Preservation of the right to privacy: perception of hospitalized patient Integrative review

Introducao: A privacidade como direito humano fundamental deve ser preservada em to- das as dimensoes. Em situacao de internamento hospitalar as duas dimensoes da privacidade mais afetadas sao a privacidade fisica e de informacao. A preservacao da privacidade dos doentes e essencial no estabelecimento de uma relacao entre estes e a equipa de saude e e atualmente um indicador importante da qualidade dos cuidados. Objectivos: Conhecer as perspetivas dos doentes internados acerca do seu direito a privacidade. Metodos: Foi realizada uma revisao integrativa com base na pesquisa de estudos nas bases de dados B-on, SciELO e EBSCO nos ultimos 12 anos (2005-2016). Resultados: Foram selecionados 9 artigos, dos quais 4 sao de abordagem quantitativa e 5 qualitativa. Os artigos sugerem que as dimensoes da privacidade que mais vezes sofrem infracoes sao a dimensao fisica e informacional. Aspetos do espaco fisico sao referidos co- mo fatores que influenciam negativamente a preservacao da privacidade. Conclusao: A percecao dos doentes sobre a sua privacidade prediz a sua satisfacao acerca dos cuidados. A falta de privacidade condiciona no doente sentimentos de stress e afeta a relacao entre estes e os profissionais de saude. Palavras chave: privacidade, confidencialidade, doente internado, cuidados de enfermagem, revisao integrativa.


INTRODUCTION
Privacy is recognized as a fundamental human right that must be preserved in all dimensions. The Universal Declaration of Human Rights provides in article 12 that "no one shall be subjected to arbitrary interference with his privacy, family, home or correspondence" (1) .
In Portugal, the right to privacy is established in the Constitution of the Portuguese Republic since 1976, specifically in the chapter "Personal rights, freedoms and guarantees", article 33, which guarantees the right to privacy of private and family life (2) .
The right to privacy assumes specific and quite relevant aspects in health care contexts.
The Basic Health Law No. 48/90 of 21 August, in its Base XIV, no. 1, paragraph (c) defines the right users have to be "treated by adequate means, with humanity, promptness, technical accuracy, privacy and respect" (3) .
The hospital is an environment hostile to human nature as it enhances the physical fragility and vulnerability of patients (4) . For many years, the respect for privacy and confidentiality of patients has been an obligation of health professionals. Nowadays, this issue is still essential in nursing practices (5) . In Portugal, this requirement is explicit in the Code of Ethics for Nurses, especially in article 106, which reports to the Duty of Confidentiality, and article 107, which focuses on Respect for Intimacy (6) .
During hospitalization, physical and information are the two most affected dimensions of privacy.
Preservation of privacy is essential in establishing a relationship between patients and the health care team. It is important to consider that the intrusion of privacy can include multiple approaches such as the physical presence of an unwelcome person, examination by an unauthorized person, misleading information or decision making by inpatients themselves without their consent (7) .
The lack of privacy and confidentiality impedes communication between patients and health professionals, especially when discussing sensitive issues and important treatment options (8) .
Over the last years, patient satisfaction levels have been identified as one of the biggest indicators of quality in health care, being influenced by many factors. The protection of privacy in health care is taken as an important quality indicator (7) .

METHODS
We have developed an integrative review considering the principles of evidence-based research. According to Ercole et al. (9) , an integrative review of literature allows combining research results of a given topic in a systematic, orderly and comprehensive way. This method allows the simultaneous inclusion of quasi-experimental and experimental research, joining theoretical and empirical literature data and thus providing a more complete understanding of the subject matter.
During this study, we asked the following research question: What is the perception of inpatients about their right to privacy? We formulated the research question according to the PICOD methodology (Participants, Intervention, Comparisons, Outcomes, Design).
Considering the research question, we outlined the inclusion criteria to select the different studies: : hospitalized adults;

Phenomena of interest •
: the analyzed studies must consider the perspective of inpatients regarding their right to privacy; : results must include the patient's perception and satisfaction concerning their privacy during hospitalization; : The review will consider studies that focus on both qualitative and quantitative data.
Similarly, we defined as exclusion criteria studies not indexed to electronic research bases, articles whose full text were unavailable and that were not published in one of the follow- In a first phase we analyzed the titles of the articles found to identify those that met the objectives of this integrative review. Afterwards, we continued the process of inclusion/ exclusion of articles by reading the abstracts. Those whose abstracts were in line with the objectives of this review and met the defined inclusion criteria were analyzed in full.

RESULTS
Considering the defined strategy, the literature search in the databases mentioned resulted in 237 articles. This was followed by reading the titles and later the abstracts. We analyzed 38 articles in full. Afterwards, in accordance with the objectives and the inclusion and exclusion criteria previously defined, we selected nine studies to be part of this review.
The methodological quality of the studies was independently assessed by two authors using the critical assessment tools of the Joanna Briggs Institute (10) .
We used tables to carry out the data systematization process to facilitate the analysis of the studies. Tables covered the following aspects: identification of the study, country and date, purpose of study, study design, number and type of participants, outcomes, intervention or phenomenon of interest, results and main conclusions. According to the Joanna Briggs Institute (10) , the evidence levels found were level 2 (8) , level 3 (5,7,11) and level 4 (4,12,13,16,17) .
The studies analyzed were developed in several countries and are distributed in the following way: Brazil (2 studies), Taiwan (2 studies), Turkey, England, New Zealand, Australia and Iran (1 study each).
We grouped the results of the studies included in this review according to the methodological approach used to better understand and visualize them. Thus, four out of the nine studies analyzed had a quantitative methodology and five had a qualitative methodology.
We should also emphasize that within the quantitative studies, one is quasi-experimental and three are descriptive. Table 1 shows the selected studies to systematize and compare results.
The study sample is mostly constituted by patients admitted to emergency services (4 studies) or wards (5 studies). However, there are two studies that simultaneously consider patients and nurses, thus allowing to know the perspectives of this professional group concerning the issue.

