Nursing Ethics

http://nej.sagepub.com Intimacy - Meeting Needs and Respecting Privacy in the Care of Elderly People: what is a good moral attitude on the part of the nurse/carer?
Anne-Cathrine Mattiasson and Maja Hemberg Nurs Ethics 1998; 5; 527 DOI: 10.1177/096973309800500607 The online version of this article can be found at: http://nej.sagepub.com/cgi/content/abstract/5/6/527

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INTIMACY MEETING NEEDS AND RESPECTING PRIVACY IN THE CARE OF ELDERLY PEOPLE: WHAT IS A GOOD
MORAL ATTITUDE ON THE PART OF THE NURSE/CARER?
Anne-Cathrine Mattiasson and Maja Hemberg
Key words : care of elderly people; intimacy; privacy; sexuality; touch This article explores notions of intimacy in the caring context. The aspects discussed are: privacy and intimacy; intimacy as emotional and/or physical closeness; intimacy as touch; sexual intimacy and normal ageing; sexual intimacy and patients suffering from dementia; and intimacy as trust. Examples are given and problems are identified, with reflection on the attitude and behaviour of the carer. It is suggested that when trying to make moral decisions in concrete situations it is imperative that the carer is aware of the values upon which his or her own thinking is based. It is argued that the guiding principle should be the moral assumption that the carers responsibility can never be interpreted as a right to disregard the wishes of the patient. Hence, the key word in daily care is respect.

Introduction
Ethics is ultimately concerned with how we ought to act towards one another: what is good and bad, what is right and wrong to do to another individual? Within the study of medical ethics these questions are often equated with dramatic decisions, brought to the fore through questions of life and death, or as a consequence of the latest advances within medical technology and research. Ethics, however, is not only concerned with the spectacular or with situations where decisions of vital importance have to be made. In the ordinary care unit of a hospital, or in the daily care of elderly people in a nursing home, we encounter a type of everyday ethics, with countless small, down-to-earth decisions concerning the various aspects of care. These everyday actions are not subject to analysis each time they are performed. Rather, they reflect, consciously or
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unconsciously, the fundamental attitudes of carers. When we as carers are faced with a situation that calls for a moral decision, it is therefore imperative that we are aware of the values upon which our thinking rests. Basically, ethics has to do with a view of life and human nature. Within health care, the well-known ethical principles of, for instance, beneficence and respect for autonomy, are direct evidence of our common conviction that specific freedoms and rights exist for all. This fundamental view, transposed to the realities of health care, could be expressed thus: to care for another human being is a trust one is given, not a right that one has. To care is therefore a responsibility that can only be received, never seized. In the health care professions, the importance of the ethical responsibility is particularly evident in the inequalities that exist between carers and patients. A sick person is dependent because of his or her weakness. The core of caring is thus to aid a fellow human being who, as a patient, is in a vulnerable position but who still has rights to privacy, upon which the carer may not intrude.

Personal privacy and intimacy

One of the central problems for a person who falls victim to an illness is the experience of loss.1 The intensity of that experience often stands in relation to how far the ailment has progressed. The feeling of loss can include a change in appearance as a result of severe loss of weight for instance, but it can also be related to the loss of a part of the body or of sight, hearing, speech, mobility or intellectual capacity. The ageing individual is, almost without exception, affected in some respect. Concurrent with physical changes, an elderly persons sense of identity can often be shaken. There is an increased desire for recogniton and intimacy, but also a wish that the carer will respect ones personality. An elderly patients mental situation, as described above, shows clearly the complexity of the question of intimacy in the care of older people. On one hand there is a need for intimacy in the form of human contact and physical touch. In addition, the need for help with acts that earlier belonged to the very personal sphere grows irreversibly. On the other hand there is an elderly persons equally legitimate need for respect for his or her privacy, a rightful wish not to be forced into more intimacy than the care situation and care actions demand. The challenge for the carer is to balance these seemingly opposing needs. Our moral duty lies in trying, as far as possible, to satisfy both.

Aspects of intimacy
Intimacy as a concept can be seen as emotional as well as physical closeness in different connotations. Emotional intimacy in relation to another being is a fundamental human need. A lack of such interpersonal intimacy can inhibit mental health, development and maturity.2,3 In health care, achieving the right level of emotional intimacy touches on the important question of the degree of confidence, and thus, of familiarity and closeness, between patient and carer. Another quesDownloaded by RAVI BABU BUNGA on November 8, 2007 for the loss of social tion brought into focusfrom ishttp://nej.sagepub.com also that of how to compensate 1998 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

Intimacy meeting needs and respecting privacy in the care of elderly people 529 contacts, family life and other aspects that institutional living often incurs. Physical intimacy is closely related to emotional intimacy. It may concern bodily contact or sexuality, which are likewise to be regarded as fundamental needs that are present to varying degrees. The concept of intimacy is also brought to the fore in situations where the naked body and personal hygiene are involved. Eating, too, is seen by many as an intimate matter.

