latie
latientbood is viewed as an intensely
stressful role (McGbee, 1961; Cartwrigbt,
1964; Wilson-Barnett, 1979a,b). This state
is usually temporary but its matiy dimensions are tbreatening to an individual's
identity. Patienthood bas been described
as incapacitating and demeaning, generating dependency, loss of power and control, and forcing reciprocity on tbe patient
(Robinson, 1979).
In addition, illness and hospitalisation
tend to break down tbe integrity of tbe
self, rather tban enbancing it. Robinson
(1979) states tbat people wbo are catapulted into tbe patient role tend to be
adults who bave developed their own style
of living wbicb includes tbe value tbat they
place on privacy. Wben they are in hospital tbis will invariably be affected as tbey
are expected to conform to tbe 'patient
role' within an environment tbat is built
for tbe purpose of its staff ratber tban its
occupants. However, despite tbe formal
design of a bospital, another factor tbat
could directly affect the provision of privacy is the nurse bimself/berself.
'When an individual loses privacy
because of illness, (s)be may emerge from
tbe experience better able to trust others
or less so' (Smith, 1969).

Sally Glen is Head of the

Division of Nursing and
Midwifery Education at the
School of^Education and
Health Studies, Southbank
University, London, and
Sheila Jownally is Staff
Nurse at Ashford Hospital,
Middlesex

A patient's capacity to deal witb the

stress of bospitalisation is affected by
his/ber own personal and social support
systems and tbe degree to wbicb staff
can reinforce the patient's personbood,
regardless of tbe pbysical or emotional
exposure tbat makes bim/ber particularly
vulnerable.
Tbe nurse's role involves belping tbe
patient to not oniy protect bis/ber privacy,
but also deal witb tbe loss of privacy that
is inevitable in tbe bospital situation, but
not unavoidable.
Altbougb tbe nurse cannot prevent a crisis wbicb sometimes results from distressing exposure tbrougb bis/ber actions and
attitudes, he/sbe can lessen tbe patient's

embarrassment by indicating continued

respect for the patient, and belping
bim/her to move towards independence
with tbe realisation tbat be/sbc is regarded
and treated with compassion and respect.
According to Smitb (1969):
'Tbis can belp make tbe difference for tbe
patient between tbe bumility wbicb can
result from coming face to face with
b{er) human frailty and tbe humiliation
whicb can occur when tbe experience is
accompanied by others' scorn and
disregard for h(er) privacy.'
However, the nature of privacy within
nursing contexts is botb vague and
ambiguous (Margulis, 1977) and unexplored in tbe Britisb literature. Witb tbe
advent of mass information technology, a
wealtb of literature bas been generated
relating to notions sucb as computers and
data protection, publicity, intrusion and
tbe law in relation to eacb of the former.
However, witbin the healtb arena, the literature is generally restricted to tbe risk of
breecb of confidentiality due to the
increased use of computerised patients'
records. Moreover, tbe literature tbat is
available tends to be Nortb American.
It would seem tbat privacy, as a key nursing concept, is somewhat neglected in tbe

UK.
Definition
Tbe word privacy bas its roots in tbe Latin
privatiis wbicb literally means 'belongs to
oneself. Tbus, Rawnsley (1980) refers to
privacy as a cbameleonic concept whicb is
reflected in official statements. Sbe states:
'The claim to privacy is fragile but
persistent, it is as subtle and powerful as
the need for personal dignity; it is a
fundamental aspect of individual
freedom and work.*
Rawnsley identifies tbree sources of our
modern notions of privacy: privacy as a
legal rigbt; social privilege; and psycbological function.

Privacy: a key nursing concept

'Witbin the
healtb arena,
privacy can be
coyiceptualised as
a comi7iodity. In
essencey it is the
cot?imodification
of a health care
value. An
example of this
would be paying
for a private room
in hospital.'