Qualitative studies
Patients mentioned the behavioral factors that contribute to the protection and maintenance of privacy in hospital contexts, highlighting respect as the most important one, followed by personal control over situations that can violate this privacy. Qualitative studies The post-intervention group had significantly higher values of satisfaction and general perception of privacy; they also had better levels of satisfaction in the "personal information heard by third parties," "be seen by irrelevant people," "inappropriate conversations intentionally heard by health professionals," and "respect for privacy" categories. There was no difference between the two groups in the "room privacy for physical examination" category. The overall analysis shows that the intervention improved the perception of privacy and patient satisfaction.
Privacy is more important for women than for men. Patients who stay in spaces divided only by curtains report more privacy violations.
The higher the stay in healthcare facilities, the larger is the patient perception of privacy violations. Patients tend to withdraw information or to refuse examination when they notice previous privacy violations.
Lack of privacy is a given: effective privacy is lower than expected. Physical constraints, desire for a private place where to discuss private  for feeling that their information may be inappropriately disclosed; 19% claim to be reluctant to be physically examined for feeling that their body may be inappropriately exposed; 75% believe that privacy is very important in the ER; older patients and with longer stays have lower levels of general perception of privacy; patients who are treated in hallways also have lower levels of general perception of privacy.
There is a strong and meaningful relationship between privacy and satisfaction as well as privacy and placement of patients' beds (they referred to privacy as "weak" in public areas without curtains and "better" in rooms with curtains); there is also a relationship between patient age and privacy; older patients report more privacy violations; informational privacy respect was considered "weak" by 30% of patients and as "pretty good" by the same percentage; about 30% of patients said "weak" regarding psychosocial privacy; the longer the hospitalization period, the more likely are privacy violations; patients that said their privacy has been preserved indicate higher levels of satisfaction.

DISCUSSION OF RESULTS
As result of the analysis of the selected studies, we can see that patients who had their privacy respected had higher levels of satisfaction (5,7,8) . We found that the length of stay and patient age are related to the perception of privacy: the longer the stay and the older the patient, the greater the number of privacy violations reported (5,7,11) .
Physical space was referred several times as a factor that hinders the preservation of privacy. Patients report that spaces divided only by hospital curtains have less privacy (7,11,12,13) .
Authors such as Downey & Lloyd (14) and Guimarães & Dourado (15) also support these findings, stating the essential role of strategic measures such as the use of folding screens and curtains as well as the carefulness when undressing patients as ways of protecting their privacy.
As result of the disregard for privacy as perceived by patients, some refuse to be examined given previous observations of violation (5,11) .
Information privacy is also a very present dimension in the studies analyzed (7) . Most patients said to withdraw personal information for feeling that their privacy could be inappropriately disclosed (5,11,13) . These findings reflect the results in Soares (18) , who points out that professional comments are often voiced about patients' personal information in places that go beyond the care practice.
Hospitalization is most often seen as a time of depersonalization. Patients view their limitations when choosing the aspects related to their private life during hospitalization as a decrease in privacy (4,16) .
In studies that include the nurses' perception, these professionals consider adopting measures to promote the patient privacy (12) . However, in two qualitative and non-participatory observation studies there is an overall inappropriate attitude concerning nurses, which can cause failure in patient privacy protection (16,17) . Backes et al. (19) states that this aspect reveals the disruption of values in which the oversight by ethical principles seem to be a part of the everyday of these professionals.
Regarding the methodology used by the different studies analyzed, there are aspects which we believe can hinder the reliability of results. The most common are: the use of reduced samples, the sample type used and the use of recall strategies in the clearing of the data.
One of the studies analyzed (13) , which had interviews with patients after their hospitalization period, focused on the analysis of a subjective perception, the perception of privacy, using recall strategies, which could cause information bias.
Convenience sampling was used in three of the quantitative studies analyzed (5,7,11) . This aspect can restrict the study because since this type of sample includes subjects available on site at the time of data collection, these people can have different characteristics of the target population, which prevents the generalization of results (20) . In addition, the sample in the analyzed quasi-experimental study (8) was not randomized, which according to Eccles et al. (21) can hinder and interfere with results, since it is difficult to obtain samples with similar characteristics in the two periods of the study. The number of patients and the type of pathology in two periods of the study may have been different, which can affect the perception of privacy.
We also understand the reduced number of samples as a limiting factor, since it implies studying a group of people who may not be representative of the issue. Out of the studies analyzed, the largest sample consisted of 360 people (7) and the smallest sample consisted of 12 people (13,17) . According to Fortin (20) large samples usually lead to better approximations to population parameters. However, in studies whose goal is to explore and describe phenomena, the sample size can be reduced.
Finally, we think that is necessary to reflect on the different socio-cultural contexts where data collection happen. The analysis of a dimension as subjective and culturally dependent as privacy, evaluated in countries with social and cultural conditions as different as those that integrate this review, can also influence the generalization of results.

CONCLUSIONS
This integrative review concluded that inpatients' perception regarding privacy is related to their satisfaction with the care provided. Most patients perceived physical or informational violations regarding their own privacy or the privacy of others. According to them, the lack of privacy is related to their dignity, respect and guarantee of autonomy. The lack of privacy can create stress and affects the relationship between patients and health professionals.
The results presented by the several studies included in this review allow us to infer some implications for clinical practice. One of the points made was the importance of professional development of health teams in ethics and patients' rights, since the increase of knowledge in this area can improve the privacy given to patients. The studies reviewed show the need to improve the physical space of health facilities as constraints of physical space are related to multiple privacy violations.