1.1 NHS Ayrshire & Arran's commitment to promoting a culture where everyone is treated with dignity and respect.

NHS Ayrshire & Arran is committed to promoting a culture where everyone is treated with dignity and respect. The promotion of privacy, dignity and respect for each individual is integral to all interactions with patients, the public, staff and stakeholders. 

Responsibility for protecting and promoting privacy, dignity and respect does not lie with one individual or group but with all staff to embed a culture where everyone matters.  People should also be treated with kindness, compassion, courtesy, understanding and honesty.  This incorporates the Quality Ambitions within The Healthcare Quality Strategy for NHS Scotland²   (Scottish Government 2010), which ensures that care is person-centred, safe, effective, efficient, equitable and timely.  This commitment is reflected in NHS Ayrshire & Arrans core values of Caring, Safe and Respectful.

Human dignity is an underlying principle of Human Rights (Scottish Human Rights Commission 2012).  Home | Scottish Human Rights Commission 

Loss of dignity compromises self-esteem, respect and confidence. It can make an individual feel unimportant, unworthy or lost and misplaced, which can have a far-reaching impact for the person, on their functioning and their relationships which can perpetuate mental health/illness issues and inhibit recovery.  It is recognised that the provision of single sex accommodation in health care organisations is considered to be a key factor to maximise patient dignity and ensure that privacy is promoted and respected. 

The eradication of mixed sex accommodation in the NHS in Scotland has been a target for the Scottish Government since 2002, and this was re-affirmed by the issue of Chief Executive Letter (CEL 48) in 2008  Provision of single room accommodation and bed spacing (scot.nhs.uk)³   regarding the provision of single room accommodation and bed spacing. 

 NHS Ayrshire & Arran is committed to delivering same sex accommodation to enhance the privacy and dignity of service users.  There are however a small number of exceptions to this policy as outlined in section 4.1. 

1.2 Definitions used in this policy

Single sex accommodation - For the purposes of this policy, single sex accommodation is defined as when a room or bay is specifically for one sex with washing facilities also available solely for this one sex.  

Privacy - Privacy is the freedom from intrusion and embarrassment and refers to all information and practice that is personal or sensitive to the individual.  Privacy is a key principle which underpins human dignity, and remains a basic human right and the reasonable expectation of every person.

Dignity - Dignity is to treat a person in a way that is respectful of them as valued individuals, being of equal value and worth irrespective of differences such as age, race, culture, gender, sex (male or female) sexual orientation, social background, health, marital status, disability, religion or political conviction.

Respect - Respect is positive regard shown to a person as a human being and an individual, by others, and demonstrated as courtesy, good communication, taking time and equal access to services and care.

Modesty - Modesty refers to treatment and care being given in such a way that avoids unnecessary exposure and therefore minimises anxiety and distress.

2.1 Policy aims

This policy aims to:

• Ensure purpose and scope are clear.
• Ensure care is person centred with respect to individual values and beliefs.
• Consider and define exemption areas.
• Clearly communicate and update staff responsibilities aligned to Health and Social Care Standards (2017)⁴ 

The policy also identifies the requirement and processes to monitor for breaches of compliance, and the actions, escalation and reporting of any breaches to enable teams to learn and improve care.

2.2 Policy purpose

This policy outlines NHS Ayrshire & Arran’s arrangements and processes to promote the privacy and dignity of all people and to comply with the provision of single sex accommodation for patients. 

2.3 Policy scope

The policy applies to all staff and provides clear information to inform them of their roles and responsibilities in relation to maintaining patients’ privacy and dignity and the requirement to comply with single sex accommodation for all adult patients admitted to in-patient areas across NHS Ayrshire & Arran.

2.4 Trans patients

Trans is an umbrella term for people who, for whatever reason, feel their gender identity or gender expression differs from their sex assigned at birth. NHS Ayrshire & Arran enacts the definition for gender reassignment outlined within the Equality Act 2010⁵. The Act defines gender reassignment as:

‘where a person has proposed, started or completed a process (or part of a process) for the purpose of reassigning the person’s sex by changing physiological or other attributes of sex’.

