Patient modesty concerns pertaining to surgery

Specialties Operating Room

Published

Want to get feedback about how we all handle pt concerns about modesty and/or being naked as part of surgery. Concerns about who sees them and for how long? Why do they need to be naked? When is the gown removed, etc? How much do you tell them? How do you handle pt that is concerned about students practicing pelvic exams on them without concent? How to handle the situation when after the surgery they realize they had been "exposed"?

Advocates can come from many places: volunteers such as family and/or friends all the way to paid advocates. The real problem right now is that education seems to be in the eye of the (advocate) beholder. Almost anyone can call themselves that with no real background training, and yes..get paid for it.

I'm working with educators to come up with an actual level of training, but unregulated this is slow work. So in the meantime, a Berkely class in all things HIPPA, Medicare/Medicaid, and small crisis training gets you a certificate.

My version is a little bit more complicated, but I believe an advocate whether volunteer or paid should be somewhat skilled and comfortable in a medical environment. But in the end, the patient is choosing this person, so their comfort and trust level is the goal.

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Advocates in the OR? Okay. But I think the profession should start examining why some people perceive this need for advocates and try to make this perceived need unnecessary

in the eyes of most patients.

I recall years ago working with a large company that didn't have a union. And every

time a union tried to get in it failed. I studied why. The company examined all the

contracts this union had initiated with other companies and made sure their employees

not only got the same benefits, but better benefits. The union had no chance there

because the employees realized they probably wouldn't get a better deal with the union.

Smart business decision, huh?

Perhaps the medical profession should start examining the reasons why some

people feel the way they do about modesty, exams, surgery, etc ., and putting in

place specific polices that mitigate this perceived need. I've said it before and I'll say

it again -- it's more about open, honest, sincere, authentic communication than it is

about modesty. It's about trust. Bring up these issues with patients. Ask if these

are issues they want to discuss, or if they would feel more comfortable not discussing

them. Find out why patients feel uncomfortable, unsafe, embarrassed. Just bringing

up the topic, facing it, will help patients realize that you're in touch with their

feelings and care. Try it.

I've suggested and I'll suggest again, a good place to start is with websites. Dedicate a page to this whole issue of modesty, embarrassment, gender choice. Face the issue. Discuss it. Don't lock it up in the closet. The argument I get against actions like this from medical professionals is twofold: 1. By bringing it up we'll bring up something that isn't an issue but

that will then become an issue. This argument is only valid if you actually belief this isn't an issue. Face the facts. It is an issue for a significant number of patients. Is it possible that by

bringing it up it may become an issue for some for whom it wasn't an issue before? I suppose that's possible. But honesty is always best. 2. The other argument, a more practical one, is that why bring it up, offer choice, if we can't accommodate. That is a practical matter, I agree. But this argument still hands behind the issue rather than facing it. If it's an latent need, an

accommodation that will benefit your patients -- face the music and make it happen. It can be made to happen. And my guess is that, if you make it know that you do accommodate, that

information alone will be enough for some patients to make them feel more respected. Try it.

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I think an advocate would work if it was for an elective/minor surgery or procedure. The "advocate" could be a spouse, family member or friend; someone the patient feels comfortable with. That person could be in the operating room observing on the sidelines; not particularly in the way or in the immediate arena of action. I think that would help a large number of people with the trust/exposure issue once they are sedated.

I also agree on more communication. I still think offering the patient a detailed (including things like who will be assisting, what they will be doing, how the patient will be draped, what exposure will be required, etc.) printout or video before they commit to the procedure/operation would help, also. I know that I would have appreciated it because especially as a first time sedated patient you do not know what to ask and feel upset afterwards when things are discovered. I was told, and I believe this is probably true for some practitioners, that they do not tell patients everything because it is difficult to determine how much to tell each patient not knowing how much that person would really like to know. In other words, there are people out there who also do not like to know anything that is going to happen to them once they are under. So, I guess they just make the assumption that "most" people feel that way; a bad assumption in my opinion.

I do think a lot of change will happen, for individuals anyways, once they have a negative experience, especially after reading blogs like this. They can then feel more empowered to ask questions and arrange things to make them feel more comfortable and respected. It is unfortunate, however, that some patients have to have these unpleasant first-time experiences because I can tell you it sure makes them hesitant to enter the medical arena again.

