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Environmental Issues in Patient Care Management: Proxemics, Personal Space, and Territoriality
Patient privacy issues play a significant role in healthcare policy. However, concern for patient privacy may not always carry over into patient care activities. An Association of Rehabilitation Nurses chapter research committee undertook a study to assess rehabilitation nurses’ knowledge of proxemics, personal space, and territoriality and their application in rehabilitation nursing practice. The theoretical framework was Hall’s 1966 theory of proxemics. A pretest–posttest design with a 1-hour educational intervention was used with a convenience sample of rehabilitation nurses (N = 43). The tests consisted of 12 multiple-choice questions and 1 open-ended question related to practice. Paired-samples t tests of pretest and posttest scores demonstrated improvement in posttest scores (p < .0005). Analyses of variance were conducted to determine whether there were any differences on the posttest scores when looking at education level, years of work experience, years of work experience in rehabilitation nursing, and certification. Higher education levels correlated with higher test scores (p < .005). Although findings are limited by sample size, results indicate that rehabilitation nurses are not familiar with the impact of proxemics. The nurses’ application of these principles in the open-ended question indicates that a patient’s personal space in a healthcare setting is determined by the nurse, not the patient. The implications that result from a call to action on these issues are discussed.
Rehabilitation patients’ need for privacy, communication, and comfort in the care environment is a basic principle learned early in a nurse’s education. The American Hospital Association (2003) delineated the expectations, rights, and responsibilities of the patient care partnership to include protection of privacy of medical information. Rehabilitation nursing standards of care establish consideration of the patient’s environment in planning, implementing, and evaluating care (Association of Rehabilitation Nurses, 2000). This study examines some of the underlying concepts of rehabilitation nursing and their potential effects on interactions with patients in the rehabilitation or hospital setting. Those concepts are proxemics, personal space, and territoriality.
A review of the nursing literature for these key topics reveals that little has been written about them since the 1990s. The more current studies are found in the literature of environmental psychology, architecture, training in therapeutic boundaries for mental health workers, physical therapy interaction, and virtual media development. Proxemics, the study of how groups and individuals systematically use space, was first described by anthropologist Edward T. Hall, who published in the 1960s and 1970s (Hall, 1966). His work described how man unconsciously structures microspace. Microspace is the distance between people in their interactions. Hall also postulated four “distance zones”: intimate, personal, social, and public. Each is further broken down into a “close” and “far” phase (Table 1).
Territoriality is the behavior used by a person or group to lay claim to an area and to defend it against others (Bell, Greene, Fisher, & Baum, 2001). The functions of territoriality are to help establish autonomy and identity; to establish control, predictability, and role organization; and to provide safety and protection (Bell et al.; Hayter, 1981). Personal space is one’s personal territory and is dynamic, expanding and contracting (Hall, 1966). It is the space in which one feels one must acknowledge another person and react if they enter.
The literature describes many factors that influence personal space, including age, gender, cultural background, disability, social context, personality, and mood or emotional state.
Webb and Weber (2003) described mobility in older adults as a significant factor in personal space. They stated that the “ability to flee is the most basic protective mechanism” (p. 709). Male–male interactions tend to take place face to face, whereas females position themselves beside one another (Edwards, 1998; Sommer, 1969).
Lomranz (1976) found support for a priori cultural differences in proxemic behavior; that is, learned cultural differences seem to remain intact when the person moves from culture to culture and situation to situation. In general, people with physical disabilities are allotted more personal space in interactions than those without disabilities (Kilbury, Brodieri, & Wong, 1996; Lomranz, 1976). Edwards (1998) was one of the first nurses to research personal space during illness. She described how the social setting of the hospital unit delineates territorial boundaries for staff and patient. These boundaries are dynamic and influenced by the severity of a patient’s illness and, most particularly, his or her mobility in the space; the more mobile the patient, the broader his or her territory.
When personal space is invaded (i.e., territorial intrusions), Sommer (1969) stated that tension levels increase dramatically. The person’s response to that intrusion varies according to the factors noted previously. The practice of rehabilitation nursing often involves “far intimate” personal space distance. The nurse also controls the therapeutic space in a patient’s room. The literature indicates that human behavior in response to personal space intrusion may include blocking or avoidance through turning away, averting gaze, or becoming immobile. Other responses may include anxiety-reduction behavior such as hair pulling, foot tapping, getting red in the face, or even leaving the area. Some become angry, irritable, or fidgety, or are uncooperative (Burkeman, 1999; Summers, 1979). A study of institutionalized patients indicated that they attempted to exercise freedom over body territory through manipulation of the body, adornment, or penetration or modification of the space. For example, a patient may take up two chairs to prevent others from being close (Cooper, 1984; Roosa, 1982).