The definition of gender reassignment no longer requires the person to be under medical supervision to be protected by the law.

Trans people will receive equitable access to all NHS Ayrshire & Arran services. The organisation understands that a person’s expressed gender identity will not exclude them from the high standards of care expected. This policy applies equally to Trans patients and, as is the case for all patients, all breaches must be recorded and submitted in the data return.  

As in-patient accommodation remains configured by sex, Trans patients will be offered accommodation that matches the gender in which they are currently living. For example, Trans women will not be placed on male wards or vice versa. To do so would be insensitive and may constitute a breach of the Equality Act 2010 and incur both financial and reputational risk to NHS Ayrshire & Arran. Healthcare professionals should ensure that Trans people receiving hospital care have access to the necessary privacy and facilities to maintain post-surgical regimes and so a single room may be more appropriate.

Some patients may present as non-binary where they do not see themselves in either sex, male or female.  Where this is the case, discussions relating to accommodation within our acute hospital must take place with this broader understanding of gender and gender identity. 

All staff in NHS Ayrshire & Arran including bank or agency and staff on temporary or honorary contracts must comply with this policy. 

Staff are accountable for their behaviours and have an individual responsibility for implementing this policy as part of their normal duties and responsibilities in their working environment. Staff should also learn from and improve their practice in response to patient or colleague feedback.

Staff must report breaches for this policy (as outlined in section 5 and Appendix 1)

It is the responsibility of the Senior Charge Nurse (SCN) or Nurse in Charge (NIC), with support from the Clinical Nurse Manager (CNM)) and/or the Clinical Operations Manager (COM) to ensure that this Dignity & Privacy (Single Sex Accommodation) policy is complied with, and regularly monitor compliance.  

The maintenance of patients’ privacy and dignity is a fundamental component of patient care. The Human Rights Act 1998 (legislation.gov.uk)⁶  is based on the core principles of dignity, equality and respect and translates these protections into UK law, which all public bodies including hospitals must comply with. 

Every patient has the right to receive high quality care that is safe, effective and respects their privacy and dignity.  NHS Ayrshire & Arran is committed to providing every patient with single sex accommodation, to help safeguard their privacy and dignity when they are often at their most vulnerable.

The Health and Social Care Standards ⁷ (Scottish Government, 2018) highlight that the standards reflect how all people should be treated and are underpinned by five principles:

1. Dignity and respect
2. Be included
3. Receive care that is responsive
4. Ensure support and
5. Wellbeing.

Patients and service users should experience care in an environment that actively encompasses respect for individual values, beliefs and personal relationships. Staff will reinforce high standards of dignity and respect at all times, for example, not entering closed curtains.

NHS Ayrshire & Arran will ensure that when adult patients are admitted to any of our hospitals they will:

• Only share the room in which they sleep with patients of the same sex.
• Have access to same sex toilet and washing facilities, which will be located close to their sleeping areas and which are clearly signposted and labelled.

All adult in-patients across NHS Ayrshire & Arran will be cared for in wards or enclosed rooms/bays/areas that are for single sex occupancy.  Exceptions to the provision of single sex accommodation apply to the following areas:

• Intensive Care/Designated High Dependency areas
• Major Trauma(up to 2 x 6 bedded bay in orthopaedic trauma)
• Hyper Acute Stroke Assessment (up to 2 x 6 bedded bays)
• Emergency/ Urgent Care Assessment
• Day Surgery Units/Endoscopy Day Unit
• Clinical Investigation areas
• Emergency Department Observation areas
• Theatre Reception and Theatre Recovery areas.

In all cases where mixed gender accommodation cannot be avoided significant attempts at preserving privacy and dignity must always be taken. Numbers of patients affected by each breach will be monitored and reported. In these instances, staff must ensure that patients will be cared for in a manner that is supportive of their individual privacy and dignity requirements and that patients are transferred to single sex accommodation as soon as their clinical condition allows.

Temporary exemptions may be considered in exceptional circumstances as it is recognised that there are situations whereby compliance with single sex accommodation is particularly challenging due to extremis such as major incidents and/or processes needed to manage infection control risks such as Covid 19.