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i agree with the theory, cul2 , that heathcare should be doing more to mitigate these circumstances. i actually see strides here to understand and perhaps move in this direction. however, when/if/until this happens, i don't see a difference in a trained advocate being present vs any number of other people who could be present (it seems) at any given time.

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advo-kate2 -- I'm not opposed to an advocate, as you suggest, but not as a regular thing.

We don't want to continue to erode the trust element in medicine. We must work to

create policies that bolster that trust rather than erode it. Medicine is doing its work to

erode this trust, too, when CYA policies trump patient dignity -- polices that, for example,

"require" chaperones without asking patient permission first. Indeed, any policies that don't

as a rule, ask patient permission for the presence of students, shadows, or anything else.

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I see a couple of real problems with having advocates be friends, family members, or others close to the patient.

First is a lack of objectivity. The last thing anyone--the patient included--needs is someone who is not familiar with surgical procedures having a bad reaction because they are freaked by seeing surgery on someone they care about. If complications happen, this could be a real nightmare, especially where sterile procedure can be so easily compromised.

Second, there may be many things that a "personal' advocate would not know how to interpret correctly. Their understanding of something could be influenced by fear, by the natural tendency to protect their loved one, and by a serious lack of understanding of the surgical world in general.

Third, anything less than a perfect outcome could lean toward this heavily biased person being drawn into a malpractice lawsuit, again because they are unfamiliar with what is normal and/or freaked out by someone they care about having problems.

And fourth, there are a great many people who would become uncomfortable with an actual surgery--the sight of blood and the many other sensory details that go with it--no matter how dedicated they were to the task at hand. Add to this that they know and care about the patient, and it's is just more than some can handle. They may not realize this until it's in front of them, and then the staff's attention is diverted from the patient.

I just don't see this as being a practical option.

What would be more likely and more workable are people with special advocate training who would be available, when needed, much like interpreters are now. These could be retired medical folks or others who are willing to invest some time in learning their role and who are not beholden to either the staff or the patients. A disinterested (but not uninterested) person might be able to give peace of mind to those who feel the need for this kind of service without jeopardizing or interfering with their care.

Advocate training could include familiarization with the OR milieu, the importance of maintaining a sterile field, how to speak assertively about the issues they are there to monitor, HIPAA regulations, and anything else that would be appropriate. If they aren't already comfortable in a surgical setting (with the sights, sounds and smells of the OR), they could perhaps sit in on a couple of surgeries they are not connected with to see if this is something they can handle. They would also need to see how long a period of observation they could endure.

Whether this would be a paid or voluntary role (or some combination of the two), that remains to be seen. But I would not recommend the use of untrained and untested advocates who have an ongoing relationship with the patient. There is too much at stake to send in someone who is neither objective nor prepared.

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Specializes in OR Hearts 10.

I agree with rn/writer

"I see a couple of real problems with having advocates be friends, family members, or others close to the patient.

First is a lack of objectivity. The last thing anyone--the patient included--needs is someone who is not familiar with surgical procedures having a bad reaction because they are freaked by seeing surgery on someone they care about. If complications happen, this could be a real nightmare, especially where sterile procedure can be so easily compromised. "

Before going to nursing school I was an Oral Surgery Assistant for 12 years. I cannot tell you how many family members pass out / got sick etc just watching their family get wisdom teeth removed under sedation. Nurses were the worst, it's different when it's your loved one being worked on. Nothing like having to leave your pt to take care of the "watcher"..... really can't see how it would work in the OR.

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I too am LARGELY in favor of an advocate for the patient (seperate from the medical staff). Thing is I constantly hear medical professionals talk about how they are the advocate for the patient. The problem is the issue of the Fox guarding the hen house.

This is simple... read some of the posts on here. Post where a nurse talks about patients routinely being brought up from the ER naked for no reason. The post about the gyn calling a crowd over to look at a girls lady parts only to talk about the way she shaves.(while she was under). A post about a doctor jiggling the body fat of a patient and singing a song about it while the nurses/techs all laughed.I also recall a post about a high school student watching a patient have a surgery as part of a program used to encourage students to enter the healthcare field . Thing is I'm CERTAIN the patient had no idea she was some kids "homework."