Intimacy from the patients perspective

Another approach to understanding the different aspects of intimacy is to adopt the patients perspective. Here, we find the need for emotional closeness in the form of psychological needs. The patient needs to feel trust and to be able to confide in a carer, unburden herself or himself and be affirmed as a person. The patient also has social needs, which can involve such matters as shared or single rooms, everyday noises, voices, friendship, participation in activities and communication. Patients also have spiritual needs, which concern the possibility of discussing existential questions such as ones approaching death and similar thoughts. Finally the patient has physical or physiological needs that are expressed in a desire for bodily nearness in the form of skin contact or sexuality. It is important to observe that when we speak of practical needs, for example, diet and eating, hygiene and treatment, we mean needs of a fundamentally different nature. In this case, we no longer speak of a desire for intimacy but rather of the opposite, that is, a type of forced intimacy occurring as a consequence of a need for help. Knowledge is a first and an important precondition for meaningful ethical reflection in situations in which morally good action is desired. Much is now known about the consequences of different ways of experiencing intimacy. Some of these aspects are presented below.

Intimacy as touch
Touching can occur in two general ways: task-related and nontask-related. Taskrelated touch is the necessary touching that follows a specific treatment or procedure, such as applying a bandage, taking the pulse, administering an injection, or bathing a patient. In the nursing literature, various terms are used, such as instrumental, procedural or task-orientated touch. Nontask-related touch refers to other spontaneous forms of touching, which include holding a patients hand, stroking a persons cheek or putting an arm around someone. This kind of touch is also referred to as expressive, comforting, non-necessary or affective touch. For a recent literature review, see Routasalo.4 Touch has always been used as part of the caring process, to express understanding, give comfort and ease pain. It is ordinarily described as nonverbal communication and is considered by many as that which best communicates empathy.5 The importance of touch for a patients sense of identity and selfesteem, as well as for well-being, is stressed recurringly in health care literature.1,6 Downloaded from http://nej.sagepub.com by RAVI BABU BUNGA on November 8, 2007 For instance, a strong correlation has been shown between light touching and 1998 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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improved appetite in a group of patients with chronic organic brain disease.7 Nonprocedural touching was used as a form of encouragement and confirmation during eating. As early as 1967 a study carried out with a group of mentally ill patients showed that verbal communication as well as social behaviour improved when spontaneous touching was employed.8 We see that bodily touching can fulfil not only physical but also psychological and social needs. It is important that carers are aware that touching can be perceived very individually. Studies have shown that patients interpret touch in different ways; carers should be aware of this in every situation.5,911 Some patients experience touching as gentle, comforting and important. Others, however, can react to all touching as invasive; some can even feel threatened and become defensive. The reason for a certain reaction can be found in the individuals personal disposition, but one should also be aware of cultural differences.12 Patients can be unfamiliar with touching because of their own earlier social situation and therefore may misinterpret it as too great an intimacy or even as a sexual advance. It has been shown that a carers personal attitude to skin contact plays an essential role in the way patients react to touching.5,13 Carers unconsciously convey their attitude to patients. To be able to touch the patient in a natural way it is necessary to have insight into ones own needs and feelings and to be able to deal with these. This perspective, however, has been very little explored. A study carried out in 1977 reported that no less than 60% of carers felt ill at ease and occasionally anxious when they touched elderly patients.14 Despite the lack of more recent research, we can learn from this study that it is essential first to analyse ones own reactions and then to direct ones attention to the patients perception and the purpose of touching. The carer can then feel secure in the professional role. In a very enlightening study, elderly nursing home patients described the conditions in which they perceived touching in a positive way.5 These were when: (1) touching was perceived as adequate in a given situation; (2) no greater intimacy was forced upon patients than they themselves desired; and (3) a condescending attitude was not mediated. Touching was perceived as negative when any of these three conditions were not met. They can serve as a good summary of what a carers goal should always be. The care of elderly people consists to a high degree of what is known as intimate care. Carers often meet patients who are in advanced bodily decline. Practically every care treatment involves touching and, with every touch, the carer invades the persons private sphere. This is a sphere that, for the individual, had always been reserved for the intimate functions and contacts over which the person normally had control. When the body becomes an object for care, there is a risk of invasion of personal privacy. All touching should therefore be performed on the receivers terms. The carer must be aware of what message he or she communicates by touching and then try to interpret the elderly persons perception of it through body language, gesture, facial expression and eye contact. Being dependent on someone else for ones own personal hygiene is not in itself undignified, but baring the body or having intimate zones touched nevertheless often causes feelings of shyness, shame or humiliation. Patients who perceive that they are merely objects to a carer will feel invaded and abused. An elderly persons Downloaded http://nej.sagepub.com by RAVI BABU November sensitivity 8, 2007 exposed situation mustfrom be compensated forBUNGA by on extra concerning the 1998 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