All wards must have single sex toilet and washing facilities. Any toilet and/or washing facility located within exemption or exception areas must be lockable by patients, ensuring that these locks can be opened by staff in emergency situations.

It is accepted that there are exceptional clinical situations where it is clearly in the patient's best interest that they receive rapid or specialist treatment and single sex accommodation is not the priority. In these cases privacy and dignity must be protected, and patients transferred to single sex accommodation immediately after the exceptional situation ceases to apply. These exceptional situations that do not constitute a breach of the policy include:

• Safety - In the event of a life-threatening emergency, either on admission or due to sudden deterioration in a patients’ condition or when segregation would put the patient at risk of harm.
• Acuity - Where a critically ill patient requires constant one to one nursing care i.e. where a nurse must be physically present in the room/bay at all times.
• Specialist Care or Observation - Where a short period of close patient observation/supervision is necessary.
• Times of Major Incident - Will be recorded as part of the detail of the incident in DATIX . 

In cases where it has been clinically justified to mix genders, as outlined, regular review must take place. When a decision is made that a patient no longer requires the level of care that justifies the exemption, then the patient must be moved to a single gender accommodation. If this cannot be achieved then this must be reported as a breach. Please note that although more than one patient may be affected, this is classified as a single breach.

At times, patients may share some communal spaces such as day and dining rooms where these are available. Patients will encounter patients of the opposite gender in other departments such as x ray.

It is highly likely that visitors of the opposite gender will come into same sex bays at visiting times – some patients even like to visit each other.

A breach occurs when a patient is placed in mixed sex accommodation (out with the exempted areas and exceptional situations listed above in section 4.1). This breach must be reported on the DATIX Adverse Event Management System .

The Datix reporting must include the numbers of patients affected and use the sub category “single sex policy breach” to enable reports to be obtained from the system. 

• All patients and/or their families and carers must receive a verbal apology immediately the breach occurs and an explanation offered, followed by a formal letter of apology (See Appendix 2).
• The breach and rationale must be clearly documented in the patients nursing record and Ward Risk/Checklist for Breaches completed. (See Appendix 3).
• Staff will provide extra personal nursing support to the patient, for example use a separate quiet room for personal conversations and avoid giving personal care (for example toileting) in the mixed bay/area where possible.
• Patient screens must be available around all individual bed areas.

A report of the breach must be made at the point of decision as well as recording how many other patients are affected.

The breach reporting process can be found in Section 5.1.1 & 5.1.2 and Appendix 3 of this policy.

5.1 Escalation

If it is not possible to provide single sex accommodation and a breach has occurred this must be escalated as follows:

5.1.1 Mixed gender accommodation breach escalation and reporting process in hours

Decision about where best to accommodate a patient is made by ward/department Nurse in Charge in collaboration with Clinical Operations Manager and if necessary the Clinical Nurse Manager in conjunction with General Management colleagues.

A breach may occur when all other options to accommodate in same gender room have been exhausted and there are no clinical justifications/exemptions or exceptions.

If a breach is identified, alert the CNM for the ward/department to enable adverse event reporting to occur and if possible an additional member of staff will be allocated to the room to ensure the safety, dignity and privacy of all patients in the room.

Please see Appendix 1

5.1.2 Mixed gender accommodation breach escalation and reporting process out of hours

Decision about where best to accommodate a patient is made by ward/department Nurse in Charge in collaboration with Night Coordinator and if necessary the Duty Manager.

A breach may occur when all other options to accommodate in same gender room have been exhausted and there are no clinical justifications.

If a breach is identified, alert the Duty Manager to enable adverse event reporting to occur and if possible an additional member of staff will be allocated to the room to ensure the safety, dignity and privacy of all patients in the room.

 Please see Appendix 1

NHS Ayrshire & Arran will monitor compliance, audit and report through the following mechanisms:

• Feedback from patient experience gathered locally is used to inform any actions required by individual teams, led by the Senior Charge Nurse/Midwife e.g. patient experience questionnaires.
• Adverse Event Management reports will be made available to all Nursing Directors quarterly and will be reviewed locally with action plans and escalation where appropriate.
• Local clinical governance meetings will report breaches as required and ensure appropriate actions/escalation are made. This will ensure learning is shared within and across directorates.
• Annual summary report of compliance will be reported annually through the Healthcare Governance Committee Management report to the NHS Ayrshire & Arran Board.