Someone made reference and called modesty concerns patient had "hangups,phobias and quirks." This type of attitude is EXACTLY WHY there is a need for advocates for the patient.

If an advocate was in that room what are the odds that the doctor would have kept his stupid song to himself. Much less grabbing the patient they way he did. Much less have a room filled with "healthcare providers" laughing.

This is simply one example but the list goes on and on and on.

When one poster brought up the issue of a patient advocate someone responded how it would be a problem because of additional "traffic" The problem is without an advocate patients OFTEN end up with more people walking in who "wanna look" and crowd around.The patient can often feel embarrassed ,humiliated,intimidated,shy lets face it. Their was a poster i believe under another thread say the reason he wouldnt ask if his prescene in the room was okay (i believe it had to do w a woman giving birth) is because he knew she would say no. So he would just enter and unless the patient said anything then it was "okay' wink wink.....

The arguement:Consent forms would have to be changed stating that a medically unneccasary person would be in the room. THIS IS ALREADY HAPPENING!!!! Id rather have one person on my side to ensure 5 medically unnecassary people werent in the room gawking at me.Again I'm making reference to conscience patients as well as those under and knocked out.

The arguement:you asked would the person stand and watch or get in your way. Well so a chaperone,medical students and the pizza delivery guy can stand and watch with no problem. But an advocate that is there on my behalf is all of a sudden knocking over supplies and filling the latex gloves with water for fun.

You also asked how much "education"will the person have . Great Question!!!! However I suggest we start with its innappropriate to grab a patients fat and jigglie it while singing a song and work from there.

A comment was made about the staff resenting being "watched."Well try this resent being watched, get naked and place your feet in stirrups and now invite in 5 more people. This is what patients are made to feel like when they are brought up from an ER naked with no reason, when doors are carelessly left open, when they are having a doctor talk about the way you shave your pubic hair in front of a group of people.

Medical professionals certainly have rights ....yes we all agree...but again the fox is guarding the hen house here.

This change IS coming to the healthcare industry.People are pushing for it and are demanding it and organizing.:yeah:The argument:a hospital that uses these techniques (advocates/cameras)shows it doesnt trust its employees. LET me be clear MANY PaTIENTS DO NOT TRUST THE EMPLOYEES . Just read some of the posts on this board!!!!! Why in the world would they???????

Thank you for this, when I suggested it earlier I was told that I needed mental counseling! It is good to see that change does not always equal crazy!

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Specializes in I have watched actors portray nurses.

I'm not sure an advocate option would be practical for half the patient population. And, from a male perspective, this would likely do little to address the double standard. If advocates are volunteers, or professionally trained people, they will likely be mostly female. In much the same way nurses are mostly female, advocates would likely be mostly female. For a boy or man with modesty issues, this may simply mean one more female in the room already containing too many females. And, if we are speaking only to surgeory situations in which the patient is out, well... I don't know.... what would the advocate actually do? Would she stand aside and do a crossword puzzle? And, also from a male perspective, such a solution would never really be meaningful to boys and men. I doubt there would be very many boys or men ever willing to admit they would want an advocate (particularly if their choices are only females) to accompany them through their medical experience/ordeal -- that would be unmanly!

I mean, if the goal is to simply put a damper on any unprofessional behavior on the part of the care giving team, well.. then... I guess her (advocate) mere presence should do the trick? Is that the thinking here?

Truthfully, I am more concerned about the modesty consideration breaches that occur when the patient is awake -- those hold the most potential for hurt feelings and psychological damage to the patient. And, sorry to bring this up again, but in those "awake" situations there is more risk to boys and men simply based on the

undercurrents of current cultural influence. They lay there, awake, fully exposed waiting for the team to get everything in place. They lay there, awake, fully exposed when their sisters do not. Everyone needs the same, equal, consideration and care on this issue.

I just think that the real change will have to come through less dramatic interventions.

Things like improved, and increased, education in nursing schools and medical schools.

Sensitivity training and exercises. More and better defined accountability protocols, procedures and guidelines. Close oversight from supervisors, etc.

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It seems to me that we have two different kinds of patients regarding the modesty issue.

1) Those whose issues can be mitigated through trust, communication, and honest dissclosure of what is going to happen. Perhaps gender may mean less (but not disappear) if everything is discussed. They are free at that point to say yes or no. If trust is the barrier then an advocate may help.