Intimacy meeting needs and respecting privacy in the care of elderly people 531 limits of personal privacy and an openness on the part of the carer to respond, even to the unseen reaction of the patient. The balance between nearness and distance must be assessed and maintained so that the patient can feel a sense of control. Every step in a care treatment should be accompanied by some type of explanation and description and an introductory question such as I would now like to . . . Mrs X. May I . . . ? This may is a key word not only in care situations that include touching the patients body but in any care procedure. This helps the patient to feel that he or she is still in control of his or her own situation. A patient appreciatively said to a nursing student who worked in this manner: I feel that I could make you stop if I wanted to.1 This, perhaps, expresses the very essence of what is meant by the right to dignity and self-respect.

Sexual intimacy and normal ageing

Peoples sexual needs apparently last throughout life.1517 As we age, sexual activity is reduced and is gradually expressed more through touching, stroking, huging and warmth.18 Regardless of health status, there is always a need to find expression for ones sexuality in some form. Belonging and togetherness with another person are thereby confirmed. The study of institutionalized elderly people and their feelings on sexuality is a rarely explored area, but the data available seem to confirm that sexual needs remain.1921 With institutional care, there is a risk that the needs of sexual expression in elderly persons are overlooked. This can be the case if the carer does not have sufficient knowledge of this area and, as a result, feels uncertain about his or her approach. 22 Neglecting this type of need in elderly persons is to signal that such intimacy is neither expected nor proper in people of their age and health status. The carer needs to be trained in being able to discuss questions on sex in an open manner. Even if the task of the nurse or carer does not include being a sexual therapist, it is often him or her who becomes closest to the patient in daily care. A natural state of dependence between the carer and the patient is built into the care relationship. Matters can be complicated in that, traditionally, the majority of nurses and care personnel are women. It is not uncommon for sexual desires to find their way into this relationship. A look of appeal, trying to hold hands a bit longer than necessary, flirting, these examples are, of course, not necessarily expressions of sexual invitations but can be a desire for recognition and an attempt to uphold ones identity. The carer, as a professional, must be aware of it if and when subtle signals of sexuality are expressed. If this should be the case, the carer should be direct and not encouraging in a way that would arouse false hopes. The patient, in such situations, is first and foremost a patient. Professionalism involves the ability to set limits. There can be differing opinions about such limits. A nurse or carer who feels secure in that role need not over-react. Many situations of this type are innocent and can be handled generously. However, a playful tone must be evident. Desirable goals are clarity and setting limits without offending. By this, the carer mediates both self-respect and respect for the patient. The goal must be to find a balance and, in a natural and confident manDownloaded from http://nej.sagepub.com by RAVI BABU BUNGA on November the 8, 2007 needs for contact withner, be able to touch the elderly person and answer 1998 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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out signalling more than consideration. To this comes the readiness to meet the patient in a trusting dialogue and thereby allowing the possibility of channelling sexual thoughts that cannot otherwise be expressed. The foregoing concerns male patients in relation to female carers. Obviously the same approach is also valid in situations when there is a female patient and a male carer. Female sexuality has, through the centuries, been denied in many cultures.23,24 The fact that it has still not been recognized to the same degree as male sexuality makes even greater the carers responsibility to identify it and meet it adequately. Homosexuality, perhaps to an even greater extent than heterosexuality, is something about which we all have individual feelings and moral values that influence both our personal and professional lives. It may be even more difficult to feel intuitively how one, as a carer, should approach the possible homosexuality of a patient compared with the sexuality of patients in general. The carer may first need to come to terms with his or her own general attitude towards homosexuality.25 These problems, naturally, are also important for a homosexual carer in relation to heterosexual patients. The overall aim is that the caring staff should treat all patients with the same respect. It is important to stress that we are not responsible for our feelings as such but we are responsible for how we deal with them and express them. Sexual behaviour in an institution is unlike that in a persons home in one essential aspect. Within the collective situation of a nursing home, sexual behaviour is no longer a private matter but a public one, affecting, in one way or another, carers, other patients and, occasionally, also relatives. Thus, the loyalty and responsibility of the carer concerns several parties, not only the patient.