Literature examining how private rooms affect patient outcomes suggests a strong link between physical environment and patient outcomes (Chaudhury, Mahmood, & Valente, 2006; Ulrich, Quan, Zimring, Joseph, & Choudhary, 2004). A recent extensive review of the literature (Ulrich et al.) comparing single-bed rooms and multibed rooms concluded that a patient-centered and psychologically supportive acute care environment facilitates “positive patient outcomes, such as increased patient privacy, increased patient control over personal information, and increased opportunity to rest and to discuss needs with family members and friends” (Chaudhury et al., p. 118). Barlas, Sama, Ward, and Lesser (2001) found that 5% of patients in curtained spaces reported withholding portions of their medical history and refused parts of the examination because they lacked privacy. None of the patients in private rooms reported withholding information.
Magnet status, sought after by many hospitals, emphasizes enhancing patient outcomes. Although magnet criteria do not specifically address personal space, territoriality, and privacy, these concepts are significant in providing the positive patient care environment the criteria describe. Incorporating these concepts into patient care will meet patients’ cultural and ethnic needs as well. Finally, patient satisfaction with overall care and nursing care will be optimized. It is clear that nurses are charged with respecting patients and their families and maintaining their privacy and dignity. The concepts of territoriality and personal space provide a framework for applying these standard nursing principles. In rehabilitation nursing the patient is dealing with life-altering health problems and can be hospitalized for an extended period of time. Incorporating concern for personal space and territoriality is paramount as rehabilitation nurses facilitate patients’ transition to independence. The patient’s control of his or her space is a critical factor in the transition to wellness. As the literature suggests, invasion of personal space may result in the stress response of increased anxiety and tension. These behaviors affect the patient’s readiness to learn and participate in therapy activities and the rehabilitation nurse–patient relationship.
This study was designed to assess rehabilitation nurses’ knowledge of proxemics, personal space, and territoriality and their impact on patient behaviors. The intervention was an approved nursing contact hour program that provided information about how patients might behave when their personal space and territory are infringed upon and the interventions nurses can use to ameliorate the effects of that infringement. The 1-hour program was presented at a regular rehabilitation nurses’ chapter meeting.
The research questions to be studied were as follows:
The format for this study was a pretest–posttest method with an educational intervention. The tests consisted of 12 multiple-choice questions and one open-ended question. The tests were developed through a literature review. A 15-item questionnaire was developed from the literature. It was administered to a panel of expert rehabilitation nurses (educators and clinical practice rehabilitation nurses) who had performed a literature review of personal space and territoriality. This group determined that the content of three questions was redundant to other questionnaire items. This expert panel’s assessment for content validity resulted in the final 12 multiple-choice questions, with an additional open-ended question. Each multiple-choice question had five potential answers from which participants could choose. A demographic questionnaire was also included. Table 2 shows the demographic data for these subjects.
A convenience sample of 43 rehabilitation nurses who are members of the Southeast Texas Chapter Association of Rehabilitation Nurses participated in the study.
The data were collected at a regularly scheduled monthly Southeast Texas Chapter Association of Rehabilitation Nurses meeting. The meeting was advertised to the members and included a notice that a study was being conducted. The members were asked to arrive early to have time to fill out the pretest. As participants checked into the meeting they were given a letter of consent for participation in the study. Before the meeting began, members filled out the pretest questionnaire and demographic sheet. The meeting was an education session titled “Environmental Issues in Patient Care Management,” presented by an experienced rehabilitation nurse educator. At the end of the educational program, each participant was given the posttest to complete.
The first analysis was a paired-samples t test to detect any differences between the pretest and posttest scores. Although the result was significant (Table 3), it is important to note that the pretest and posttest were newly developed and require further study for reliability. Additional studies using the questionnaire can help determine the strength of the questions for analysis. The questionnaire was not statistically assessed for validity; an expert panel was used.
The next analysis was conducted to determine whether the posttest scores varied with education level, years of work experience, years of work experience in rehabilitation nursing, and certification (Tables 4–7). According to the analyses of variance (ANOVAs), significance was found in the education level between the master of science in nursing (MSN) and licensed vocational nurse (LVN), bachelor of science in nursing (BSN) and diploma, and between BSN and LVN. Because the numbers were small, the data were collapsed into two groups. This increased the size of the cells for analysis. A decision was made to collapse the cells by education levels to determine significance based on an assumption that advanced nursing education provides more theoretical background in social behavior. This was validated in our findings (p ≤ .005).
Group 1—LVN, associate degree in nursing (ADN), and diploma nurses—were compared with Group 2—MSN and BSN. According to the ANOVA, significance at p < .005 was found after these groups were collapsed (Table 8).
The open-ended statement, “Name a rehabilitation nursing intervention that would enhance your client’s personal space,” was presented on the pretest and posttest. Responses were tallied and compared.