2) Those whose issues are absolutely about gender, and the only way to mitigate would be a same gender team. Perhaps then the advocate would only serve to insure that no other personell or opposite gender would expect to enter after the patient is not awake. In that case, maybe not so important to have one.

What I have found (to date) is that those who ask if I would advocate for them are mostly people who feel that either way they are having a difficult time expressing their needs. The subject for many is still intimidating.

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and tbrd450.....you may be right. it never occurred to me that most advocates may indeed turn out to be women. some recruiting techniques may well be in order...............point well taken!

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Specializes in I have watched actors portray nurses.
It may seem "trivial and unnecessary" to those providing patient care, but it never should be so. Patients have a right to their modesty, and just because a nurse or doctor has no such sensitivity, he/she should never assume that the patient does not. Even worse is to assume that a patient has no defensible reason to have expectations of modesty being preserved.

One never knows who has been sexually abused, so please do not ever trivialize a patient's need to avoid unnecessary exposure.

It was always a strong tenet in training that lax attitudes, most especially including not discussing patients' anatomies, much less in a derogatory fashion, is the height of a lack of professionalism. Perhaps those who see it as such a negligible issue need to spend some time as patients themselves.

As one who has suffered her share of indignities, as well as her share of truly thoughtful, heartily appreciated treatment, I find this a real hot button issue, so I'm sorry to come off so indignant. However, that I am! :)

And, bravo, to the poster above! Well said, and much food for thought.

When I wrote the post on desensitization, I was trying to get at the why behind the behavior. Let's break from describing the behavior for a moment and try to unearth the roots.

I happen to believe that when any organized groups of people come together, in almost any institutional setting, a unique culture can and often does emerge and prevail. And while it accounts (or attempts to account) for diversity of individuals, across gender, race, religious beliefs and value systems, what commonly emerges is a single guidepost reflecting the collective wisdom of the group. Just as an example, take the correctional community/environment. It is a prime example of this process, a clear example of how collective mentality often emerges, premeates and ultimately dominates. I believe that when within the context of human interaction involving power imbalance, and care, service and oversight to/of others, a degree of desensitization is inevitable over time.

As Psychology professor Dr. Phillip Zimbardo showed with his 1971 Stanford Prison Experiment, desensitization to behavioral impact, and strict adherence to the collective, is amazingly fast and consistent under certain circumstances. Unless carefully crafted, well-maintained, and vigorously enforced safeguards are developed and implemented, such a dangerous desensitizing descent will likely happen. It happens with decent, normal, everyday people.

Now, please recognize that I am not trying to draw an analogy between desensitized medical professionals' inappropriate behavior on the modesty front with that behavior of desensitized prison guards harboring sadistic tendencies. Rather, the byproduct of the institutional culture -- desensitization -- is somewhat similar.

The doctor who popped in on the exposed patient to chit chat with his colleagues about a TV program was, in all liklihood, not doing so from an underlying sadistic/cruel motive. While nobody knows that for certain (except him), nothing in the story described paints that picture. Okay, so, then why?

I think it is probably true that doctors and nurses see so many patients -- modest patients, immodest patients, vulnerable patients, crying patients, female patients, male patients; scrotums, lady partss, memberes, breasts, piercings, toe rings, funny bones, ankles, hands, eyes, etc. -- that after some time they begin to disconnect a little more each time from a sensitized, immediate awareness of the potential concerns, feelings, emotions, insecurities and embarrassments often so closely associated with those patient body parts. Boys and men are typically viewed, perceived and assumed to be less concerned about their exposure -- society and culture sets that stage for them. Girls and women are typically viewed, perceived and assumed to be much more concerned about their exposure -- society and culture sets that stage for them. In my opinion, both are generally false presumptions. The truth is probably that we all, individually, lie on a spectrum not divided along gender lines. Some of us are more concerned than others. Believe me when I say I have met women in my life who were extremely immodest, some even actually anti-modest. And, I have met some men who have been extremely, and some painfully, modest about their own nudity.