Legal right
In the legal arena, privacy as a rigbt bas
evolved tbrougb court cases, being seen as
nil intangible property emerging from corporate property and therefore having a
right to be protected by law (Ernst
and Schwartz, 1962).
One might argue tbat legal references to
alleged privacy leave open to debate tbe
issue of the nature of privacy. As Gross
(1980, cited in Rawnsley, 1980) notes, privacy is an:
'...ill-defined embryonic notion wben
compared with establisbed legal concepts
sucb as trespass and nuisance.'
Tbus, Rawnsley (1980) concludes from a
legal perspective that:
'Tbe boundaries of privacy are defined
by tbeir disruption, leaving tbe essence
of tbe concept to be determined by
default.'
Social privilege
Within tbe bealtb arena, privacy can be
conceptualised as a commodity. In
essence, it is the commodification of a
bealth care value. An example of this
would be paying for a private room in
bospital.
Psychological function
Rawnsley (1980) identifies three different
psycbologicai perspectives of privacy: an
antisocial anachronism; a defence against
tbe pressures of society; and a vital condition for personal growtb. Many writers
(Rosenblatt, 1973, cited in Scbulz, 1977;
Barron, 1990) view privacy as a basic
buman need as well as a right. Jourard
(1991) refers to privacy as a way of seeking
change in tbat not only will tbe environment be different, but also tbe way one
feels about oneself.
Jourard (1991) suggests that when we
leave tbe presence of otbers it is possible
to act in a different manner from when we
are witb them. Tbis is because being witb
otber people infers a contract from one
person to behave and react before others
in the same way tbat be/she always has. A
person therefore comes to expect certain
behaviour from someone and consequently chains tbat person to an identity,
making any deviation from this difficult.
Scbulz (1977) and Tborndike-Barnbeart
(1985, cited in Alexis, 1986), conclude tbat
individuals can find privacy in private, or
away from tbe prying eyes of tbe
public.

Intrusion of territory and

personal space
Allekian's (1973) investigation aimed to
see wbetber intrusion of territory and personal space produced anxiety in hospitalised clients. The results revealed tbat
anxiety responses to personal space intrusion were less tban expected and tbat tbis
may be attributed to tbe fact tbat people
wbo enter hospital anticipate a certain
amount of physical contact and are tberefore psycbologically prepared for these
intrusions.
The difference between individuals is in
tbeir reactions to personal space, intrusions and to territorial intrusions whicb
may be seen as reducing their personal
control, individuality and identity. This is
supported by Hayter (1981) who suggests
that patients may think that invasion of
tbeir personal space is inevitable when
they are sick, but tbat tbey do not see tbe
necessity of baving their pbysicai space
invaded.
Allekian (1973) indicates tbat space
sbould be considered a part of tbe realm of
non-verbal communication. Tbe patient
wbo is intruded upon unnecessarily may
feel tbat tbe hospital staff are sbowing an
indifference to bis/ber comfort and dignity. Therefore, tbe patient may feel
depersonalised and experience a loss of
identity and status because, in effect,
be/she bas little control over tbe total situation as territorial and personal space
intrusions are a source of annoyance or
unease for bim/her.
In view of this, bospital staff may, witbout knowledge, produce anxiety in bospitalised patients tbrougb their intrusion
into the patients' territory and personal
space.

Control of choice
Control of choice to engage or not to
engage in interpersonal interaction and to
manipulate tbe self, togetber witb boundaries, are important themes in the conceptualisation of privacy. Prosbanky et al
(1970, cited in Archea, 1977), view privacy
as obtaining freedom of choice or being
given options to control wbat and to
wbom information about oneself is communicated. The more information one
person bas about another, tbe more control be/sbe is able to exercise over
bim/ber.
Furtbermore, if tbe information is vital
or personal, tbe greater the power of one
and the greater tbe vulnerability of tbe

Privacy: a key nursing concept

Although a
multiplicity of
meanings are
embraced by the
single term
privacy, a central
theme emerging
from the
literature appears
to be the ability to
control the degree
to which people
and institutions
impinge upon
one's
life...together
with the ability to
adjust the level of
privacy to
changing needs.

otber, especially in a therapeutic relationsbip wbere tbe only information yielded

relates to tbe patient.
Lako (1986) and Maciorowski (1991)
describe tbis excbange of knowledge/information as privacy being tbe
capacity of tbe individual to determine
wbicb information is communicated to
wbom. Tbey suggest tbat privacy is not an
individual rigbt, but assert tbat a buman
rigbt to privacy exists. In view of tbis,
tbe definition of privacy implies that
information-handling practices in particular may conflict witb tbis buman right to
privacy.
Altman (1974, cited in Archea, 1977),
summarises definitions of privacy as being
the 'selective control of access to the self.
In a later article, Altman (1975) expands
on this, suggesting tbat privacy can be seen
as a dynamic interpersonal boundary regulation process, whereby individuals or
groups can control and regulate interaction. Curtin (1992) suggests tbat 'boundaries' and 'limits' of privacy will, to a
certain degree, vary from culture to culture. A person's perception of privacy will
invariably be affected by socialisation and
life experiences, tbe overall function of
privacy being to increase the number of
options available to the individual.

