The nature of the A&E Department makes maintaining privacy and dignity a challenge. When I initially considered improving privacy and dignity for patients, the options seemed endless.

Most patients' first encounter in A&E involves divulging personal details about themselves and their illness to reception staff surrounded by other patients doing the same. They might then go to the minor injuries treatment area where there are only curtain partitions separating patients. The doctors/nurses desk is in the middle of the department from which conversations about patients can be heard by the rest of the people in the room.

Patients who go to 'majors'- a treatment area for higher dependency patients who require further investigation- might be taken into a cubicle for their initial consultation, or, if that is not possible, the consultation might have to take place somewhere much less private. Commonly, due to a lack of space, history taking and phlebotomy takes place in the 'corridor', despite efforts by staff to avoid this whenever possible.

The resuscitation room consists of five bays separated by lead screens, with portable screens that can be placed in front of the patients if necessary. The resuscitation room is generally a busy environment with members of the medical and nursing staff as well as patients' relatives walking in and out regularly. Conversations about patients can be heard throughout the room.

Many of the problems with maintaining privacy and dignity in A&E are environmental, and without changing the structure of the department little can be done to change this. However, there are some improvements that could viably be made. I decided that in order for this to be achievable, I would have to concentrate on a small group of patients initially, and adapt the process of change to suit other patients if results were achieved.

I decided to focus on pregnant women presenting to A&E with PV (vaginal) bleeding. Raving previously written an essay relating to the experience of women having spontaneous abortions, I had already identified the necessity to improve practice in A&E. This seemed the ideal opportunity.

Currently, pregnant women presenting to A&E with PV bleeding are moved into a cubicle with a door as soon as possible, where they generally stay, until a doctor has examined them. There is a sink in the cubicle, but no other washing facilities. Attempts are made to ensure that only one nurse and one doctor are involved with the patient to establish an element of familiarity and trust. Occasionally, however, patients have to be moved out of the cubicle on a trolley, if the cubicle is required by another patient. At the end of the patient's experience in A&B, there is little written information for them to explain what has happened and what will happen next. However, this is often provided when the patient attends the early pregnancy assessment unit (EPAU).

In order to establish what, if anything, needed to he changed to give more respect to the privacy and dignity of women presenting to A&B with PV bleeding, I needed to know how they felt about their experiences. Initially I decided to ask patients to complete a questionnaire on their departure from the department.

I asked the following questions:

• Was your situation explained to you in a manner you understood?
• Did you feel adequately informed about any procedures which were performed?
• Were you given the opportunity to ask any questions by the doctor or the nurse?
• Do you feel your dignity was respected as much as possible under the circumstances?
• Did the environment provide you with sufficient privacy?
• What improvements could we make to respect the privacy and dignity of women in your position?

The questions required only a 'yes' or 'no' answer, apart from the last question. All 30 questionnaires completed came back with 100% 'yes' answers, and no other comments. One could conclude, therefore, that no changes were necessary, and that the privacy and dignity of pregnant women presenting to A&F with PV bleeding was in fact maintained optimally.

Considering the possible inadequacies of questionnaires in collating information, I decided to take a different approach. Spending time talking to patients in A&E and having an informal conversation, rather than using structured questions, I would be more likely to acquire the necessary information. I also decided to speak to patients who were referred to the early pregnancy assessment unit from A&E, hoping that by speaking to women several days afier their experience in A&F, they would have had more time to reflect on their experiences, and be in a better position to talk about them. I did this in conjunction with another senior staff nurse from the A&E Department.

There were many interesting comments made by the women we spoke to. There was a combination of positive and negative comments, as well as suggestions for change. From these observations, we aimed to improve the environment in A&E for pregnant women presenting with PV bleeding. We also we hoped to highlight best practise for these patients, and improve care from a nursing and medical perspective.

The comments and suggestions by patients predominantly fell into three categories, these encompassed environment, attitude of staff and communication.

With regards to environment, several women identified that they were glad to be in a cubicle with a door, as they were worried about someone walking in as they were being examined. However, one patient said she felt isolated in a cubicle with a door and felt as though she had been forgotten. Many women felt embarrassed about being in blood-stained clothing and would have liked washing facilities, this issue was particularly upsetting for women who were moved from the cubicle into the 'corridor' area where they could be seen by most people in the department.

Two women thought the examination room they were in was depressing and suggested making changes to create a nicer environment. Although there is a trolley in the A&B Department with everything necessary for a PV examination, a number of women made remarks about the doctor or nurse leaving the room several times to get the correct equipment, even during the examination.

Surprisingly there were several comments made by patients about attitudes of staff during their experience in A&E. There were positive comments whereby patients thought nurses and doctors had handled this difficult situation empathetically, however, worryingly there were more negative comments. Women described how their experience of probable miscarriage was trivialised, and how the staff didn't seem to understand they were possibly losing their baby. One patient summarised several women's feelings by saying "I know you deal with this every day, but for me it was devastating, I needed some support."

Generally comments about communication by medical and nursing staff were positive. Most women felt prepared for any procedures they encountered, and were given the opportunity to ask questions. However, several women wanted explanations for why they were bleeding and did not feel the information they received was adequate. An overall impression that women would have liked more information about what was happening to them was evident. However women we spoke to in EPAU said they had forgotten most of the information they were given in A&IE by the time they got home.

These are only a few of the comments and suggestions made by the women we spoke to, but already there are evident implications for practice. From here we intend to make arrangements with the relevant people in order to create a dedicated cubicle for such patients. We believe the cubicle should have washing facilities: a sink, towels and bowls, a linen skip and a supply of sanitary towels, linen and gowns. There should be a trolley with everything necessary for a PV examination, which should always be stocked and should not be taken from the cubicle.

We would like to produce information packs to be kept in the cubicle, including written information about what a PV examination involves, what happens in EPAU, as well as information from the Miscarriage Association about what causes bleeding in pregnancy, and the options available in the event of a miscarriage.

When considering attitudes of staff it is less likely that members of the nursing and medical teams see the event of potential miscarriage as trivial, but that they have little time to provide the necessary support for women in this situation. However, it would be beneficial for the health care professionals to be made more aware of the implications of this event for women, and to learn from experts in this field about the best way to support patients. Perhaps as part of a clinical governance day it would be advantageous to have a seminar by a counsellor from the Miscarriage Association who would be able to advise A&E nurses on the best way to support women in the A&E environment. This information could then be incorporated into the A&F teaching rota to ensure adequate conveyance of the information.

Patient-focused benchmarking aims to create best practice for optimal patient care. We have based optimal care upon requirements guided by patients themselves. The planned changes encompass the majority of amendments suggested by the patients. All of these seem achievable and will hopefully be implemented in the A&B Department in the next few months.