The doctor who callously popped in on the exposed female patient during her operation just to chit chat with his colleagues probably just walked down a hospital hallway to get there. A hallway likely containing a gurney holding a fully exposed male teenager just brought in by the paramedics from a skateboard accident. Or, he may have just come from a delivery room where a woman gave birth in front of a live studio audience:o. The spectrum is wide and we all fall on it somewhere. Feminism -- true feminism -- taught me that my gender doesn't have to dictate where I fall.

My main point here is, and was, that desensitization can and probably often does occur in medical settings from a natural and organic impetus. I read, for example, in a different thread in here as a veteran nurse advised a new nurse with concerns. The new nurse posted that she was nervous and concerned about performing intimate care procedures on male patients, given that she was so young and had little experience with that anatomy. The veteran nurse assured her that very soon it would just seem like old hat -- something to that effect (I'm paraphrasing here). In other words, that soon she would just become desensitized to nudity, even the anatomy (male) she had little exposure to in the past. Interestingly, the new nurse commented something about how the "hunky" male patients will likely be a bit more of a struggle to deal with without blushing. something like that...

From the caregiver's perspective, desensitization is understandable. From a care receiver's perspective, that is a potentially dangerous and slippery slope. Desensitization probably explains a significant number of these modesty horror stories. But, that is clearly different than explanations based on deliberate, intentional abuse of power, or underling sadistic tendencies.

For the deviants out there (and yes, they exist in every walk of life including the medical profession), no amount of sensitizing education or awareness intervention will ever impact their behavior. They will always find a way to justify popping in on a nude patient to grab an eye full. Incidentally, when the deviants turn out to be female, it is dramatically much easier for them to couch and rationalize their behavior in "legitimate" window dressing. Society and culture permits and supports that double standard. All in all, I think we are talking about the rare professional here motivated by this.

Most likely, modesty breaches and inconsiderate actions are tied to desensitization and operational efficiency. It is probably similarly explained, I believe, why over time in the line of duty, some church-going, pillar-of-society, correctional officers begin to administer 4 jolts of the taser instead of 3. And, so the thinking goes, the taser really doesn't do permanent damage so what's just one more jolt? ... it gets the inmate in the restraint chair faster!

Another contributor, or confounder, is probably one that is much easier to grasp -- operational efficiency. When it is genuninely argued (as opposed to disingenuinely justified) that patient exposure is valid on efficiency grounds, it is easy to understand. I may not necessarily agree with the argument, but I'm not doing the job and can't dispute the detailed explanation. I understand the argument when it is genunine.

Ensuring patient modesty consideration at every twist and turn of the rolling gurney requires focused attention, ongoing proactive consideration and, ultimately, a bit more leg work. Stuff can just get done faster when we don't have to worry about covering up the skate boarder's twigs and berries! It's just that simple. (not agreeing, just understanding). After all, the thinking often goes, his junk here looks just like that dude's junk over there...so what's the big deal!?! And, more importantly, my lunch break starts in 15 minutes and fully intend to start it on time today! And, yea, If you really want me to admit it.... it helps that the guy sort of looks like a young Brad Pitt.

The 1971 Stanford prison experiment particpants were just normal, everyday college student volunteers. They were not evil felons with alterior motives. Those volunteers in the role of guard began to behave outside their normal range of standardized decency. They began to think outside the box in some very negative ways. Power can be intoxicating, particularly for weak minded individuals. They came to realize later, well after the experiment was abruptly shut down, that they had changed (during the experiment) without recognizing the transition within themselves. Professor Zimbardo himself acknowledged his own desensitization - his change. And, he wasn't even actively participating directly in the experiment. He was simply observing and recording. What a powerful lesson to draw on.

What happens to the patient? Regardless of why something happens that shouldn't (or doesn't that should) the impact on the patient can be exactly the same. He/she is unnecessarily hurt by the experience -- some patients more than others. That's why caregiver statements, however genuinely expressed and well-meaning, such as "oh, don't worry honey, I've seen a thousand of these before," or "Oh, I don't like doing this any more than you do," etc. are so blatantly offensive for patients to hear. It is an attempt to turn it around and make it about the caregiver's nudity viewing background or desensitization. The patient couldn't care less about that. It is irrelevant. It is salt in the dignity wound. It minimizes, instead of validates, the patient's feelings around his/her vulnerability and embarrassment. It actually has the opposite effect than what is truly needed in that moment.

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