Implications for nursing

Although a multiplicity of meanings are
embraced by the single term privacy, a
central tbeme emerging from the literature
appears to be the ability to control the
degree to wbicb people and institutions
impinge upon one's life (Westin, 1967;
Proshansky et al, 1970, cited in Arcbea,
1977), togetber witb the ability to adjust
tbe level of privacy to changing needs.
Choice seems to be essential to the attainment of privacy.
As Marsball (1972) states:
'It is not enough simply to be alone, as
one must be able to be alone wben one
chooses.*
Nurses can be seen as the patients' custodians. Tbey not only supervise daily
activities and treatment, but also regulate
tbe number of visitors tbe patient receives
and, to a certain extent, influence patient
bebaviour. Consequently, if patients had
increased privacy and the autonomy that
accompanies privacy, this would give
rise to questions concerning the custodial
role of tbe nurse. As Van Mooft (1990)
states:

'Questions of patient advocacy, privacy

and the tensions arising from cultural
differences are more frequent and often
more difficult than tbe seemingly
dramatic dilemmas wbicb are discussed
in the daily press.*
The implications of privacy, as applied
to nursing contexts, is one of patient
autonomy. When a patient is admitted to
hospital it is tbe nurse's duty to belp
bim/ber establish a temporary territory,
tbus enabling the patient to adapt to the
loss of bis/ber own physical and personal
space, territory and role (Hayter, 1981).
Hayter (1981) suggests tbat if the nursing staff respect patients' autonomy,
patients will be in a place tbey can control,
tbus feeling safe, less tbreatened and
anxious, wbich in turn will aid recovery
and make the hospital experience less
stressful.
Respecting tbe patient's autonomy is
synonymous witb giving tbe patient
cboice. Tbis is particularly prominent witb
tbe advent of The Patient's Charter
(Department of Healtb, 1991) and tbe
notion of tbe patient's advocate. For
example, wben given tbeir own territory,
patients may feel at ease to ask questions,
resist treatment, or take a more active role
in their care, wbereas patients wbo perceive tbemselves to be out of tbeir own
territory may consent to treatment witbout question, as a result of believing tbat
tbey bave no control.
People enter bospital wben tbey require
belp. It is tbeir need for assistance which
can result in disclosure of tbe 'private self.
Whether personal or intimate knowledge
is revealed, patients must believe tbat tbe
professional can help, will not reject tbem
and will protect tbeir confidences. As
Curtin (1992) notes:
*In essence, a tberapeutic relationsbip is
one in wbicb an artificial intimacy is
imposed by tbe need for belp.'

Staff privacy
Kerr's (1985) observational study into tbe
use of space by staff in terms of status,
function, territories and opportunity for
privacy appeared to reinforce earlier work
by Esser et al (1970, cited in Kerr, 1985),
and Esser (1968, cited in Kerr, 1985), who
found that tbe bigber tbe status of healtb
care workers, tbe greater tbe treedom to
move about an area. For instance, doctors
were allocated more private spaces witb
built-in boundary control mechanisms

71

Privacy: a key nursing concept

such as doors, whereas nurses or secretaries had none.
Freedom of choice or movement also
offered staff different opportunities for
privacy. Botb doctors and nurses bad
greater freedom to move about the ward
tban ward clerks and tberefore could use
this freedom to control interaction or
achieve some desired level of privacy.

Conclusion
Tbe concept of privacy, applied to tbe
nursing context, raises many issues and
implications for nursing practice, wbicb
need to be more fully explored in tbe literature. One important issue for nursing
wbicb bas not been discussed in this article
is tbe devolution of skill mix, i.e. more
people relating to tbe individual, whicb
makes tbe notion of privacy an unobtainable ideal.
Witb the advent of more private contractors in areas such as domestic services,
together with the increased use of agency
staff and bank staff, and the implementation of information technology on tbe
wards in the form of computerised patient
records, not only is continuity of care
being sacrificed, but also the opportunities

KEY POINTS
Patienthood is a stressful role.
Privacy is a key nursing concept
The nurses' role is both to protect the patient's privacy and
help the patient deai with ioss of privacy.

for tbe invasion of privacy are increased. Is

it any wonder tbat patients feel tbat privacy is not possible in bospital?
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