1. Scottish Government. Carers (Scotland) Act 2016: statutory guidance - updated July 2021.[Accessed 08 February 2023] Available from: https://www.gov.scot/publications/carers-scotland-act-2016-statutory-guidance-updated-july-2021/

2. Scottish Government. Healthcare quality strategy for NHSScotland. 2010. [Accessed 08 February 2023]. Available from: https://www.gov.scot/publications/healthcare-quality-strategy-nhsscotland/

3. Scottish Government. Chief Nursing Officer Directorate. Provision of single room accommodation and bed spacing. 2008. CEL 48. Available from: https://www.sehd.scot.nhs.uk/mels/CEL2008_48.pdf

4. Scottish Government. Health and social care standards: my support, my life. 2017. [Accessed 08 February 2023]. Available from: https://www.gov.scot/publications/health-social-care-standards-support-life/

5. UK Government. Equality Act. 2010. [Accessed 08 February 2023]. Available from: https://www.legislation.gov.uk/ukpga/2010/15/contents

6. UK Government. Human Rights Act. 1998. [Accessed 08 February 2023]. Available from: https://www.legislation.gov.uk/ukpga/1998/42/contents

7. Scottish Government. Health and social care standards: my support, my life easy read version. 2018. [Accessed 08 February 2023]. Available from: https://www.gov.scot/publications/health-social-care-standards-support-life-easy-read-version/

Not specifically referenced in text:-

• UK Department of Health. Privacy and dignity: a report by the Chief Nursing Officer into mixed sex accommodation in hospitals. 2007.
• Scottish Government. Gender Recognition (disclosure of information) (Scotland) Order 2005.
• National infection prevention and control manual. https://nipcm.scot.nhs.uk/
• NICE. Patient experience in adult NHS services: improving the experience of care for people using adult NHS services. [CG 138] Published 24 February 2012. Last updated 17 June 2021. Available from: https://www.nice.org.uk/guidance/cg138
• The European Convention on Human Rights and Gender Reassignment (article 8, 10 & 14)

In hours

0-2 hours

• Breaches should be recorded within 2hrs using DATIX system by the Clinical Operations Manager and should be recorded at the site safety huddles.
• The clinical area will be required to confirm that the patient has been given a verbal and written letter of apology and this should be documented in the patient's medical record.

4-6 hours

• The patient should be reviewed at four and six hours and if the breach has not been resolved it should be escalated to the Site Director or Chief Nurse and recorded on the ward based risk assessment in the patients nursing record and at all times the situation should be discussed with the patient and their concerns addressed.

12-24 hours

• Review the breach at 12 hours and if it has not been resolved escalate to the Site Director or Chief Nurse.
• Review the breach again at 24 hours if not resolved. Ensure the Duty Manager is requested to meet the patient and apologise for failure to resolve the breach.

Out of hours

0-2 hours

• Breaches should be reported within 2 hours using DATIX system by the Night Coordinator and should also be recorded at the site safety huddle. 
• The clinical area will be required to confirm that the patient has been given a verbal apology and this should be documented in the patient's medical record with a written letter of apology in working hours.

4-6 hours

• The patient should be reviewed at four and six hours and if the breach has not been resolved it should be escalated to the Duty Manager and recorded on the ward based risk assessment in the patients nursing record and at all times the situation should be discussed with the patient and their concerns addressed.

12-24 hours

• Review the breach at 12 hours and if it has not been resolved escalate via the Duty Manager to the Director On Call.
• Review the breach again at 24 hours. If not resolved ensure the Duty Manager is requested to meet the patient and apologise for failure to resolve the breach.

Appendix 2: CEO letter

Appendix 3: Checklist

Appendix 4: NHS Ayrshire & Arran - policy approval checklist

Appendix 5: Equality impact assessment