On the open-ended question from the pretest, no response was given most frequently (n = 9, 21%), followed by some form of maintaining privacy (n = 6, 14%) and allowing the patient some control or honoring choices (n = 5, 12%). The remainder of the responses varied, some pertaining to enhancing personal space while others were unrelated. Examples included “Keep 4 feet from patient when feasible,” “Sit down to talk with patient in wheelchair,” “Introduce yourself,” “Setting boundaries,” and “Orient patient to his or her space.”
On the posttest, no response was given by only four participants (9%). (These were different participants than on the pretest.) The majority of responses included some form of maintaining client privacy: asking permission (n = 12, 28%), knocking before entering (n = 11, 26%), and maintaining privacy (n = 6, 14%) by using privacy curtains or a private room. The remainder of responses included interventions such as leaving personal items where patients placed them, allowing patients to make decisions, interacting at eye level, asking what is important, and having patients bring personal items from home.
The results of this study indicate that nurses need information and education on the concepts of personal space, territoriality, and proxemics. In the review of the literature, the nursing journals that addressed these topics were mainly from the 1970s and 1980s, with a few from the mid-1990s. The more recent literature on proxemics was found in journals from other disciplines, as previously noted. In this study the posttest mean was 5.93 out of a possible 12.0, even after a 1-hour educational program. This indicates an area in which more education is needed.
Another possible explanation for nurses’ lack of knowledge about proxemics relates to how nurses are educated about these issues. Privacy is stressed in nursing curricula, but it is discussed mainly as the nurse providing privacy for the patient. As can be seen in the open-ended question, nurses view proxemics as “knocking on the door” or “closing a curtain” to ensure privacy. Nurses still view the patient as a part of the hospital room in the healthcare domain. For example, the bedside table is a work space for the nurse and not part of the patient’s space. Home health nurses see themselves as guests in their patient’s territory, whereas hospital nurses still maintain control of the environment of the patient’s room. Nurses also protect the privacy of their patients from visitors to the hospital but seemingly do not consider themselves outsiders in the patient’s personal space.
Nurses are acutely aware of the Health Insurance Portability and Accountability Act and the privacy issues that emanate from this legislation. These issues of privacy do not include the cultural and social aspects of the privacy of the patient’s territory. Nurses respect the dignity of their patients through interventions such as closing a curtain or door but do little to enhance patients’ control of their space during hospitalization. This suggests that this is a nurse-centered activity whereby the nurse structures the environment for his or her patient care activities, aligned with regulatory requirements for patient privacy, dignity, and respect. This creates a nurse-controlled environment rather than a patient-centered environment.
In addition to understanding the concept of proxemics, rehabilitation nurses need to be aware of the behavioral effects, such as increased anxiety and tension, when the patient’s personal space is intruded on by healthcare workers. This assertion is supported by the research examining how private rooms affect patient outcomes. Rehabilitation nurses need to explore nursing interventions that enhance personal space and patient-centered care. Analysis of the open-ended question reveals that rehabilitation nurses have limited knowledge about appropriate interventions. Some appropriate interventions identified were to stand or sit at the level of the patient and knock before entering a room. In addition, interventions such as encouraging patients to bring items from home, always asking permission before beginning a procedure, and preserving arrangements of personal items in a room enhance patients’ control of their personal space.
This study has several limitations for generalizability. A convenience sample was used, and the sample was small. The survey had been piloted. However, participants reported that some of the questions were vague; they believed that two questions had more than one correct answer. Both questions had been designed as multiple-multiple choice. To improve this questionnaire for future use, these questions should be redesigned as simple multiple choice. The number of questions severely limits the ability to perform statistical analyses of the questionnaire for construct validity. Use of the questionnaire in other research studies of personal space and territoriality can only enhance its strength.
What the study did accomplish was to open a dialogue about proxemics for the nurses involved. It also pointed the way for continued research with disability and personal space. Generalized research into proxemics in nursing should also be conducted. This study should be replicated with a larger sample to permit generalization. This is an understudied area that has significance for rehabilitation practice.
Another avenue for dissemination of the importance of proxemics is in nursing curricula. The Health Insurance Portability and Accountability Act and patient privacy are taught, but a deeper knowledge of a patient’s space and how an intrusion on this space affects the patient should be taught and discussed. Proxemics should also be a component of ethical studies and discussions for nurses.
Lastly, information about this important concept should be made available to nursing staff currently working—both rehabilitation nurses and nurses in all other areas of practice.
About the Authors
Celeste McLaughlin, MS RN CNS CRRN, is assistant director of nursing at Harris County Hospital District in Houston, TX. Address correspondence to her at firstname.lastname@example.org.
Rhonda Olson, MS RN CRRN, is a private consultant in Houston, TX.
Mary Joe White, PhD RN, is an associate professor of nursing at the University of Texas Health Science Center at Houston in Houston, TX.
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