Sexual intimacy and illnesses of dementia

Another problem that carers may face is in handling uninhibited sexual behaviour in elderly persons with dementia in whom deteriorating cerebral function affects the control of impulses. Confused patients may exhibit themselves naked, undress in the presence of others, fiddle with their clothes in a way reminiscent of sexual behaviour, or lie down in a fellow patients bed. He or she can also make approaches to staff or to other patients. In these and similar situations it is the carers responsibility to try to divert the patient and restore him or her to a type of behaviour that is as normal as possible. Arrangements may have to be made to prevent the patient from further attempts of this kind. It is the carers responsibility to act in such a way that other patients private lives are protected from undesired invasion. The progression of dementia must determine if, or to what degree, it is possible to talk with the elderly person as tactfully as possible to help him or her to understand why a certain behaviour is not desirable and is offensive to others. Under all circumstances it is the ethical responsibility of the carer to explain to all concerned that a person with dementia is not in control of his or her actions. This is particularly important to convey to family and friends, who, when witnessing such situations, may find them very distressing.26 Institutions should not Downloaded from http://nej.sagepub.com by RAVI BABU on November 8, 2007 create rules that are too rigid regarding theBUNGA sexual activities of elderly persons, 1998 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

Intimacy meeting needs and respecting privacy in the care of elderly people 533 but limits need to be set now and then for those who have lost their inhibitions because of illness. Both patients and their environment need to be protected.

Intimacy as trust
The patientcarer relationship has been discussed above. In the unwritten contract between a carer and a patient it is assumed that the carer has undertaken the task of helping the sick person regardless of who he or she is. Here, it is irrelevant if the carer and the patient already know one another personally or what their opinion of each other may be. In unfortunate cases it happens that the carers task becomes solely a burdensome duty because positive emotional responses are absent. This is hopefully the exception rather than the rule. In most cases the carer and the patient seek spontaneously to create a mutually trusting relationship. Although such contact is not, and must not, be allowed to become a condition for the provision of the best possible care, it is unquestionably true that, in practice, confidence and trust are important factors in good care. An earlier section of this article stressed the patients fundamental human need for emotional nearness. Of course, this need can, to a large extent, be fulfilled by family and friends, but many elderly people have neither family nor friends who are still alive. Regardless of whether the patient has family or friends, the trust that can arise between a carer and a patient serves a special purpose. Elderly and sick persons have the possibility, without having to consider other people or be false to themselves, to relate their situation to others who not only understand but are also responsible for their care and who can influence it. Seeing a patients situation from the other side may give the carer even greater knowledge and understanding and the possibility of allowing the patient to feel understood. Hence, nothing seems to hinder carers from establishing a trusting relationship with patients. However, being a confidant(e) also involves risks. Empathy can become intrusive.27 Carers must seek to utilize their empathic abilities for the sole purpose of helping patients. One must remember to show respect when touching anothers body, as well as when gaining access to anothers innermost self. Other factors may also go against unconditionally allowing a relationship to become too intimate. Such a relationship must never be allowed to compete with family and friendship ties that already exist, it must only complement them. Carers should also make it clear to patients that they are prevented from entering into certain types of discussions in which they are expected to give their own opinions or confidences. Commenting upon other patients or other carers are examples of situations in which both the obligation to observe professional secrecy and the duty to show respect are binding. Mere listening is often enough in such cases, and can ensure that a satisfactory patientcarer relationship can nevertheless be maintained.

Closing remarks
Ethics seldom provides ready-made answers. The question of intimacy in the care of elderly people will always demand reflection in each particular situation, but, Downloaded from http://nej.sagepub.com by RAVI BABU BUNGA on November 8, 2007 if our fundamental moral assumption is that the caring responsibility can never 1998 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.

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be interpreted as a right to act against the wishes of the patient, then the key aspect will be respect. To be able to show this respect, carers must have knowledge and show openness. When this is the case, there is no contradiction between meeting elderly persons needs of intimacy and respecting their personal privacy. Anne-Cathrine Mattiasson, HM Queen Sophia University College of Nursing, Stockholm, Sweden. Maja Hemberg, Lund University, Lund, Sweden.

References
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